EXCLUSIVELY FOR MADAM PROFESSOR

Psychotherapy Volume 38/Spring 2001/Number 1

REVIVING FREUD'S VISION OF A PSYCHOANALYTIC SCIENCE: IMPLICATIONS FOR CLINICAL

TRAINING AND EDUCATION

ALEXANDER J. SCHUT LOUIS G. CASTONGUAY Pennsylvania State University

Traditional assumptions about the analytic encounter have contributed to the detachment of psychoanalytic psychotherapy from the empirical movement that has dominated mainstream academic clinical psychology. However, recent research findings on the process and mechanisms of change within psychoanalytic forms of treatment now provide much needed empirical support for some of the basic tenets of psychoanalytic theory and practice, challenge long-standing notions regarding the link between therapeutic technique and clinical improvement, and suggest that factors once believed to be unique to psychoanalytic psychotherapy might be playing a crucial role in the promotion of change in other therapeutic modalities. The implications of these process research findings for the present state and future of clinical training and education are provided.

Preparation of this manuscript was supported in part by National Institute of Mental Health Research Grant MH- 58593.

An earlier version of this article was submitted by the first author and awarded first prize in 1999 for the American Psy- chological Association's Division 29 Student Paper Competi- tion on Education and Training.

Correspondence regarding this article should be addressed to Alexander J. Schut, Department of Psychology, Pennsylva- nia State University, 429 Moore Building, University Park, PA 16802. E-mail: [email protected]

Although Freud expressed his wish for a scien- tifically informed psychoanalytic psychotherapy over 100 years ago (see Westen, 1998), a survey of modern-day practitioners indicates that the bevy of empirical findings generated from aca- demic psychology (e.g., psychotherapy research) has little, if any, impact on actual, day-to-day clinical practice (Beutler, Williams, Wakefield, & Entwistle, 1995). Indeed, many analytically oriented psychologists would probably agree that the research activities expected of them during their graduate training are either irrelevant to or far removed from the conduct of analytic work. Although this state of affairs is probably multiply determined, we believe that the schism analysts face between the "ivory tower" of academic psy- chology and the "real world" of psychoanalytic practice is a product of at least two tacit assump- tions about the analytic encounter that have been perpetuated within the scientific and practicing communities. First, there has been a long- standing belief that the analytic process is, and should remain, exempt from the scientific endeav- ors of academic psychology because of its inher- ent complexity and/or because it involves the as- sessment and treatment of private, hard-to- operationalize structures, processes, and contents of the mind. Second is the assumption that re- searching the analytic encounter in some way con- taminates or disrupts the treatment process, thereby invalidating the very phenomenon to be studied.

These two assumptions have contributed to the virtual detachment of psychoanalytic psy- chotherapy from the empirical movement that has dominated the rest of academic clinical psy- chology (Strupp, 1976). In our view, this dis- connection of analytic practice from scientific inquiry is problematic for at least two reasons. First, with the infiltration of managed-care or- ganizations in psychotherapy practice and the

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press for implementing empirically supported treatments (usually brief, symptom-oriented treatment methods) (e.g., Chambless & Hollon, 1998), the failure of the analytic community to provide scientific support for its concepts or treatment methods threatens to render psycho- analytic psychotherapy a nonreimbursable form of therapy and push it toward the realm of an outdated pseudoclinical science. Second, the weak impact of scientific findings on the appli- cation of psychoanalytic psychotherapy is anti- thetical to the mission of clinical training and education set forth by the American Psychologi- cal Association (APA) after it adopted the Boul- der Model in 1949 (APA, 1950). Trainees are, at the least, expected to read relevant scientific literature and utilize research methodology to bolster the efficacy of their analytic treatment or to provide empirical support for their theoretical conceptualizations regarding psychopathology or psychotherapy.

Fortunately, however, over the last two-and- a-half decades, a contingent of psychoanalytic psychotherapy researchers has begun to gener- ate a substantial body of empirical research on the analytic encounter, breathing new life into the psychoanalytic approach and reaffirming its position as a worthy clinical and scientific enter- prise. Recent publications have already pre- sented clear evidence for the beneficial impact of psychodynamically oriented therapy (Ander- son & Lambert, 1995; Crits-Christoph, 1992; Luborsky et al., 1993). In this article, we first specifically highlight empirical studies that ex- plicate the process and mechanisms of change in psychoanalytic psychotherapy and show how such programmatic research demonstrates em- pirical support for some of the basic tenets of psychoanalytic theory and practice. Next, we summarize recent process research findings on analytic treatment that present a challenge to traditionally held theoretical notions or assump- tions regarding therapeutic technique and clini- cal improvement, which, in turn, may suggest the need for conceptual and/or clinical refine- ments. Finally, we show how the study of pro- cess in psychoanalytic and nonanalytic psycho- therapies has generated strong evidence to suggest that analytic researchers can inform the- oreticians and researchers of other orientations about the basic mechanisms of change operating in their approaches. The implications of these reviewed empirical findings in terms of the pres-

ent state and future of clinical training and edu- cation are offered in the closing section.1

A Sample of Research Findings on Some Basic Tenets of Psychoanalytic Theory and Practice

Within the last 25 years, several groups initi- ated sophisticated programs of research investi- gating the fundamental assumptions about the psychoanalytic process as originally posited by Freud or other important authors of this tradition (e.g., Sullivan). Perhaps one of the more prolific groups associated with this line of clinical re- search was started by Lester Luborsky at the Uni- versity of Pennsylvania. Luborsky and his col- leagues (1985) have committed to a series of investigations of what they aptly called "Freud's grandest clinical hypothesis": the phenomenon of transference. Using clients' narratives of their interpersonal relationships or "relationship epi- sodes" as the source of data, Luborsky and col- leagues developed a system to objectively de- scribe clients' central relationship patterns. Their method, entitled the "core conflictual relationship theme" (CCRT), was intended to operationalize and extract the template or general relationship pattern that Freud (1912/1958) suggested clients brought to session. These templates or relation- ship patterns, Freud argued, are eventually expe- rienced in the moment with the therapist and are expressed by the client via the transference.

As described by Luborsky and Crits-Christoph (1990), the CCRT has three components: the cli- ents' wishes, intentions, or needs; the (expected) responses of others, and the responses of self. Research shows that each of the CCRT compo- nents—the presumed elements of Freud's hy- pothesized transference template—as well as the relationship episodes themselves can be reliably identified in psychotherapy transcripts (Crits- Christoph, Luborsky, Popp, Mellon, & Mark, 1990). This line of research also generated empir- ical evidence corresponding with many of Freud's basic assumptions about transference phenomena as outlined in his clinical "technique" papers

1 Although we focus attention in this article on empirically derived psychoanalytic psychotherapy process findings and their implications for clinical training and education, it is important to note that the research programs from which these findings are based are indebted to the groundbreaking efforts of many psychoanalytic clinical investigations that have taken place over the last century.

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(e.g., Freud, 1912/1958; 1914/1958). Using the CCRT method, Luborsky (1990) and his col- leagues showed that (a) clients' main relational patterns are found within relationship episodes about the therapist, that is, their pattern comes to "involve" the therapist; (b) the relational pattern originates in early parental relationships and ex- hibits consistency over time; (c) clients' wishes conflict with responses of self and others; and (d) the use of interpretations, particularly those that focus on the client's pattern as reflected in the CCRT, change the expression of the pattern and are associated with client improvement.

The CCRT method is just one of the many systems currently used to assess transference phe- nomena. More generally, such systems are used to develop psychodynamic case formulations that later serve to guide actual therapeutic interven- tions. Although describing each system is beyond the scope of this article, the reader is directed to recent volumes and journal articles devoted to comparing the psychometric properties and clini- cal usage of some of the more popular systems (e.g., Horowitz, 1991; Luborsky, Popp, & Bar- ber, 1994).

Alongside these developments in transference/ case-formulation measures are equally exciting innovations in other domains of analytic theory and practice. They include the movement toward operationalizing and empirically demonstrating (a) the clinical ramifications of the quality and depth of patients' object representations (e.g., Blatt, Stayner, Auerbach, & Behrends, 1996), (b) the patient's representation and internalization of the therapist (e.g., Harrist, Quintana, Strupp, & Henry, 1994; Orlinsky & Geller, 1993), (c) the relationship between perceived childhood experiences with primary caregivers and actions directed towards the self in adulthood (e.g., Ben- jamin, 1996), (d) the development of the thera- peutic alliance and its link with treatment outcome (e.g., Gaston, 1990; Horvath & Symonds, 1991; Westerman, 1998), (e) mechanisms of defense (e.g., Perry, 1993), (f) countertransference phe- nomena (e.g., Hayes, Riker, & Ingram, 1997; Normandin & Bouchard, 1993), (g) primary and secondary process mentation (e.g., Bucci & Miller, 1993), (h) the structure and functions of emotions (e.g., Dahl, 1991), and (i) the system- atic codification of psychoanalytic technique (e.g., Barber & Crits-Christoph, 1996; Jones & Pulos, 1993; Piper, Debbane, de Carufel, & Bien- venu, 1987).

While many more lines of research on psycho- analytic theory and practice continue to emerge (see reviews by Beutler & Crago, 1991; Bornstein & Masling, 1998; Fisher & Greenberg, 1996; Henry, Strupp, Schacht, & Gaston, 1994; Lubor- sky, Barber, & Beutler, 1993; Luborsky, Barber, & Crits-Christoph, 1990; Miller, Luborsky, Bar- ber, & Docherty, 1993; Wallerstein & DeWitt, 1997; Weiss & Sampson, 1986; Westen, 1998), the take-home message for the reader is that the psychoanalytic encounter can, indeed, be subjected to rigorous scientific methods and survive! Strong evidence now suggests that once-considered vague analytic constructs and techniques can be operation- alized, reliably and validly assessed, and meaning- fully linked with client improvement.

Recent Challenges to Old Assumptions About the Link Between Technique and the Process of Change

Alongside these advancements within the psy- choanalytic psychotherapy research field are intri- guing data that raise serious questions about traditional views of the relationship between psy- choanalytic technique and the process of change. For example, Strachey (1934) and others have argued extensively in the clinical literature that the "mutative" factor or the vehicle of cure in psychoanalytic psychotherapy is the interpreta- tion of the transference. Until recently, this clini- cal hypothesis went unchallenged by convincing empirical evidence and perhaps inadvertently led some analysts to take this clinical postulate to an extreme position, for example, the idea that frequent use of transference interpretations intrin- sically leads to greater client improvement than moderate or infrequent use of such interventions (see Piper, Azim, Joyce, & McCallum, 1991).

However, several recent, well-controlled em- pirical studies conducted at independent sites in- dicate that such an extreme position is far from accurate (see Henry et al., 1994; Piper, Joyce, McCallum, & Azim, 1993, for reviews). In gen- eral, excessive use of transference interpretations has been found to be either ineffective or actually detrimental to the therapeutic alliance and to out- come (e.g., H0glend, 1993; Piper et al., 1991; Piper, Debbane, Bienvenu, de Carufel, & Garant, 1986). This does not mean, however, that trans- ference interpretations are not helpful or that they should not be used in treatment. For example, research shows that the accuracy or suitability of the therapist's interpretations, including transfer-

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ence interpretations, is predictive of clients' in- session progress or productivity (e.g., Silb- erschatz, Fretter, & Curtis, 1986), the develop- ment of the therapeutic alliance (Crits-Christoph, Barber, & Kurcias, 1993), and outcome (Crits- Christoph, Cooper, & Luborsky, 1988). More finer-grained analyses indicate that the clients' quality of object relations (i.e., primitive vs. ma- ture) may also moderate the relationships among transference interpretations, alliance, and treat- ment outcome. For example, research by Piper et al. (1993) has showed that a low frequency of highly accurate transference interpretations ap- pears to facilitate positive outcomes in individuals with mature object relations. For those with less mature object relations, Piper et al. (1993) found that highly accurate transference interpretations were associated with poorer therapeutic alliance and outcome. More recently, Connolly et al. (1999) and Ogrodniczuk, Piper, Joyce, and McCallum (1999) found that higher levels of transference interpretations were associated with poorer outcomes for those clients described as having low quality of object relations. Conse- quently, Connolly et al. (1999) and Piper, Joyce, McCallum, and Azim (1998) suggested that more supportive, as opposed to interpretive, therapeu- tic work might be beneficial for individuals pre- senting with primitive modes of relating. This is in line with other investigations demonstrating that less disturbed patients benefited more from expressive (or interpretive) interventions, whereas more disturbed patients improved with supportive types of therapeutic techniques (Horo- witz, Marmar, Weiss, DeWitt, & Rosenbaum, 1984; Jones, Gumming, & Horowitz, 1988).

As cogently argued by Binder and Strupp (1997), however, the majority of research investi- gating proposed links between therapeutic tech- niques and outcome have typically failed to con- sider the interpersonal tone and context from within which such interventions are provided. Thus, the frequent failure to find strong positive links between technique and outcome (Lambert, 1992) may be more a function of how and under what interpersonal context the therapist provides his or her interventions (i.e., an issue of process) rather than a function of the actual type of inter- ventions he or she uses (i.e., an issue of content).

The distinction between process and content is not necessarily new to analysts regarding their clinical work, but it does potentially shed addi- tional light on older notions from classical theory

that suggest simply providing particular types of interventions (e.g., confrontations, interpreta- tions) be related to client improvement. The im- portance of the process/content distinction is highlighted from the Vanderbilt I and II Psycho- therapy Research Projects. In these studies, it was revealed that therapists, while using similar tech- niques with similar patients, exhibited markedly different interpersonal behaviors in their "poor" outcome cases as compared to their "good" out- come cases (Henry, Schacht, & Strupp, 1986, 1990). Specifically, therapists' "good" outcome cases involved significantly more affiliative modes of therapist communication (e.g., they were more affirming and understanding, more helping and protecting, and less belittling and blaming), whereas therapists' "poor" outcome cases involved significantly more negative (i.e., hostile and controlling) types of interpersonal ex- changes. For example, there was a greater fre- quency in the poor outcome cases of negative interpersonal complementarity, where hostility from one member of the therapeutic dyad "pulled for" hostility from the other participant.

Although Henry et al. (1986, 1990) did not investigate the relationship between specific types of interventions and interpersonal process within the client-therapist dyad, their results suggest that while the content of interventions may not vary across clients, the process by which the therapist provides his or her interventions may yield radi- cally different therapeutic outcomes. Interest- ingly, even specific training designed to help ther- apists detect and manage negative process within the therapeutic relationship did not guarantee im- proved outcome, as many therapists showed more frequent hostile or complex communication (e.g., communication that simultaneously supports and blames) while increasing their adherence to tech- niques (e.g., transference interpretations) follow- ing such training (Henry, Strupp, Butler, Schacht, & Binder, 1993).

Clearly, these data cast doubt on old notions that simply implementing techniques undoubtedly leads to client improvement. The negative transference-countertransference matrix created by particular client-therapist interactions may only add "fuel to the fire" unless careful consider- ation is given to the ways in which one offers his or her interventions. Binder and Strupp (1997), along with many other analysts (e.g., Aron, 1996; Kohut, 1984; Schwaber, 1983), argued that great care must also be made with respect to the theoret-

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ical and philosophical propositions from which one works. More specifically, it has been argued that individuals working from the classical psy- choanalytic perspective often use methods that are "experience-distant," that implicitly blame the client for his or her troubles, and/or that promote the view that the client is distorting reality and t h a t the therapist is the arbiter of t r u t h . Such mod- els may serve to only disengage the client and therapist from one another and promote negative process (Binder & Strupp, 1997).-

An alternative, relational view of the analytic process (e.g., Aron, 1996; Mitchell, 1988;Safran & Muran, 2000) strives for a more "experience- near" perspective in which the therapist and client both examine their contributions to the unfolding of the therapeutic relationship. Through "meta- communicative feedback," whereby the therapist aims to process his or her observations about the here-and-now interaction w i t h the client, it is ar- gued that negative process can be more easily detected and effectively managed (Binder & Strupp, 1997, p. 133).

Building Bridges: Identification of the Basic Mechanisms of Change and the Movement Toward Psychotherapy Integration

Recent studies devoted to comparing the pro- cess of change in psychoanalytic and other forms of psychotherapy have also yielded surprising evi- dence suggesting that factors once believed to be unique to psychoanalytic psychotherapy may actu- ally play a crucial role in the promotion of change in other therapeutic modalities. For example, in a study comparing the process of change in cognitive- behavioral and brief psychodynamic psychotherapy for depression, Jones and Pulos (1993) found that

2 These clinical insights have received preliminary empiri- cal support from an exploratory study conducted by Caston- guay. Goldfried. Hayes, Raue, Wiser, and Shapiro (1990). These authors found that psychodynamic therapist interven- tions aimed at changing clients' views of self were negatively related to improvement. Content analyses conducted to clarify this finding revealed that the therapists frequently reattributed the responsibility to clients (or blamed them) for their prob- lems (e.g., "Is it possible that the way your wife behaves is, in part, a reaction to your own behavior?"). These results, however, should be considered with caution u n t i l replicated. Although the size of the negative correlation between the therapist interventions and client improvement was substantial (i.e., — 0 . 5 1 ) , this correlation was only marginally significant (p < .1) due to the small sample.

actions and techniques typically associated w i t h psychodynamic approaches ( e . g . , therapists' em- phasis on deepening clients' feelings; interpreta- tion of clients' warded-off wishes, feelings, or ideas; linking of clients' feelings or perceptions to situations of the past) were associated w i t h client improvement in both cognitive-behavioral and psychodynamic treatments. However, none of the techniques and activities typically associ- ated with cognitive-behavioral therapy (e.g., therapists' didactic-like behavior; emphasis of specific activities clients should engage in outside of treatment; discussion of clients' ideas or belief systems) were found to relate to positive change in either treatment. In a similar vein, Hayes, Cas- tonguay and Goldfried (1996), using a theory- neutral coding system to study the process of change in cognitive therapy for depression, dis- covered that interventions addressing interper- sonal and developmental aspects of clients' func- tioning (e.g., attachment experiences with parents) were found to be positively associated w i t h client improvement, whereas i n t e r v e n t i o n s addressing intrapersonal aspects of cognition were not. F i n a l l y , studies of the p s y c h o d y n a m i c construct of the working or t h e r a p e u t i c alliance ( e . g . , Zetzel, 1956) have shown t h a t the alli- ance is strongly predictive of outcome in psy- chodynamic therapy and also in c o g n i t i v e , c o g n i t i v e - b e h a v i o r a l , interpersonal, and phar- macological therapies (e.g., Castonguay, Gold- fried, Wiser, Raue, & Hayes, 1996; Krupnick et a l . , 1996).

The results of these process studies provide much needed empirical support for psychoana- lytic models of change. However, these data also point to the identification of basic mechanisms of change that may cut across other theoretical orientations. This latter observation is particularly noteworthy given the recent trend in psychother- apy research for identifying "common factors" of treatment (e.g.. Arkowitz, 1992) and given the increasingly popular movement toward the prac- tice of eclectic or integrative psychotherapy (Cas- tonguay & Goldfried, 1994; Jensen, Bergin, & Greaves, 1990). In fact, several theorists from nonanalytic orientations have already begun the process of integrating psychoanalytic clinical wis- dom into their practice. Perhaps one of the more well-known integrative models comes from Jer- emy Safran, who has developed a f r u i t f u l line of clinical-research integrating psychodynamic- interpersonal, experiential, and cognitive tradi-

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tions. His integrative approach has stemmed a vast number of studies devoted to helping clini- cians negotiate and repair ruptures to the thera- peutic alliance (e.g., Safran & Muran, 1996).

Largely influenced by the work of Safran and substantially based on the process findings de- scribed above, a group of researchers has devel- oped a, form of therapy that integrates psychody- namic and interpersonal techniques within a cognitive-behavioral treatment (CBT) for gen- eralized anxiety disorder (GAD) (Newman, Cas- tonguay, & Borkovec, 1999). Specifically, the protocol adds to the coping and skill-training techniques of CBT a number of procedures to (a) increase emotional deepening, (b) explore and resolve conflicts between needs and fears, (c) ex- plore past relationships with early caregivers, (d) address current maladaptive interpersonal pat- terns, and (e) explore and repair alliance ruptures that emerge in therapy. The rationale underlying the addition of these techniques is based on the fact that although CBT therapists tend not to focus substantially on emotional, conflictual, develop- mental, and interpersonal issues, process findings suggest that when they do so in ways that are reminiscent of psychodynamic and interpersonal practices their patients show greater improvement (see Castonguay, 2000). Results from a prelimi- nary investigation of this new treatment indicate that CBT and psychodynamically oriented tech- niques can indeed be integrated, that is, that thera- pists can adhere to the treatment protocol and implement it with minimal competence (New- man, Castonguay, Borkovec, & Schut, 1999), and that the therapist and client experience (e.g., feelings, thoughts, actions) in therapy is consist- ent with the model of change underlying the pro- tocol (Castonguay, Schut, Newman, & Borko- vec, 1999). Based on preliminary, but promising, outcome results (Borkovec, Newman, & Caston- guay, 1998; Newman, Castonguay, Borkovec, & Molnar, in press), a large clinical trial is currently being conducted comparing the integrative form of therapy with CBT—which currently stands as the gold-standard treatment for GAD.

Despite these recent trends and preliminary re- sults from comparative process studies, however, much more research on the psychoanalytic pro- cess (and on the identification of the specific ac- tive ingredients in psychoanalytic psychotherapy) needs to be conducted before more precise con- clusions can be made. This observation coalesces with the recommendations made by members of

the National Institute of Mental Health (NIMH) workshop on psychotherapy integration, who in- dicated that researchers must continue to elucidate the "crucial components of treatment" before more fruitful integration is to occur (Wolfe & Goldfried, 1988, p. 449). This being said, future researchers may wish to investigate the role of other factors that have rich clinical and theoretical roots within psychoanalytic forms of treatment (e.g., holding and containing functions on the part of the analyst, the use of support), as well as factors that have traditionally gone under- investigated (e.g., clients' and therapists' race, ethnicity, sexual orientation) as they may relate to the process of change.

Implications of the Reviewed Psychoanalytic Process Research Findings for Clinical Training and Education

We began this article by describing how psy- choanalytic clinicians have historically either failed to see the relevance of their graduate re- search training on the practice of psychoanalytic psychotherapy or refused to integrate clinical re- search methods or empirical findings from aca- demic psychology into their current-day analytic work. We then noted how these realities, stem- ming from traditionally held assumptions about the analytic process, have contributed to the de- tachment of psychoanalytic psychotherapy from the empirical approach that has dominated main- stream academic clinical psychology throughout this century. In our opinion, this disregard for the scientific tradition by individuals within the analytic community reflects a breakdown in the graduate clinical training and education process. Specifically, we strongly believe that there needs to be greater effort made by the training faculty in clinical programs to expose students to the type of process research findings and methodologies we reviewed in this article. Programs that fail to introduce such clinically relevant data and meth- odology in their graduate seminars on research methods, advanced psychotherapy, or clinical practica perform a great disservice to the profes- sional development of their trainees and perpetu- ate the already-existing schism between the scien- tific and practicing communities. In our view, process research findings such as those described above speak directly to the conduct of psychother- apy, which, in turn, lead to better theoretical and clinical developments regarding the nature and task of therapeutic change. For analytic prac-

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titioners in particular, process research findings that lend support to some of the long-held theoret- ical constructs or techniques developed from clin- ical wisdom may be (within the current social and political climate) required if psychoanalytic psychotherapy plans to remain a viable clinical science.

It is thus no longer appropriate or valid for the psychodynamically oriented therapist who also serves as a faculty member, mentor, or clinical supervisor to students to believe that research on the moment-to-moment processes between thera- pist and patient fails to capture the complexity and vicissitudes of the therapeutic interaction, is unreliable, or is unable to measure such private internal or interpersonal states. As we have shown, programmatic research shows that some of the most fundamental aspects and core tenets of psychoanalytic theory and practice (e.g., trans- ference) can indeed be operationalized, reliably and validly assessed, and meaningfully linked with client improvement. Studies such as these need to continue, but the onus now lies with the educators in terms of integrating these process research methods into their graduate-training cur- ricula. Clearly, advisors could encourage trainees to conduct psychoanalytic process research stud- ies as part of their master's or dissertation projects or enlist their skills for their own ongoing process research. Client and therapist self-reports of the therapeutic encounter (e.g., Orlinsky & Howard, 1966) or observer-based coding of the intra- psychic and interpersonal aspects of the analyst- patient dyad (e.g., Benjamin, 1974) can be imple- mented into any research paradigm. Trainees may also wish to study the process and mechanisms of change using archival data sets or organize data collection for research on more naturalistic settings, for example, some state psychological associations have begun to implement practice- research networks (cf. Borkovec & Castonguay, 1998).

Our review of some of the more recent psycho- analytic process research findings on transference interpretation challenges assumptions carried over from classical analytic theory regarding the link between technique and client improvement. We believe that this line of research clearly high- lights how scientific exploration of the conditions under which therapists use such techniques can inform clinical practice as well as the training of future therapists. As discussed by Henry et al. (1993) and Binder and Strupp (1997), the prepon-

derance of negative process in psychotherapy is commonly a function of the use of therapeutic techniques under poor interpersonal contexts. The literature we have summarized by Henry et al. (1986, 1990) thus suggests that clinical training and supervision may need to expand its focus from simply training students in the use of particu- lar therapeutic techniques to include the training of how to detect and manage negative interper- sonal cycles. According to Binder and Strupp (1997), metacommunication may be a highly therapeutic tool when working with negative in- terpersonal complementarity between members of the analytic dyad. From this perspective of clini- cal training, students could feasibly empirically observe the effects of various interpersonal trans- actions within their own caseload. Such intensive, single-case process research designs have been encouraged by Moras, Telfer, and Barlow (1993) and by Rice and Greenberg (1984).

Finally, our brief review of studies examining the process of change in psychoanalytic and non- analytic forms of treatment appear to inform the practice and training of not only dynamic thera- pists but also those of other orientations. For ex- ample, it was revealed that mechanisms once con- sidered unique to psychoanalytic psychotherapy (e.g., the link between present-day functioning and early experience with primary caregivers) may, surprisingly, serve as a vehicle of change in these other treatment modalities. These findings clearly provide needed empirical support for psy- choanalytic theories of change. However, as we have shown with a new treatment for GAD, re- searchers and clinicians from other theoretical/ clinical orientations (e.g., cognitive-behavioral, humanistic) may also find that integrating the above findings into their clinical research pro- grams or private practices will assist them in the construction and development of more effective treatments (Grencavage & Norcross, 1990). In ad- dition, nonpsychodynamically oriented graduate programs could integrate these findings in such a way as to improve the clinical training and educa- tion of their students. Students involved in cogni- tive-behavioral programs, for example, should be exposed to the empirical findings that demonstrate that not only do psychodynamic processes (e.g., emotional deepening, exploration of attachment issues) take place in cognitive-behavioral therapy but that they are also related to client improve- ment. Because research evidence indicates that such processes are active ingredients of change,

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they deserve to become integral parts of any grad- uate training anchored in the Boulder Model.

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