The equivalence of psychodynamic therapy and cognitive behavioral therapy for depressive disorders in adults: A meta-analytic review

BACKGROUND

Meta-analyses on the relative efficacy of psychodynamic psychotherapy (PDT) and cognitive behavioral therapy (CBT) for depressive disorders are limited by heterogeneity in diagnostic samples and comparators and a lack of equivalence testing.

OBJECTIVE

We addressed this through a meta-analytic test of the equivalence of manualized PDT and CBT in treating adults with depressive disorders as determined by diagnostic interviews. Sensitivity analyses evaluated the impact of pretreatment differences, mixed diagnostic samples, author allegiance, study quality, year of publication and outliers on findings.

METHOD

A comprehensive literature search across multiple databases using reliable screening methods identified nine randomized controlled trials directly comparing manualized PDT and CBT for diagnosed depressive disorders in adults. Following pre-registration, we employed random effect models for our meta-analyses and two one-sided test procedures for equivalence testing.

RESULTS

Independent raters determined that all studies were of adequate quality. Immediately posttreatment, depressive symptoms were statistically equivalent across PDT and CBT (k = 9; g = -0.11, 90% confidence interval [90% CI]: -0.24 to 0.02, pequivalence = .048, pNHST = .212, I2 = 32.7). At follow-up, the longest time point within a year, depressive symptoms were neither statistically equivalent nor statistically different (k = 6; g = -0.16, 90% CI: -0.31 to -0.02, pequivalence = .184, pNHST = .126, I2 = 0.00).

CONCLUSION

The efficacy of manualized PDT is equal to manualized CBT immediately at posttreatment for depressive disorders in the adult general population. Nevertheless, insufficient data exists to reach a conclusion regarding equivalence at follow-up.

CBT Meets Process: Assimilative Integration with Reference to Group Psychotherapy

This paper offers a brief overview of the historically predominant form of psychotherapy research both for individual and group psychotherapies, the randomized control trial (RCT), and its surrounding controversies and critiques as the backdrop from which new directions in both clinical theory building and research are being pursued, including efforts at building integrative models of treatment. The paper explores one promising integrative model, namely the incorporation of process and dynamic orientations into the province of group cognitive behavioral therapy (CBT) and identifies challenges in implementing this model.

The absurdity of the latent disease model in mental health: 10,130,814 ways to have a DSM-5-TR psychological disorder

BACKGROUND

Latent disease classification is currently the accepted approach to mental illness diagnosis. In the United States, this takes the form of the Diagnostic and Statistical Manual of Mental Disorders-5-Text Revision (DSM-5-TR). Latent disease classification has been criticized for reliability and validity problems, particularly regarding diagnostic heterogeneity. No authors have calculated the scope of the heterogeneity problem of the entire DSM-5-TR.

AIMS

We addressed this issue by calculating the unique diagnostic profiles that exist for every DSM-5-TR diagnosis.

METHODS

We did this by applying formulas previously used in smaller heterogeneity analyses to all diagnoses within the DSM-5-TR.

RESULTS

We found that there are 10,130,814 ways to be diagnosed with a mental illness using DSM-5-TR criteria. When specifiers are considered, this number balloons to over 161 septillion unique diagnostic presentations (driven mainly by bipolar II disorder). Additionally, there are 1,951,065 ways to present with psychiatric symptoms, yet not meet diagnostic criteria.

CONCLUSIONS

Latent disease classification leads to considerable heterogeneity in possible presentations. We provide examples of how latent disease classification harms research and treatment programs. We echo recommendations for the dismissal of latent disease classification as a mental illness diagnostic program.

The cultural change narrative as a core component of therapeutic change

Introduction

Research indicates a similar effect of Mentalization-based treatment (MBT) and Dialectical behavior therapy (DBT) for borderline personality disorder (BPD). However, there is a paucity in studies investigating the change narrative received from and developed in these treatments. The aim of the present study is to investigate similarities and differences in the change narratives provided by MBT and DBT, and how these narratives reflect the rationale, explanations, and procedures of the provided treatment.

Methods

The study is a qualitative analysis of seven interviews conducted by the authors. Three of the participants had received MBT, and four of the participants had received DBT. This study presents an Interpretative Phenomenological Analysis (IPA) of the change narratives received in two specialized treatments for BPD.

Results

The main findings from the IPA were that the change narratives described by the participants reflected the treatment they received. The DBT participants highlighted explicit learning of tools and techniques, with predictable and safe therapists. In contrast, the MBT participants emphasized a long-lasting process of exploring to create procedural learning with therapists who followed their lead.

Discussion

The participants' stories of change shed light on how a change narrative was developed, and therefore how the rationale, explanations and procedures were conveyed differently by MBT and DBT.

'Isolated together': online group treatments during the COVID-19 pandemic. A systematic review

Considering the emerging need to face the negative impact of the pandemic on mental health, social support, and access to health services, it became a critical issue to adapt to online group settings and create new group interventions to face the developing distress during this time. The aim of the current study is to investigate the main findings on OPGI conducted during the COVID-19 pandemic from March 2020 until March 2022, with a particular focus on: i) the therapeutic group factors; ii) what kind of OPGI works and for whom; iii) settings and emerging dimensions. In accordance with PRISMA guidelines, we performed a systematic review on scientific databases (PsychINFO, PubMed, Web of Science and EBSCO) searching for studies published between March 2020 and March 2022. 'Group intervention' or 'group therapy' or 'group treatment' crossed with 'COVID-19' and synonymous, were used as keywords. Internet based intervention was used as an eligibility criteria during the full-text screening. A total of 1326 articles were identified, of which 24 met the inclusion criteria. Among all studies, with different participants and different orientations, data extracted supported psychological online group interventions as an effective approach to reducing psychological distress and increasing psychological resources in the interpersonal field. Our findings also showed that COVID-19 has led to new needs and issues, that require the investigation of new dimensions for online psychological interventions. Methodological and clinical implications will be discussed through a descriptive table related to setting characteristics. Recommendations are made for future research.

The relationship between responsibility attribution and session outcomes: Two-dimension attribution and two-person perspective

OBJECTIVE

Blame attribution (who is to blame for problem causes) and solution attribution (who is to control problem solving) are two critical dimensions of responsibility attribution in psychotherapy. The present study aimed to (1) investigate the impacts of blame attribution and solution attribution on session outcomes from both client and therapist perspectives and (2) clarify the relationship between the therapist-client congruence of responsibility attribution and session outcomes.

METHOD

A total of 69 clients were recruited at a university counselling centre. Client-rated responsibility attribution (to what extent they were responsible for the causes and solution of their current concerns), therapist-rated responsibility attribution (to what extent they thought their clients should be responsible for the causes and solution of clients' current concerns), client-rated session quality and symptom level for each session were collected across 387 sessions. Multilevel regression was used to explore the relationship between responsibility attribution and session outcomes. Truth and bias model and response surface analysis were utilized to analyse the within-client and between-client client-therapist congruence effects.

RESULTS

The main results included that (1) the clients with higher solution responsibility had more symptom improvement and higher evaluation of session quality (between-client level). A client's perceived solution responsibility predicted better session quality and fewer next session symptom levels (within-client level). (2) If a therapist attributed more solution responsibility to his/her client, the session quality was higher (within-client level). (3) Neither clients' nor therapists' perspectives on blame attribution directly affected session outcomes. But the higher the client's blame for his/her problem causes, the stronger the association between solution responsibility and symptom reduction (within-client level). (4) Higher within-client client-therapist congruence on blame responsibility led to better session outcomes.

CONCLUSION

The clients' solution responsibility and client-therapist congruence on blame for problem causes contribute to session outcomes in psychotherapy.

Dialectical Thinking: A Proposed Foundation for a Post-modern Psychology

For the authors, the way from a modern to a post-modern psychology requires dialectical thinking. Dialectical thinking recognizes the importance of contradiction, change, and synthesis; it also includes recognition of the value as well as limits of modern epistemological approaches. The article describes foundations for both ongoing efforts to understand and research the ontogeny of dialectical thinking and for appreciating the scope of dialectical thinking and its relevance for establishing a bridge from modern to post-modern psychology.

Treatment Satisfaction in a Civil Commitment Facility for Sexually Violent Persons

Evaluating patient satisfaction in therapeutic settings is consistent with a Risk-Needs-Responsivity (RNR) model. This study provides results from a program improvement initiative in a sexually violent person (SVP) civil commitment facility that queried patients and treatment providers about their satisfaction with therapeutic processes and assessment methods. Overall, patients reported high levels of satisfaction with treatment at the facility, with the highest levels of satisfaction on items about being treated with kindness and respect and staff acting professionally. Providers rated current assessment methods such as the Penile Plethysmography (PPG) assessment, polygraph testing, and neuropsychological testing as most helpful for patients in treatment progress; however, patients rated PPG assessment and polygraph testing as the least helpful of the assessments conducted. Soliciting patient feedback periodically could be important for maintaining treatment engagement and discovering opportunities to enhance patient satisfaction to treatment in a SVP civil commitment setting.

"There is Just a Different Energy": Changes in the Therapeutic Relationship with the Telehealth Transition

The therapeutic relationship (TR), including its therapeutic frame, is the foundation of the therapeutic endeavor. In response to the COVID-19 pandemic and the rapid transition to videoconferencing for therapeutic encounters, we employed a cross-sectional exploratory survey with 1490 respondents to understand how practitioners adapted to the changes. In this secondary analysis focused on the TR, we analyze the clinicians' (N = 448) spontaneous narratives about facets of the TR. Temporally, we focused on how these adaptations occurred during the initial part of the pandemic before vaccination was available and while the TR was still adapting to teletherapy videoconferencing under the duress of pandemic crises. We find three broad themes: (1) It is a "much more remote relationship"; (2) The "connection…remains surprisingly strong"; and (3) It is "energetically taxing." Each reflects clinicians' views of the TR as altered, but surprisingly resilient. Although grateful for the safety of virtual therapeutic encounters, clinicians mourned the loss of an embodied encounter, experienced depletion of energy beyond Zoom fatigue, and nonetheless recognized their clients' and their own abilities to adapt.

The Strength of Alliance in Individual Psychotherapy and Patient's Wellbeing: The Relationships of the Therapeutic Alliance to Psychological Wellbeing, Satisfaction With Life, and Flourishing in Adult Patients Attending Individual Psychotherapy

OBJECTIVES

The central aim of the research was to verify and determine the strength of the relationships of therapeutic alliance to wellbeing, life satisfaction, and flourishing in patients attending individual psychotherapy. The relationships were assessed based on different sources of information about the quality of the working alliance: patient's evaluation and patient's and psychotherapist's joint evaluations.

DESIGN

The author applied Bordin's pantheoretical model of alliance and two different conceptions of wellbeing, operationalized as hedonistic and eudaimonic.

METHODS

The 411 participants included 252 patients and 159 psychotherapists. To test the hypotheses, 16 joint and separate models of structural relations were built and analyzed empirically using SEM. Correlations were analyzed between alliance factors and those of wellbeing, satisfaction, and flourishing.

RESULTS

The actual impact of working alliance quality on psychological wellbeing proved to be stronger compared to the relations between alliance and satisfaction or flourishing. The results of analyses revealed low, though usually positive and significant, correlations between the dimensions of alliance and those of wellbeing, life satisfaction, and flourishing.

CONCLUSIONS

The empirical data and the strategy of analyses brought the expected results, confirming that patient's and psychotherapist's perception of a strong therapeutic alliance is crucial for the optimization of patient's functioning and wellbeing. It turns out that the therapeutic alliance is, above all, a factor of wellbeing understood more deeply than merely as current pleasure. The study also showed that no factor isolated from other components of alliance increased the quality of patient's mental functioning more than others.

Psychotherapy as a Moderator of the Relationship Between Coping Strategies and Anxiety During the COVID-19 Pandemic

The COVID-19 pandemic has led to the development of several risk factors for mental health, not only for people directly infected but also for those experiencing social isolation, loneliness, and concern for their health. The impact of these factors on individuals' health and well-being also depends on the type of coping strategies adopted. Moreover, one of the main effects of COVID-19 is the increase in the prevalence of people who manifest anxious or depressive syndromes. This study investigates the relationship between coping strategies and a multidimensional assessment of anxiety symptoms measured during the COVID-19 pandemic in people who were having psychotherapy sessions, while participating in the study had psychotherapy sessions (clinical group) and those who have never done them (non-clinical group). The results of a questionnaire administered online to Italian subjects from June to July, 2020 were analyzed through multiple linear regressions methods to evaluate the role of psychotherapy as moderator between anxiety symptoms and coping strategies. The results of this study highlight that there are substantial differences in functioning between the clinical and non-clinical groups, underlying the key role of psychotherapy as a moderator between anxiety and the coping strategies of avoidance, social support, and positive attitude.

Effort-Optimized Intervention Model: Framework for Building and Analyzing Digital Interventions That Require Minimal Effort for Health-Related Gains

The majority of digital health interventions lean on the promise of bringing health and self-care into people’s homes and hands. However, these interventions are delivered while people are in their triggering environments, which places competing demands on their attention. Individuals struggling to change or learn a new behavior have to work hard to achieve even a minor change because of the automatic forces propelling them back to their habitual behaviors. We posit that effort and burden should be explored at the outset and throughout the digital intervention development process as a core therapeutic mechanism, beyond the context of design or user experience testing. In effort-focused conceptualization, it is assumed that, even though goals are rational and people want to achieve them, they are overtaken by competing cognitive, emotional, and environmental processes. We offer the term effort-optimized intervention to describe interventions that focus on user engagement in the face of competing demands. We describe design components based on a 3-step process for planning an effort-optimized intervention: (1) nurturing effortless cognitive and environmental salience to help people keep effort-related goals prominent despite competition; (2) making it as effortless as possible to complete therapeutic activities to avoid ego depletion and self-efficacy reduction; and (3) turning the necessary effortful activities into sustainable assets. We conclude by presenting an example of designing a digital health intervention based on the effort-optimized intervention model.

MAGIC: a Proposed Model Based on Common Factors

The author offers an initial formulation of what an approach integrating common factors and the processes of change would look like. The dodo-verdict has been extant in the psychology literature for almost 100 years, and it is time to acknowledge the veracity of the dodo-bird verdict as we move toward therapeutic approaches focusing on factors the empirical approaches have in common. Although we now have hundreds of different theoretical models, no one model appears to be superior to any other. However, certain presenting conditions may be more suited to certain interventions. The MAGIC approach introduced here incorporates client motivation, the therapeutic alliance, goal-setting, implementation, and commitment. This gives us a basic structure of commonalities around which we will be able to build comprehensive psychotherapeutic strategies drawing on intervention techniques from many different models. After a brief consideration of historical factors, I will present one idea for an integrated approach followed by a discussion of some assumptive processes which are at work in the therapeutic cadre as well as a consideration of cultural diversities.

The Contribution of Common and Specific Therapeutic Factors to Mindfulness-Based Intervention Outcomes

While Mindfulness-Based Interventions (MBIs) have been shown to be effective for a range of patient populations and outcomes, a question remains as to the role of common therapeutic factors, as opposed to the specific effects of mindfulness practice, in contributing to patient improvements. This project used a mixed-method design to investigate the contribution of specific (mindfulness practice-related) and common (instructor and group related) therapeutic factors to client improvements within an MBI. Participants with mild-severe depression (N = 104; 73% female, M age = 40.28) participated in an 8-week MBI. Specific therapeutic factors (formal out-of-class meditation minutes and informal mindfulness practice frequency) and social common factors (instructor and group ratings) were entered into multilevel growth curve models to predict changes in depression, anxiety, stress, and mindfulness at six timepoints from baseline to 3-month follow-up. Qualitative interviews with participants provided rich descriptions of how instructor and group related factors played a role in therapeutic trajectories. Findings indicated that instructor ratings predicted changes in depression and stress, group ratings predicted changes in stress and self-reported mindfulness, and formal meditation predicted changes in anxiety and stress, while informal mindfulness practice did not predict client improvements. Social common factors were stronger predictors of improvements in depression, stress, and self-reported mindfulness than specific mindfulness practice-related factors. Qualitative data supported the importance of relationships with instructor and group members, involving bonding, expressing feelings, and instilling hope. Our findings dispel the myth that MBI outcomes are exclusively the result of mindfulness meditation practice, and suggest that social common factors may account for much of the effects of these interventions. Further research on meditation should take into consideration the effects of social context and other common therapeutic factors.

Was sagt die LAC-Depressionsstudie wirklich aus?

Hintergrund

Kognitiv-behaviorale und psychodynamische Therapieverfahren befinden sich in einem Konkurrenzverhältnis, was den Nachweis ihrer Wirksamkeit angeht. Obwohl es bereits vergleichende Wirksamkeitsstudien gab, bilden diese oft nicht die Versorgungssituation in Deutschland ab. Anfang des Jahres wurden die Ergebnisse der „LAC-Depressionsstudie“ vorgelegt, die diese beiden Verfahren in einem naturalistischen Studiendesign vergleicht. Diese Ergebnisse suggerieren die gleiche Effektivität von kognitiver Verhaltenstherapie (KVT) und psychoanalytischer Therapie (PAT).

Material und Methode

Methodenkritische Betrachtung mehrerer, aus den Ergebnissen der LAC-Depressionsstudie publizierter Forschungsberichte, alternative Darstellung der primären Ergebnismaße relativ zur Anzahl der Behandlungssitzungen.

Ergebnisse

Die LAC-Depressionsstudie wich an entscheidenden Stellen vom vorher veröffentlichten Versuchsprotokoll ab. Die KVT erreicht die gleichen Ergebnisse mit deutlich weniger Therapiesitzungen. Das Versuchsdesign sowie die erreichte Stichprobengröße sind ungeeignet, um die in den Hypothesen vermuteten Effekte nachzuweisen.

Schlussfolgerungen

Aufgrund von methodischen Problemen, teils deutlichen Abweichungen vom Studienprotokoll und gravierenden Dosis-Wirkung-Unterschieden können die Ergebnisse dieser Studie jedoch nicht als Beleg für eine vermeintlich gleiche Effektivität von PAT und KVT gewertet werden.

Treating Multidimensional Presenting Problems with a Mutually Integrative Approach Using the Genogram

The present article introduces a case study and describes a mutually integrative approach to treating a complex presenting problem. This article examines the specific issues surrounding integration when a supervisor and supervisee hold different theoretical perspectives. On occasion, such a relationship demands that the supervisee adhere to the model being taught by the supervisor. Examining integration in this format presents many advantages for both treatment and training. The key to the mutual integration is that two schools of psychotherapy can be combined in a way that creates a synergy; in that, together they are more powerful than either may be in isolation. A genogram with symbols from each model is incorporated to focus the treatment and create a format for the mutual integration.

Innovation in Psychotherapy, Challenges, and Opportunities: An Opinion Paper

Psychotherapy as a field tends toward conservativism, and the rate of innovation and development of new evidence-based effective treatments has been slow. The paper explores important barriers to innovation like the dodo bird verdict and the habit of starting the development of therapeutic methods from techniques. The paper looks at the opportunities for translating basic science in psychology into psychotherapeutic techniques. Metacognitive therapy stands out from other psychotherapies by its development from basic science. The paper describes the development of the techniques detached mindfulness and attention training, how they were derived from basic science and tested for their suitability in the therapy of patients with anxiety disorders. By this process, metacognitive therapy may be an important model for the innovation process in psychotherapy.

Psychotherapy in Jordan: An Investigation of the Host and Syrian Refugee Community's Perspectives

Little is known about patient satisfaction, bias, stigma, and the effects of psychotherapy within the Kingdom of Jordan or the Arab world in general. The purpose of this study was to explore the perceptions of both the Jordanian host and refugee community members from the psychotherapeutic services offered at various mental health care settings in Jordan. A sample of 100 patients who received psychosocial expert interventions was recruited between October and December 2017 in Amman, Jordan. Participants were either from the host or Syrian refugee community or contacted through multiple organizations working in the mental health field. The Patient Satisfaction Questionnaire, which consists of four subscales covering 1) patient satisfaction, 2) bias toward therapy, 3) effects of therapy, and 4) stigma, was administered. As a means of investigation and exploration, descriptive statistics of participant responses are displayed. Results revealed overall high rates of satisfaction with provided services and perceived benefits of psychotherapeutic interventions. However, respondents showed ambivalence regarding bias and stigma. Subsample analyses indicated no significant differences between both communities. These findings give an understanding of perceptions surrounding psychotherapy in Jordan and some insights on therapeutic processes that may be useful for clinical applications and future research.

Placebo Groups in Research on the Effectiveness of ABA Therapeutic Techniques

Behavior analysts have shown that a single-subject experimental design (SSED) is a useful tool for identifying the effectiveness of specific therapeutic techniques, whereas researchers outside applied behavior analysis (ABA) maintain that randomized placebo-controlled trials (RPCT) provide the most definite test of efficacy. In this paper the possible benefits that could result from supporting SSED studies by placebo control groups are discussed. However, the use of placebo groups in psychotherapy research arouses considerable controversy and many researchers argue against it. The main aim of this paper is to clarify theoretical and methodological problems associated with using placebo groups in psychotherapy research and to demonstrate that these problems can be solved if the assumptions on which they are based are reformulated. The article also discusses ethical issues about the use of placebo groups in research on the effectiveness of psychotherapy.

Mindfulness Training for People With Dementia and Their Caregivers: Rationale, Current Research, and Future Directions

The world population is aging and the prevalence of dementia is increasing. By 2050, those aged 60 years and older are expected to make up a quarter of the population. With that, the number of people with dementia is increasing. Unfortunately, there is no cure for dementia. The progression of symptoms with no hope of improvement is difficult to cope with, both for patients and their caregivers. New and evidence-based strategies are needed to support the well-being of both caregiver and patient. Mindfulness training is a body-mind intervention that has shown to improve psychological well-being in a variety of mental health conditions. Mindfulness, a non-judgmental attention to one's experience in the present moment, is a skill that can be developed with a standard 8-week training. Research has shown preliminary but promising results for mindfulness-based interventions to benefit people with dementia and caregivers. The aim of this review is (a) to provide a rationale for the application of mindfulness in the context of dementia care by giving an overview of studies on mindfulness for people with dementia and/or their caregivers and (b) to provide suggestions for future projects on mindfulness in the context of dementia and to give recommendations for future research.

Component studies of psychological treatments of adult depression: A systematic review and meta-analysis

OBJECTIVES

A recent report from the US Institute of Medicine indicated that identifying core elements of psychosocial interventions is a key step in successfully bringing evidence-based psychosocial interventions into clinical practice. Component studies have the best design to examine these core elements. Earlier reviews resulted in heterogeneous sets of studies and probably missed many studies.

METHODS

We conducted a comprehensive search of component studies on psychotherapies for adult depression and included 16 studies with 22 comparisons.

RESULTS

Fifteen components were examined of which four were examined in more than one comparison. The pooled difference between the full treatments and treatments with one component removed was g = 0.21 (95% CI: 0.03∼0.39). One study had sufficient statistical power to detect a small effect size and found that adding emotion regulation skills increased the effects of CBT. None of the other studies had enough power to detect an effect size smaller than g = 0.55. Only one study had low risk of bias.

CONCLUSIONS

The currently available component studies do not have the statistical power nor the quality to draw any meaningful conclusion about key ingredients of psychotherapies for adult depression.

The Conceptual Framework of Thematic Mapping in Case Conceptualization

This article, the 3rd in a series of 5, introduces the conceptual framework for thematic mapping, a novel approach to case conceptualization. The framework is transtheoretical in that it is not constrained by the tenets or concepts of any one therapeutic orientation and transdiagnostic in that it conceptualizes clients outside the constraints of diagnostic criteria. Thematic mapping comprises 4 components: a definition, foundational principles, defining features, and core concepts. These components of the framework, deemed building blocks, are explained in this article. Like the foundation of any structure, the heuristic value of the method requires that the building blocks have integrity, coherence, and sound anchoring. We assert that the conceptual framework provides a solid foundation, making thematic mapping a potential asset in mental health treatment.

Concepts of context in music therapy

In contemporary music therapy as well as in related interdisciplinary fields, the importance of context in relation to theory, research, and practice has been emphasized. However, the word context seems to be used in several different ways and conceptualizations of contextual approaches vary too. The objective of this theoretical article is to clarify traditions of language use in relation to context in music therapy. In reviewing and discussing the literature, we focus on the field of mental health care. When discussing issues related to context, this literature partly focuses on the surroundings of music therapy practice, partly on the ecology of reciprocal influences within and between situations or systems. On this basis, three types of context awareness in music therapy are identified: music therapy in context; music therapy as context; and music therapy as interacting contexts. The identified types of context awareness are exemplified through references to music therapy literature and then discussed in relation to two very different metaphors, namely context as frame and context as link. Implications for practice, research, and theory development in music therapy are suggested.

Properties of the Achievement of Therapeutic Objectives Scale (ATOS): a Generalizability Theory study

The psychometric properties of the process instrument Achievement of Therapeutic Objectives Scale (ATOS) were examined in this study. Generalizability Theory (GT) was used to evaluate variability attached to several possible sources of error. A random sample of 24 psychotherapy sessions was selected from a larger RCT trial including Cluster C patients and rated in different rating conditions (rating all scales versus rating a subgroup of the scales). Two G-study designs were used to compute variance components and generalizability coefficients. The results provided evidence that the ATOS is sensitive to differences among patients and to differences among subscales within patients (i.e., to different constructs within the ATOS). Rating condition contributed much to variability in scores when the ATOS scales were examined separately, but this variability was negligible when all scales were included in the same analysis. There was little variability due to raters, which indicates that adequately trained raters are able to apply the ATOS without contributing to measurement error.