Psychotherapy Research Paper

With the Age of Reason, interest was aroused in the newly discovered phenomena of electricity and magnetism. Anton Mesmer (1734–1815), a brash physician, drew on the latter when propounding his theory of animal magnetism. Since the body contained ‘magnetic fluid,’ and this could become disturbed, by applying magnets to various parts a patient could be relieved of pain and other ailments. While Mesmer’s work was ultimately denounced by a Royal Commission and he was forgotten, the observation that his methods appeared to help patients continued to attract attention. James Braid (1795–1860), a Manchester doctor, noted that he could induce a similar trance-like state by getting people to fix their gaze on a luminous object. Labeling the phenomenon hypnotism, he proceeded to demonstrate its effectiveness in treating a range of conditions.

The doyen of French neurology, Jean Martin Charcot (1835–93), considered hypnosis a neurophysiological process, and set about its study in states like somnambulism and hysteria. His pupil Pierre Janet (1859–1947) suggested that the latter was brought about by weakening of a higher brain function, resulting in a constriction of consciousness. In this ‘dissociated’ state thoughts could not be integrated, and symptoms were beyond the reach of consciousness.

In an alternative explanation, Ambroise Liebeault (1823–1904), and Hippolyte Bernheim (1840–1919) in France posited a narrowing of attention in hypnosis which rendered the patient vulnerable to the therapist’s influence by suggestion. Far from invalidating hypnosis, the power of suggestion could be investigated scientifically and accepted as a bona fide therapy. Freud (1856–1939) had studied briefly with Charcot in 1885–6 and became enthusiastic about new possible treatments for hysteria. Freud’s mentor, a respected Viennese physician, Josef Breuer (1842–1925), had described the treatment of a young woman who suffered from an array of marked hysterical symptoms. Instead of suggesting disappearance of the symptoms, Breuer had encouraged Anna O (the pseudonym given to her) to talk freely about her life under hypnosis. She did so and over time began to share memories about her father’s illness. Breuer noted that after each session, his patient became less distressed and her symptoms improved. Anna herself referred to this approach as her ‘talking cure’ or ‘chimney sweeping’; Breuer termed it ‘catharsis.’ Whereas Charcot had described physically traumatic events as possibly causal, in his hysterical patients, Breuer and Freud’s interest focused on psychological trauma such as humiliation and loss. Freud also became less keen on applying hypnosis.

Their volume, Studies in Hysteria, which included the case of Anna O, and four others treated by Freud himself, also contained ideas on defense mechanisms and an account of various techniques including suggestion, hypnosis, and catharsis. Most importantly, however, was the new concept of ‘free-association’: the patient was instructed to disclose whatever came into their mind, without any censoring, while the analyst adopted an attitude of ‘evenly-suspended attention’ in listening to and interpreting the material.

On the basis of his subsequent self-analysis and further clinical experience, Freud elaborated his theory of infantile sexuality. Sexual fantasies in young children centered around the triangular relationships of love and rivalry with their parents (the Oedipal complex). Promoting free association of this theme, as well as of dreams, slips of the tongue, and other unconsciously-based thoughts, feelings, and fantasies, Freud emphasized the centrality of the complex in the neuroses. While catharsis and insight (making the unconscious conscious) seemed pivotal to therapy, Freud soon realized that other factors also operated, particularly the role of transference, i.e., how feelings, thoughts, and fantasies stemming from childhood experiences and revived in current relationships are ‘transferred’ onto the analyst.

Interpretations were directed at this threefold nature of the analytic experience. The therapist’s response to transference (countertransference) led to analysts having their own personal therapy, the aim being to minimize it, and thus to be thoroughly objective in attending to the patient’s disclosures (Ellenberger 1970).

In summary then, psychoanalytic psychotherapy elaborated the following processes: the patient’s un-bridled disclosure of whatever enters his or her mind— free association; the transference of infantile and childlike feelings and attitudes to the therapist which were previously directed to key figures in the patient’s earlier life; interpretation of the transference as well as of defenses the patient applies to protect him herself and the resistance he she manifests to self-exploration; and finally, the repeated working through of the discoveries made in treatment. The ultimate aim is insight with translation into corresponding change in behavior and personality.

1. Variations On A Theme

Freud revised his theories at numerous points in his long professional life. In addition, many colleagues extended the boundaries of psychoanalytic thinking. But differences of opinion soon surfaced, some radical. The nature of psychoanalysis then, especially Freud’s intolerance of dissent, led notable figures to leave the fold and to evolve their own models on which corresponding schools of therapy were established. Jung and Adler were two foremost European dissidents; Karen Horney, Erich Fromm, and H. S. Sullivan were pioneering neo-Freudians in the US; and W. D. Winnicott and Melanie Klein were prominent in Britain (Mitchell and Black 1995).

Carl Gustav Jung is perhaps the most critical dissenter since he was clearly being groomed to take over leadership of the psychoanalytic movement. But he was also celebrated because of his own contribution. Specifically with regard to psychotherapy, he advanced the notion of ‘individuation’—the aim was to discover all parts of oneself and one’s creative potential. Jung was less concerned than Freud with the biological roots of behavior, especially infantile sexual development, but rather emphasized social and cultural factors. The role of transference was replaced by a more adult type of collaboration.

Furthermore, the unconscious for Jung is not merely the repository of the individual’s history but also a wider social history, a phenomenon Jung labeled the collective unconscious. He arrived at this notion through a study of myths, legends, and symbols in different cultures, in different epochs. That these are shared by a variety of cultures is not fortuitous but reflects cosmic mythical themes or archetypes, a salient feature of man’s collective history.

Alfred Adler (1870–1937), a Viennese physician, was like Jung a prominent dissenter. Adler joined Freud’s circle in 1902 but broke away to form his own school of ‘individual psychology’ after nine years. An important tenet concerns individual development. We begin life in a state of inferiority, weak, and defenseless, for which we compensate by striving for power and by evolving a lifestyle to make our lives purposeful. The pattern that emerges varies and may include such goals as acquisition of money, procreation, high ambition, or creativity. The drive for power and choice of lifestyle may, however, go awry in which case a neurosis results. A path is followed which leads to ineffective efforts to cope with the feeling of inferiority and assumption of a facade or false self.

Adler regarded therapy as a re-educative process in which the therapist, who serves as model and source of encouragement, engages in a warm relationship with the patient and enables him or her to understand the lifestyle he she has assumed. Unconscious determinants of behavior are less crucial than conscious ones and the term ‘unconscious’ is used only descriptively to refer to aspects of the person that are not understood by him.

Freud’s insistence on innate drives and infantile sexuality not only led to the schisms with Jung and Adler but also spurred a new generation of analytically oriented analysts to concentrate on interpersonal aspects of psychological experience. In the US, Sullivan pioneered the school of ‘interpersonal psychiatry,’ in which the therapist adopted the role of participant observer in treatment, the transference providing one opportunity to explore communication and its breakdown in the patient’s interpersonal world.

We can consider the chief features in the approach of the neo-Freudians by looking briefly at Karen Horney (1885–1952). She became disenchanted with Freud’s rigid focus on instinctual biological factors, arguing that cultural factors were more salient, as reflected in the differences in psychological development and behavior among different sociocultural groups. Indeed, behavior regarded as normal in one culture could be viewed as neurotic in another.

In line with her emphasis on culture, Horney advanced the role of parental love in the life of a young child. Children typically suffer anxiety, a consequence of feeling helpless in a threatening world. The child reared in a loving atmosphere succeeds in overcoming basic anxiety. By contrast, the deprived child comes to view the world as cruel and hazardous. An inevitable result is low self-esteem.

The task of therapy is to examine the patient’s defective patterns in relating to others. In part this is achieved through study of what transpires between patient and therapist. But there is no emphasis on transference as occurs in Freudian analysis. Therapy aims to enable the patient to move with others, by engaging in relationships which are reciprocal and mutual. Another goal is greater self-realization, with freedom from determined modes of thought and action.

While the neo-Freudians were establishing a new pathway for psychoanalysis, a group was equally innovative in the UK and France. In the UK, Melanie Klein (1882–1960), a physician hailing from Berlin, concluded from her study of children’s play that the Oedipal complex, as described by Freud, was a late expression of primitive unconscious anxieties which children experienced in the first 18 months of life. Given that these states could be reactivated in adult life, Klein labeled them ‘positions’ rather than stages of psychological development. She also supported the move away from Freud’s formulation of instincts and psychosexual energy toward one of object relations, namely the representations of the perception and experience of significant others. Similarly, transference was to be understood not only as a repetition of past or current relationships, but as evidence of relational patterns in the patient’s current internal world.

In tandem with Klein, other analysts in Britain proposed ways in which significant early relationships, particularly between infant or young child and its mother, exerted a formative influence on the developing psyche. John Bowlby (1907–90), in particular, observed that children who had suffered a prolonged separation from their mother underwent a grief experience which predisposed them to a range of psychopathology in later life. Donald Winnicott (1896–1971), a pediatrician and analyst, proposed that a mother’s attunement to her child, enabling him to feel psychologically ‘held’ and understood, was an essential ingredient for a stable sense of self. The American psychoanalyst Heinz Kohut advanced a similar concept, but highlighted the place of empathy whereby the mother functions as a ‘self object’ for the child.

Wilfred Bion, a student of Klein, suggested that the analyst functions as a ‘container’ into whom the patient projects their ‘unprocessed’ feelings and experiences; the analyst returns them later in a form accessible to him to work on. This experience is deemed to be crucial to the development of a person’s ability to examine his or her own state of mind and that of others.

Michael Balint, an analyst at the Tavistock Clinic, worked along similar lines to Winnicott, focusing on the opportunity for the patient to ‘regress’ in the safety of the therapeutic relationship to a state of mind in which differentiating between patient and therapist may blur. The features of the encounter—its regularity, predictability, and the therapist’s empathic attitude—creates circumstances for such regression which can then be used to examine and alter defense mechanisms.

These models have implications for practice in that the therapist expresses moment-to-moment empathic understanding of the patient’s inner experiences and as this is repeated time and again the process promotes the evolution of a coherent identity.

Jacques Lacan (1901–81), the maverick French analyst, claimed a ‘return to Freud,’ his early work in particular, but through the prisms of semiotics and linguistics. These disciplines, he contended, do not see language as a value-free means to express ideas and convey meaning but as a system of signs that communicate symbolically tacit rules and power arrangements. Language imposes on the child awareness of a separateness from its mother who represents a fantasized internal object (the imaginary mother), in whose eyes the child mirrors itself in an attempt to achieve a state of psychological unity. Lacan’s controversial proposals regarding variable duration of treatment and trainees themselves determining their competence to qualify as psychoanalysts led to his expulsion from the International Psychoanalytic Association, albeit with a dedicated following.

Humanistic experientially oriented schools of therapy became popular in the 1960s and 1970s, mainly in the US. Their chief features were: challenging patients with the way they avoid emotionally significant matters in the ‘here-and-now’; increasing awareness of nonverbal aspects of communication; facilitating emotional arousal; and providing a forum in which patients were encouraged to experiment with new behaviors.

Some of these schools have incorporated aspects of psychoanalytic theory. Transactional analysis, for instance, makes playful use of the concept of ego states, represented as parent, adult, and child; primal scream therapy is predicated on heightened arousal of the purported emotional trauma of birth; and psychodrama encourages people to enact their conflicts by personifying various roles in their psychological lives.

The most influential humanistic school has been the client-centered therapy of Carl Rogers, although it has been absorbed into psychotherapy generally and not always with appropriate acknowledgment. Its premise is that if the therapist creates an atmosphere that is nonjudgmental, empathic, and warm, people can realize their potential for self-expression and self-fulfillment.

Feminist-based psychotherapies, still evolving since the 1980s, reflect a range of opinion from those which condemn Freud as a misogynist who deliberately recanted his discovery of the actuality of childhood sexual abuse, to those who appreciate his linkage of life experience, innate drives, and corresponding defense mechanisms in influencing vulnerability to psychopathology (Elliot 1991, Appignanesi and Forrester 1992). The latter point of view, echoing a broader debate within psychoanalysis of the respective roles of internal and external reality, has led some feminist therapists to stress social reality, and others to stress physical reality.

2. The Development Of Other Modes Of Psychotherapy

Our focus, hitherto, has been on psychotherapy of the individual patient. The second half of the twentieth century saw the evolution of treatments conducted with more than one person: groups of strangers and families. In this section, we provide a brief account of the development of these two modes.

Although therapy of stranger groups was experimented on early in the century, it was not until World War II that major developments ensued. The exigencies of war were the spur in that the group format proved highly economical for dealing with huge numbers of soldier-patients. The Northfield Military Hospital in the UK was a center of remarkable innovation, led by psychoanalytically oriented therapists like Wilfred Bion and S. N. Foulkes. Bion’s (1961) influence pervaded subsequent work at the Tavistock Clinic, while Foulkes (1965) was the founding father of the Institute of Group Analysis (both in London).

In the US, the move to the study of group process was spearheaded by social psychologists, particularly Kurt Lewin. A national center was established to train people in human relations and group dynamics. Participants from diverse backgrounds studied group functioning in order to act more effectively in their own work settings. Paralleling the human potential movement in the 1960s, the group movement transferred its focus from group to personal dynamics, and before long the encounter group movement had evolved with its thrust of promoting greater selfawareness and personal growth. Encounter groups became widespread during the 1960s and 1970s but after an initial fervor, declined both in terms of membership and appeal.

Formal group therapy under professional leadership then assumed a more prominent role. The most popular model was fathered by Irvin Yalom who drew upon an interpersonalist approach, one originally molded by Harry Stack Sullivan who proposed that personality is chiefly the product of a person’s interaction with other significant people. Yalom pioneered the study of therapeutic factors specific to the group rather than following the pattern of transposing psychoanalytic or other theories from the individual setting. His Theory and Practice of Group Psychotherapy (Yalom 1995) became exceedingly influential, attested to by the appearance of four editions.

Constrained perhaps by Western medicine’s focus on the individual patient, psychiatry was slow to develop an interest in the family (Gurman and Kniskern 1991). Scattered through Freud’s writings are interesting comments about family relationships and their possible roles in both individual development and psychopathology. His description of processes like introjection, projection, and identification explained how individual experiences could be transmitted across the generations in a family. Influenced by the work in the UK of Anna Freud, Melanie Klein, and Donald Winnicott, the child guidance movement developed a model of one therapist working with a disturbed child and another with the parents, most often the mother on her own. The two clinicians collaborated in order to recognize how the mother’s anxieties distorted her perception and handling of her child, which were added to the child’s own anxieties.

Things took a different turn in the US. There, Ackerman (1958) introduced the idea of working with the family of a disturbed child using psychoanalytic methods in the 1950s. An interest in working with the family, including two or more generations, arose concurrently. Thus, Murray Bowen (1971) found that the capacity of psychotic children to differentiate themselves emotionally from their families was impaired by the consequences of unresolved losses, trauma, and other upheavals in the lives of parental and grand-parental generations.

Boszormenyi-Nagy and Spark (1984) also addressed this transgenerational theme by describing how family relationships were organized around a ledger of entitlements and obligations which conferred upon each participant a sense of justice about their position. This, in turn, reflected the experience in childhood of neglect or sacrifices for which redress was sought in adult life.

Bowen also introduced the principles of Systems Theory into his work but it was Salvador Minuchin, working with delinquent youth in New York, who highlighted the relevance of systems thinking to their interventions. The youngsters often came from emotionally deprived families, headed by a demoralized single parent (most often the mother) who alternated between excessive discipline and helpless delegation of family responsibilities to a child. Minuchin’s Structural Family Therapy deploys a series of action- oriented techniques and powerful verbal metaphors which enable the therapist to join the family, and to re- establish an appropriate hierarchy and generational boundaries between the family subsystems (marital, parent/child, siblings).

Another major development took place in Palo Alto, California, where a group of clinicians gathered around the anthropologist Gregory Bateson (1972) in the 1950s. They noted that implicit in communication were meta-communications, which defined the relationship between the participants. Any contradiction or incongruence carried great persuasive, moral, or coercive force and formed part of what they labeled a ‘double-bind’; they proposed this as a basis for schizophrenic thinking.

All these system-oriented views assume that the family is a system observed by the therapist. However, therapists are not value-neutral. They may take an active role in orchestrating change in accordance with a model of family functioning. Yet these models ignore therapists’ biases as well as the relevance of their relationships with families. This probably reflected the determination of some American family therapists to distance themselves from psychoanalytic theory, and also led them to neglect the family’s history, how it changed throughout the lifecycle, and the significance of past traumatic and other notable life events.

In response to these criticisms there was a move away from the problem-focused approach which had characterized most behavioral and communication views of psychopathology. The Milan school (1980) whose founders were psychoanalysts developed a new method of interviewing families in conjunction with observers behind a one-way screen formulating and then presenting to the family and therapist hypotheses about ‘their’ system.

Family therapists also began to consider that families might be constrained from experimenting with new solutions because of the way they had interpreted their past experiences or internalized explanatory narratives of their family, the expert’s, or society at large. This led to a shift from considering the family as a social to a linguistic system.

The narrative a family conveys about their lives is a construction which organizes past experience in particular ways; other narratives are excluded. When a family with an ill member talks to a professional, conversations are inevitably about problems (a problem-saturated description). The participants ignore times when problems were absent or minimal, or when they successfully confined problems to manageable proportions. A different story might be told if they were to examine the context that might have led, or could still lead, to better outcomes.

A number of narrative approaches have applied these concepts. Philosophically, they align themselves with postmodernism, which challenges the notion of a basic truth known only by an expert.

Many criticisms of systems approaches have been leveled including:

(a) Disregard of the subjective and intersubjective experiences of family members.

(b) Neglect of their history.

(c) Denial of unconscious motives which affect relationships.

(d) Although family members are reciprocally connected, the power they exert on one another is not equal; this is highlighted in the violence against women and in child abuse.

(e) Inequality and other forms of injustice based on societal attitudes toward differences in gender, ethnicity, class, and the like, are uncritically accepted as ‘givens’.

(f ) Minimizing the role of the therapeutic relation- ship, including attitudes members develop toward the therapist and her feelings toward them.

This critique has led to growing interest in integrating systems-oriented and psychoanalytic ideas, particularly those derived from object-relations theory. One variant is John Byng-Hall’s (1995) synthesis of attachment theory, systems-thinking, and a narrative approach.

A further criticism of systems-oriented approaches is that they minimize the impact of external reality such as physical disability or biological factors, in the etiology of mental illness, and sociopolitical phenomena like unemployment, racism, and poverty. One result is the ‘psycho-educational’ approach, which has evolved in the context of the burden schizophrenia places on the family and the potential for its members to influence its course. This has led to a series of interventions including educating the family about the nature, causes, course, and treatment of schizophrenia; providing them with opportunities to discuss their difficulties in caring for the patient, and to devise appropriate strategies; and helping them to resolve conflict related to the illness, which may be aggravated by the demands of caring for a chronically ill person.

3. The Scientific Era

Systematic research in the psychotherapies was a low priority for many decades; instead, practitioners’ interests focused on theory and technique. Investigation of the subject only took off in earnest in the early 1950s. A notable impetus was the critique by H. J. Eysenck (1952) in which he argued that the treatment of neurotic patients was no more effective than no treatment at all. Two-thirds of both groups showed improvement with time. In later reviews, Eysenck was even more damning: the effects of psychoanalysis in particular were minuscule. The attack led to much rancor and an extended battle between the psychoanalytic and behavioral camps (Eysenck featured prominently in the latter). Fortunately, a positive repercussion was the sense of challenge experienced by the analytic group. They had been riding high for several years, particularly in the US, and barely questioned whether their concepts and practice required scientific appraisal. Thus, although Eysenck’s interpretation of the research literature was flawed and biased, he had stirred a hornet’s nest.

Since the 1950s research has burgeoned and yielded much knowledge about whether psychotherapy works (outcome research) and how it works (process research). These developments were not without incident. Many therapists challenged the relevance of conventional research methodology to psychotherapy. A key argument was that the encounter between therapist and patient is unique, involving two people in a complex collaborative venture, and cannot be subject to the same form of scrutiny as occurs in the natural sciences. Moreover, the latter approach is necessarily mechanistic and reductionistic.

There is merit to the argument but actual research practice reveals that methodology can accommodate, at least in part, respect for the highly personal nature of psychological treatment. Sophisticated statistical procedures can also contribute to maintaining an appreciation that many characteristics in both patient and therapist are relevant, and they cannot be viewed as homogeneous groups. An illustration is the multi- dimensional measurement of outcome. Instead of restricting this to one or two variables only, several can be examined concurrently which together encompass the patients’ internal and interpersonal world, e.g., quality of life, self-awareness, authenticity, self-esteem, target problems, and social adjustment.

Another criticism of outcome research is examining effectiveness without adequate treatment being given. Duration of research-bound therapy in fact is often much briefer than in customary practice because of funding constraints. A similar objection relates to the follow-up period usually set. A robust test of effectiveness entails examining outcome one or more years following the end of therapy in order to judge clinical projects independent of the therapist.

4. The Effectiveness Of Psychotherapy

Several reviews have been conducted since the 1970s. A sophisticated method—meta-analysis—which relies on a rigorous statistical approach, points to psychotherapy overall generating benefits for patients who have been suitably selected. Encouragingly, better designed studies show positive results more commonly than inadequate ones. In one trail-blazing metaanalysis, levels of effectiveness were computed from 375 studies in which some 25,000 experimental and 25,000 controlled patients were tested (Smith et al. 1980). The average patient receiving psychological treatment of one kind of another was better off than 75 percent of those who were untreated—a clear demonstration of the beneficial effects of treatment in general.

With tens of ‘schools’ available, many of them claiming a distinctive approach, the obvious question arises as to whether some are superior in producing benefit. This question of comparative effectiveness is complicated in that not only may ‘schools’ be com- pared but also specific procedures such as setting a time limit or not or conducting therapy individually or within a group. Notwithstanding these difficulties, considering research on comparative effectiveness is worthwhile. Several reviews show a consistent pattern—that ‘everyone has won and must have prizes.’ This was of course the judgment of a race handed down by the dodo bird in Alice in Wonderland. In the psychotherapy stakes, it appears that everyone has won too, a finding probably attributable to factors common to all therapeutic approaches. These factors, set out originally by Jerome Frank (1973), include a confiding relationship with a helping person, a rationale which provides an account of the patient’s problems and of the methods for remedying them, instillation of hope for change, opportunity for ‘success experiences’ during treatment, facilitating emotion in the patient, and providing new knowledge, so promoting self-awareness. These ‘nonspecific’ factors comprise a significant theme in psychotherapy; they probably serve as a platform for benefits from all treatments.

Any consideration of effectiveness brings up the issue of harm. In other words, treatment may be for better or for worse. After a long gestation, the concept of a ‘negative effect’ attracted widespread attention from the 1970s (Hadley and Strupp 1976). A growing sense of confidence perhaps permitted therapists to be more open to a potential harmful impact.

To distinguish between a patient becoming worse because of their intrinsic condition or following an adverse life event, a negative effect has been defined as deterioration directly attributable to treatment itself. Such a causal link is difficult to prove but genuine negative effects certainly do occur. The definitional difficulty, however, leads to estimates of prevalence ranging from rare to common. The type of therapy appears to influence the rate. Evidence points to worsening in about 5–10 percent of cases in psychotherapy generally. The reasons for deterioration are not well established although a common view is that patient factors probably contribute, particularly selecting people for treatments for which they are unsuited. In this situation, refining assessment, thus enhancing clinicians’ ability to predict response to specific treatments, is deemed as helpful to reduce the casualty rate.

Another obvious facet is the therapist and/or technique. Here, inadequate training has emerged as salient, with poor judgment leading to inappropriate interventions. It has also been recognized that a proportion of therapists perform poorly because of their personality traits, no matter what their level of training or experience. In other words, the role of therapist does not suit all those who wish to practice. In a noteworthy study of different forms of encounter group, a substantial percentage of ‘casualties’ were produced by four leaders, who typically pummeled members to disclose personal information and express intense emotion.

During the half century of systematic research, attention has also been devoted to the processes that take place in the therapeutic encounter.

Process and outcome research are inevitably linked. If we can identify factors that promote or hinder effectiveness, we may be able to modify these and then note the result. The advent of recording techniques such as audio and video has facilitated studies of process and a wide range of observations of both verbal and non-verbal behavior, in both therapist and patient and their interaction, have been made. One illustration is the premise that a necessary condition for effective group therapy is group cohesiveness. It follows that anything enhancing cohesiveness could be advantageous. Compatibility between members has been proposed as pertinent and indeed been shown to relate to cohesiveness. Group therapy therefore could conceivably be more effective if, in selecting members, compatibility were taken into account. For example, a patient incompatible with all his peers would presumably not be placed in that group.

Research on process has been shown to be as salient as that on outcome since only with the study of what occurs in treatment can therapists appreciate its inherent nature and the factors for optimal improvement of participants. Diligent process research has provided solid foundations for establishing hypotheses about outcome.

We have dealt in general terms with the theme of psychotherapy research. The second half of the twentieth century has been a fertile period and seen much achieved; to do it justice is beyond our remit. The interested reader is recommended to consult the four editions of the Handbook of Psychotherapy and Behavior Change (Bergin and Garfield 1994) which has served the field in distilling work done and providing a critique of its quality.

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