History of Psychology Session 9: Psychotherapy Research PDF

09Psychotherapy research Montag, 18. November 2024 08:10 Reading chapter 3 Integrative/Holistig/eclectic Therapy Client centred- who guides the session? Therapist/client?...

09Psychotherapy research Montag, 18. November 2024 08:10 Reading chapter 3 Integrative/Holistig/eclectic Therapy Client centred- who guides the session? Therapist/client? HISTPSY_S9 Outcome research- does it work on the patient? _Psychot... Process research- already clear that iw works so thw question is how it works? Mechanism? -> there alsways hast to be outcome research to get process research Effectiveness vs. Efficancy Efficacy refers to the performance of an intervention under ideal and controlled circumstances. Effectiveness refers to the performance of an intervention under real-world conditions. (KI antwort) Joseph wolpe -> placeable in behaviourism Hans Eyseneck reading s 660 plus minus Systematic review-> Follow Prisma guideline-> go into established databases Metanalysis Quantify info? Common factors theory wichtig - Key common factors Align of therpist and client Empathy Belief of the patient summary Seite 1 summary Seite 2 summary Seite 3 summary Seite 4  Reading summary General facts - 4 phases of history of psychotherapeutical research - There are 2 controversities in psychotherapy until today ist positivism & operationalism vs. Structuralism, phenomenology and hermeneutics The approaches differ in their episemologal pre -assumptions -> meaning some go with rationalism some with empiricism -> toady there are increasingly more attempts to combine the approaches (combination started with proposal of Kant) => this increase of combiantions aims synergetic effets & taking position of methodological plurality => methodological pluralism (variety of research methods combined- moving behind traditional emphasis of falsification(was sich im ganzen semster durch die verscheidenen schulen zog bzw. die kritiken und wiederspruche fallen weg)) Phase 1- birth of psychotherapy research (1900s-1940s) In the 18th century the first roots of reflection on psychotherapeutic methods came up f.e. philosophers like Moritz founded the Journals "Seelenheilkunde" , journal of psychology from experience But the first phase considered as the birth was 100 years later when Bernheim introduced the term "psychotherapy" 1840-1919) Also a famous step in the beginning of psychotherapy were Freuds & Breuers studies on hysteria (Start of psychoanalysis career of Freud) 1895 - clinical case studies The hsyteria study contained a number of case studies reflected from a neurophysiological and psychological point of view. Siehe psychoanalysis zsm fassung 1920-40 Publications about psychotherapy increased Coming to 1950 concerns of psychotherapy included patient and therapist characteristics, process of psychotherapy, common treatmet factors -> now also possible limitations of psychotherapy were increasingly perceived and observed Outcome research - (30 years after freuds studies on hysteria) first statistic - based outcome studies were published in 1920s - Lancet- one of the most influental journals in the field of medical research - Effects of eysenecks attack were no allow for deep interpretations or broad generalization increased - psychometric scaling was used as a means of quantifying phenomena after Thorndike(law of effect)-> but he took an acerbic position in positivism which was criticized in later stages Roots of process outcomme research: revoulution sound recording/ sequential process research Psyhotherapy as corresponding appications of science of the mind -> meaning at the same time theoretical allegiance to the ideal of natural science -> following the positivism paradigm= objectivity, repliccability etc. Root of process research -> Beginning of systemtic phonographic recordings of sessions Invented/ inspired by Rogers -> first case of herbert bryan = fully transparent psychotherapeutic case ever published Rogers tried to find approach to illuminate the arcane caracteristics of therapeutic summary Seite 5 summary Seite 6  stages Roots of process outcomme research: revoulution sound recording/ sequential process research Psyhotherapy as corresponding appications of science of the mind -> meaning at the same time theoretical allegiance to the ideal of natural science -> following the positivism paradigm= objectivity, repliccability etc. Root of process research -> Beginning of systemtic phonographic recordings of sessions Invented/ inspired by Rogers -> first case of herbert bryan = fully transparent psychotherapeutic case ever published Rogers tried to find approach to illuminate the arcane caracteristics of therapeutic sessions -> started with: - classifications of therapist responses (f.e. questions, information giving, interpreting) - Categorizations of "directive" and "nondirective" therapist behaviour First sequential process research study Published by sydner, under supervision of rogers Responses of patient and therapist were rated ! Important outcomes: acceptance and clarification of feelings led to a higher degree of client insight than questioned and interpretations by the therapist Roger as pioneer in this kind of research They invented a new genre based on their results -> the process-outcome research (= sampling of key therapy process variables used to predict post-therapy outcome) Developments and achievements in this phase -> outcome research was refined (thanks to Eyseneck) but studies still relied strongly on a (post) positivistic model -> therapeutic sessions did a new step The catalyt effect, eysenec Phase 2 (1950s-60s) Clinical case studies becam 1950s immense growth in psychotherapy research increasing sample sizes) One of the critiques was Ey -> he asserted(behauptete) The second phase was therefore very much characterized by the aim of - that empirical researc justifying the psychotherapeutic profession through research. Moreover, this nore efficacious than n phase was characterized by a proliferation of process studies, especially by - That recovery of psych client-centered researchers, aiming at the validation of Rogers’ necessary and sufficient factors for therapeutic change (Rogers 1957) Luborsky rejoinder of e The catalyt effect evoking the work at ti -> referring to more supportive data Rosenzweig (Dodo bird -> still not enough solid evidence concerning the general efficacy of Replied to Eyseneck, c psychotherapy and standards of reco Evaluated Eysenecks c Bergins review and scrutiny of datawas a key event for eysenecks attack, as a questionable- b.c. of lo examplary model why he started the attacks ( The surprising part of Bergin’s control group results was the observation that therapists could be divided into two groups: one producing positive and another producing nega tive results. ) Nevertheless Eysenecks att psychotherapy research At the beginning of this period (phase2) logical positivism(= logical empiricism) was still in the focus Criticism: Current views criticize this for not providing deep insights into changes in experience and behavior. Methodology: Emphasis on nomothetic group designs and statistical analyses, which were key in process and outcome research. Observers' Role: Seen as scientifically trustworthy, but this is now considered insufficient. Phase Focus: The second phase was more about justification in research methods, not necessarily aligning with researchers' personal beliefs. Initial conferences and Reorganization of the field the APA organzied 3 initial conferences (1958,1962,1966) -> major aims of the very initial conference were a) the evaluation of the state of the art of psychotherapy research b) the stimulation of research (one participant was Carl Rogers) Results of the conferences were significant for the communitiy Reorganization of the field Field of psychotherapy in the 1960s was influenced by upcoming behaviour therapy Unfortunately the recent psychotherapical method and behavioural theory weren't compatible (dif. Clinical theories,&research models) -> so both methods developed quite distand from another : The growth of the field revealed the need for new organizational structures that resulted in two split branches: - On the one hand, the provisions of Kenneth Howard and David Orlinsky found their culmination point in the first meeting of the Society of Psychotherapy Research (SPR) - On the other hand, ten behavioral therapists founded the Association for the Advancement of Behavior Therapy (AABT) (few examples: Joseph Wolpe, john paul brady, andrew salter…) -> b.c. of development of behavioural therapy AABT was renamed twice, current name: Association for Behavioral and Cognitive Therapies (ABCT) The gap of these two methods can still be sensed today Outcome research in phase 2 activities of outcome research in this phase were closely linked to the necessity of producing convincing rejoinders to Eysenck’s provocative statements. some behaviourally oriented researchers used single case studies to support the influence of their treatments methods … …But major portion of research activities focused on: refinement and application of controlled experiments aim was to prove efficacy of psychotherapeutic interventions compared to control conditions -> Developmental steps: - Consequence of the context justification (Folge des Rechtfertigungskontexts) -> experimental desings were lacking (no randomized assignment, no clinical groups, just Quasi experimental & pre-post-follow up designs -> consiting of personality and psychopathology as outcome variables) - Analogue research designs(quite prominent at time) fostered the shift from survey research("Umfragen") to quasi-experimental controlled designs(i.e., because of design economy and avoidance of ethical constraints) -> but it was heavily criticized for removing studies too far from the clinical situations to allow any meaningful conclusions for the psychotherapeutic practice Nowdays single controlled experiments are not appropriate (most appropriate to quasi experiments here) Process research in phase 2 - Important for research process was development of objective measures f.e. counting of self references in verbal behaviour , tought units and chronological periods were analyzed in the sense of process variables -> Rogers additionally traced patients thematic patterns across sessions and changed in patients the client sense of self as matter of interest - Immense ammout of recorded sessions led to necessary delevopment of approaches toward time sampling (Zeitstichprobe) - Average calculation served as estimation(schätzung) for specific aspects of the process Critique: - process often seemed to be far from clinical experiences - the underlying theoretical pre-assumptions nevertheless stated an important approach, which provided a basis for the development that followed In 1960s client-centred researches were dominant -> primarily they tried to validate rogers conditions for therapeutic personality change ->BUT: Rogers made also use of nonparticipant -observational measured (at least partly based upon bias(Verzerrung) of positivism Process-outcome research phase 2 STUDY: As to the field of psychoanalysis, in the mid-1950s Karl Menninger,anAmerican psychiatrist and founder of the Menninger Clinic, initiated an impressive 30-year longitudinal process outcome study to investigate the psychoanalytic treatment of 42 patients. Mainly, two questions were addressed during the research process: What changes take place in psychotherapy? and how do those changes come about? The investigation was realized by taking three major cross-sectional perspectives (“initial, termination, and follow -up study”). In addition, the patients’ personality organization and life situation as well as the therapeutic process were taken into account. Various additional publications arose from the Menninger Project, dealing with facets of the study like psychological testing (Appelbaum 1977), the role of situational variables, factor - analytic aspects (Kernberg et al. 1972), and individual prediction of thera peutic success (Horwitz 1974) Client therapist factors Transition Phase I to II: Focused on client characteristics (age, sex, race, etc.), developmental experiences, personality, and socioeconomic status's influence on psychotherapy outcomes. Contradictory Results: This period's findings were often inconsistent, raising numerous questions. Therapist Characteristics: Increasing interest in how therapist traits, such as psychopathology, affect outcomes; therapist psychopathology hindered therapeutic efficacy. Complex Models Needed: The 1950s highlighted the need for more complex models incorporating client-therapist interactions, leading to extensive process -outcome research in subsequent decades. Major developments and achievements Pilot Status of Studies: Early research was seen as naive for focusing only on quantitative variations but was necessary for refining systematic research. Complex Relationship: Findings suggested a complex relationship between process and outcome, leading to calls for further investigation. Pre-Post Follow-Up Designs: Developed in response to Eysenck’s criticism, using elaborate measures, interviews, and tests. Landmark Volumes: Important research titles included terms like "evaluation" and "effective psychotherapy," reflecting the period's focus. 1950s Research: Shifted from simple case studies to complex experimental controlled studies, advancing process research significantly. Fulfilled Promise: The period successfully built up the scientific field of psychotherapy, with ongoing expectations for major developments and changes Phase 3 (1970s-1980s) Refinement and challenge of the mainstream - Task of this period: expansion and refinement within the methodological mainstream of process and outcomeresearch - Main achievement: convincing answer to eysenecks criticism that psychotherapy works - Meta analysis as new statistical technique - New concepts & methods for process -outcome studies Negative effects and accountability -> researchers became concerned with negativ effects of psychotherapeutic treatment Bergin: - Pioneer dealing with the topic of reanalyzing cases with minor changes in treatment outcome studies. Issue of accountability (Rechenschaftspflicht) -> key consideration for psychotherapists and researchers (in 1970s) Scope of community - this phase was very important for the scope of the community in a concrete sense because, the collegial communication was outstandingly supported by the creation of the Society for Psychotherapy Research (SPR) in 1970 and the Advancement of Behaviour Therapy (AABT) in 1966 So the expert exchange was essencial at time Outcome research in phase 3 -> search for therapeutic approaches (based on the proof that psychotherapy works phase 1&2) - proliferation(verbreitung) of different therapeutic models -> increasing accomplishment of comparative outcome studies ->ambitions for the design of randomized con trolled trials (RCTs) emerged At 1970s psychotherapy adopted RCT designs Treatment of depression TDCRP Launch: The Treatment of Depression Collaborative Research Program (TDCRP), coordinated by Irene summary Seite 7 ck 1950s me more criticized (needed more systematc clincial surveys with ysenecks attack on the effects of psychotherapy in general ): ch did not support the claim that psychotherapeutic approaches were neural conditions hopathology was just reflecting spontaneus remission rates eysenecks ideas , starting point of his career with eysenecks critique ime and working in eysenecks controll groups rd verdict) criticized the different standards of severity(ernsthaftigkeit) of illness overy in his empirical data. comparison to be little validity and his generalizations to be highly low resemblance in the standards for the experimental and the tack had huge impact / catalyst effect on development of summary Seite 8  Outcome research in phase 3 -> search for therapeutic approaches (based on the proof that psychotherapy works phase 1&2) - proliferation(verbreitung) of different therapeutic models -> increasing accomplishment of comparative outcome studies ->ambitions for the design of randomized con trolled trials (RCTs) emerged At 1970s psychotherapy adopted RCT designs Treatment of depression TDCRP Launch: The Treatment of Depression Collaborative Research Program (TDCRP), coordinated by Irene Elkin, marked a significant methodological advancement in psychotherapy outcome research. Study Design: It featured a collaborative, multisite, controlled, comparative trial with a large sample size, investigating cognitive therapy and interpersonal psychotherapy for depression compared to psychopharmacological treatments. Methodological Advancement: The TDCRP aimed to determine the feasibility of multisite clinical trial designs in psychotherapy, previously used in psychopharmacology. Research Balance: Elkin balanced rigorous research methods with the complex human aspects of psychotherapy, allowing for the investigation of key theoretical and practical questions beyond efficacy issues. Legacy: The TDCRP's design and data collection provided a valuable foundation for future research in psychotherapy. Meta analytic strategies -> this milestone in outcome research -> like this activities of phase 1 &2 were strenghtened in their function as rejoinder to Eyseneck -> with this era new research interests arised based on the new methods f.e. outcome measures and single case experimental approaches using Process and Process outcome Reseach phase 3 1. Working alliance(=conceptualized as a construct with distinguish able components; research activities intensively focused on this concept, including the construc tion and application of new instruments in pro cess research) In the middle of the 1970s, Bordin (1979) offered a reformulation of the therapeutic relationship, and the term “working alliance” 2. Kieslers Influence (1980s) - Kiesler assumed that the development and main tenance of individuals’ patterns of behaving and experiencing are mainly influenced by interpersonal relationships through patterned interaction styles. - Published "the process of psychotherapy: empirical foundations and systems of analysis" - communicated significant methodological advances and the refinement of measurements in the field of process research - Equivalent to outcome measuring of waskow and parloff(phase 3 outcome research) - Kiesler created a new conceptual and methodological basis for analyzing the therapeutic relationship by developing an observational system based upon his circumplex model - constitutive milestone for process research, in the form of offering a comprehensive, precise theoretical model, a circumplex providing an interpersonal circle taxonomy as well as major methodological advancements, namely, the development of the Impact Message Inven tory (IMI=measures impacts corresponding to the interpersonal circle cate gories;used in research on interpersonal elements of depression, personality…) and Checklist of Interpersonal Trans actions (CLOIT=rather focused on interpersonal transactions in therapy like metacommunication, patient-therapist matching, countertransference, and therapeutic alliance) - Published article: "some myths about psychotherapy research and the search for a paradigm" -> summarized rejoinders to Eysenck and designed the type of research that was needed to refute Eysenck’s provocations - Another fundamental contribution of Kiesler was the refutation of the spontaneous remission myth, stating a direct counterreaction to Eysenck’s claims Kiesler Eyseneck - One example for the currency of the impact of Kiesler’s model on research and clinical practice is the cognitive behavioral analysis system of psychotherapy (CBASP), developed by James McCullough for patients suffering from chronic depression - He also worked with Rogers back in the days Major Achievements & developments Major Achievements in Phase III : Refinement of research questions and methods, leading to more concise and detailed issues. Meta-Analytic Strategies: Enabled summarizing a large body of outcome studies, stabilizing evidence for psychotherapy effects. Freedom for Researchers: With less focus on justification, researchers challenged mainstream approaches, especially in process and process -outcome research, and pursued more creative questions and method developments. Phase 4 (1990s- now) From verification to discovery informed by contructivism -imterpretivism Shift in Focus: The fourth phase marked a shift from verification to discovery, highlighted by increased use of qualitative research and exploration of process -outcome relations through linear and nonlinear models. Constructivist-Interpretivist Paradigm: Emphasized individual understanding and subjective experiences, rooted in philosophical hermeneutics and phenomenology. Key Topics: Client and therapist variables, treatment selection and placement, and bridging the gap between research and clinical practice gained more attention. Critical View on Simplicity: Researchers acknowledged the need to move beyond simplicity, stressing the importance of context variables and the complexity of therapist -patient communication. Significant Positive Effects: Having demonstrated the efficacy of psychotherapeutic interventions, the focus shifted to understanding how these effects are achieved, closely linking process and outcome variables. Ongoing Questions and Controversy : The phase is characterized by ongoing critical discussions on different scientific philosophies, methods, clinical significance, and growth models, highlighting the complexity and ongoing evolution of the field. The shift of paradigms -> qualitative Reseach was confirmed Qualitative research in general aims at a deep understanding of human behavior, which especially asks the question of why people behave in a certain manner. This means that instead of verification and generalization, discov ery is a major aim. This implies: a) a critical view on traditional quantitative research designs b) the advancement of new research paradigms Despite the permanent but slowly increasing relevance of qualitative paradigms in psycho therapy research, still a disbalance in favor of the quantitative approaches can be observed Outcome Research phase 4 Skepticism Toward RCTs: Researchers noted that treatments effective under controlled conditions (RCTs) didn't always work in naturalistic settings, fueling skepticism toward RCTs. Shifted focus from efficacy (controlled conditions) to effectiveness (natural conditions), emphasizing external validity and generalization. Statistical vs. Clinical Significance : Debate arose over the importance of statistical vs. clinical significance. Suggested using critical scholarship and thoughtful debate to define clinical significance. Two main approaches for measuring clinical significance: 1. Statistically reliable changes after treatment. 2. Empirical distinction from "normal" controls. The Reliable Change Index (RCI) was introduced as a valuable measure of clinical significance. Both topics emphasize the need for more realistic and meaningful assessments of psychotherapy effectiveness Process and Processoutcome Research in Phase 4 Psychological Processes Instead of Diagnoses: During Phase IV, the focus shifted from diagnostic categories to underlying psychological processes. Standard diagnostic classifications were criticized for oversimplifying case conceptualizations and ignoring relevant predictive variables. Emphasis was placed on variables like cognitive functions, emotional regulation, personality structure, and attachment history. Elaborated Quantitative Analytical Methods: New quantitative methods focused on session patterns and longitudinal perspectives. Techniques like growth curve analysis, dynamic factor analyses, and multivariate time series analyses became prominent. These methods addressed the temporal dimension of psychotherapy, aiming to understand changes in emotions, cognitions, and behavior over time. The Qualitative Helpful Factor Design: Qualitative research methods influenced process-outcome research, leading to the development of the qualitative helpful factor design. Two main methods: qualitative change interviews (focusing on client experiences) and the helpful aspects of therapy form (post-session questionnaires). These methods provided insights into immediate and delayed effects of therapeutic change. The Task-Analytic Approach: Rice and Greenberg challenged the mainstream approach of homogeneous group investigations. They emphasized focusing on specific change events within sessions and identifying markers of client and therapist behavior. This approach led to a paradigm shift in process-outcome research, highlighting the complexity of human experience and therapeutic processes. Major developments and achievements Intensive Deepening of Process Research: The fourth phase is marked by a deepening of process and process-outcome research. Emergence of qualitative and mixed-method approaches, enhancing both justification and discovery in psychotherapy research. Key Research Areas: Client-Therapist Interaction: Analysis of factors like mutual therapeutic engagement, therapeutic negotiation, undirected client reminiscence, and sustained therapist work. Working Alliance: Identified as the most robust influence on therapeutic outcomes, particularly from clients' perspectives. Methodological Advances: Focus on dynamics at the microlevel (e.g., in-session level). Development of adaptive prognoses, allowing for more precise predictions based on process characteristics. Emphasis on recovery curves for treatment optimization and avoiding negative effects. Modern Trends: Studies now include online psychotherapy and follow-up care via email, reflecting the rapid growth of internet usage in everyday life. Birth and development of Common factors Saul Rosenzweig: Saul Rosenzweig (1907–2004): An American psychologist who introduced the concept of common factors in psychotherapy, emphasizing their importance over specific therapeutic techniques. Key Factors: Suggested factors like catharsis, the therapist's personality, and the consistency of the therapeutic doctrine as crucial for client recovery. Therapeutic Equivalence: Argued that the success of different therapeutic approaches indicates that therapeutic results are not reliable guides to the validity of theories. Historical Research: Rosenzweig's work included historical research on the precursors of psychotherapy, noting similarities in healing concepts. Dodo Bird Metaphor: Introduced the metaphor from "Alice’s Adventures in Wonderland" to illustrate the equivalence of different psychotherapeutic treatments. Heine (1953): Supported Rosenzweig’s ideas, suggesting that theoretical approaches are less important than the therapist and advocating for the development of a single, integrated psychotherapy. summary Seite 9  Bergins article summary Seite 10  Therapeutic Equivalence: Argued that the success of different therapeutic approaches indicates that therapeutic results are not reliable guides to the validity of theories. Historical Research: Rosenzweig's work included historical research on the precursors of psychotherapy, noting similarities in healing concepts. Dodo Bird Metaphor: Introduced the metaphor from "Alice’s Adventures in Wonderland" to illustrate the equivalence of different psychotherapeutic treatments. Heine (1953): Supported Rosenzweig’s ideas, suggesting that theoretical approaches are less important than the therapist and advocating for the development of a single, integrated psychotherapy. Medical Model vs. Contextual model: Medical Model: Concept: Assumes disorders can be explained and treated through specific mechanisms of change. Focus: Particular therapeutic interventions are seen as the cause of positive outcomes. Analogy: Comparable to treating diseases in medicine with specific substances or "ingredients". Specificity: Refers to the unique effects of particular treatments. Contextual Model: Origin: Proposed by Jerome Frank. Concept: Emphasizes contextual factors like the therapeutic relationship, healing environment, and the rationale provided to the client. Common Factors: These are seen as crucial for clinical change and are common across different psychotherapies. Application: Techniques and ingredients are necessary to create a credible and hopeful treatment setting for the client and a confident framework for the therapist. Common factors The First Common Factor Model: Saul Rosenzweig (1936): Introduced the concept of common factors in psychotherapy, emphasizing their importance over specific therapeutic techniques. Jerome Frank (1961): Published a book on common factors across various mental healing approaches, identifying key factors like emotional confiding relationships, healing settings, rationales, and rituals. Gap in References: Subsequent developments in common factor models often failed to credit Rosenzweig, despite his foundational work. The Very First Panel on Common Factors (1940): Organized by Goodwin Watson: Emphasized the importance of the fitness of psychological interpretations for specific clients. Carl Rogers and Rosenzweig: Both presented ideas, with Rogers later referencing Rosenzweig in his work. Evidence for Common Factor Models: Intertwined with Medicine: Psychotherapy's development closely linked with medicine, though specific treatment methods' superiority may be historically rather than scientifically justified. Current Research: Emphasizes a core set of pan-theoretical factors that transcend different approaches, with specific treatment models accounting for only a small variance in outcomes. Contextualization of Common Factors: Recent approaches focus on the dynamic and interdependent nature of common factors within the therapeutic process. Working Alliance Predictor of Outcome: A positive client-perceived alliance, especially formed early in therapy, strongly predicts therapeutic outcomes. Therapist Factors Impact: Successful therapists make better use of common factors and contribute more effectively to the therapeutic alliance. Variability in therapist efficacy is linked to their ability to build and maintain this bond. The Rationale Importance: A well-communicated rationale for treatment helps clients accept and engage in therapy, enhancing its effectiveness. Techniques serve as general healing factors by creating a structured treatment setting. Client Factors Neglect and Importance: Clients' strengths, readiness to change, hope, social support, and life events are crucial but often overlooked in research. Therapy should be tailored to individual client needs. Integrative Approaches Development: Integrative therapies combine strategies from different schools, focusing on severe symptomatology or personality disorders. Examples include cognitive analytic therapy, mindfulness-based cognitive therapy, and dialectic behavior therapy. FUTURE PERSPECTIVE: Future Perspectives in Psychotherapy Research: Research Methods: Further refinement of quantitative and qualitative methods to consider contextuality and time dependency of change processes. Mixed-Method Approaches: Promoted to unify strengths of both quantitative and qualitative research. Common Factor Research: Enhancing methodologies for studying common factors in psychotherapy. Intercultural Issues: Need for more empirical research on the role of cultural characteristics in psychotherapy. Evaluation Designs: Development of adequate evaluation designs for psychotherapy delivery systems. Shift in Theories: Moving away from dominant theories towards more pragmatic, case- specific approaches. Collaborative Efforts: Emphasis on the role of creative and interconnected researchers in advancing the field. summary Seite 11 summary Seite 12 summary Seite 13 summary Seite 14 summary Seite 15 summary Seite 16 summary Seite 17 summary Seite 18 summary Seite 19 summary Seite 20