Therapist Session Intentions in Cognitive-Behavioral and Psychodynamic-Interpersonal Psychotherapy
William B. Stiles Miami University Mike Startup University of Wales, Bangor Gillian E. Hardy, Michael Barkharn, Shirley Reynolds Anne Rees, and David A. Shapiro University of East Anglia University of Leeds Theories of psychotherapy are implemented by therapists' intentional actions within sessions. This study examined the structure and construct validity of the Therapist Session Intentions (TSI) form. Ten therapists rated their therapeutic intentions following each of 2,305 therapy sessions of cognitive-behavioral or psychodynamic-interpersonal therapy in the Second Sheffield Psychotherapy Project. Seven conceptually coherent clusters of intentions, or therapeutic foci, were identified: treatment context, session structure, affect, obstacles, encouraging change, behavior, and cognition-insight. Contrasting patterns of therapeutic focus across treatments and changes in focus across sessions within treatments appeared conceptually coherent. Correlations across a subsample of sessions confirmed correspon- dences of the TSI foci with dimensions found previously in observers' ratings. The therapist is responsible for translating psychotherapy theory into practice by a series of intentional actions. This article reports a study of therapists' intentions in sessions of two theoretically different psychotherapies--one cognitive- behavioral (CB) and one psychodynamic-interpersonal (PI)--as implemented in the Second Sheffield Psychother- apy Project (Shapiro, Barkham, Hardy, & Morrison, 1990; Shapiro et al., 1994). Our goal was to assess the structure and construct validity of a postsession self-report instrument and to identify subscales for use in future studies. We examined how therapists' intentions clustered together within sessions of each treatment and how they changed systematically across sessions. We also compared thera- pists' reported intentions in sessions with ratings of their behaviors by raters who had listened to a subsample of the session tape recordings to assess the degree of convergence of descriptions of sessions' contents from these different perspectives. William B. Stiles, Department of Psychology, Miami Univer- sity, Oxford, Ohio; Mike Startup, School of Psychology, Univer- sity of Wales, Bangor, Wales; Gillian E. Hardy, Michael Barkham, Anne Rees, and David A. Shapiro, Psychological Therapies Re- search Centre, University of Leeds, England; Shirley Reynolds, Health Policy and Practice Unit, University of East Anglia, Nor- wich, England. This article was written in part while William B. Stiles was at the MRC/ESRC Social and Applied Psychology Unit, University of Sheffield, Sheffield, England, supported in part by Senior Interna- tional Fellowship 1 F06 TW01808-01 from the Fogarty Interna- tional Center of the National Institutes of Health. We thank Jane Hall and Mary Lou Hughes for administration of the clinic. Correspondence concerning this article should be addressed to William B. Stiles, Department of Psychology, Miami University, Oxford, Ohio 45056. Electronic mail may be sent via Internet to wbstiles @miamiu.muohio.edu. 402 As reported elsewhere (Shapiro et al., 1994, 1995), most clients in all cells of the Sheffield project design improved substantially across treatment, suggesting that both CB and PI treatments were very effective. There were no substantial mean differences in outcomes between clients who received CB versus PI treatment at termination or 3-month follow- up. Thus, the intentions we studied took place, in general, in the context of equivalently successful treatments. The Concept of Therapist Intention According to Hill and O'Grady (1985), Intentions can be defined as a therapist's rationale for select- ing a specific behavior, response mode, technique, or inter- vention to use with a client at any given moment within the session. Intentions represent what the therapist wants to ac- complish through his or her behavior within the session. An intention is the cognitive component that mediates the choice of intervention. (p. 3) Defined in this way, therapist intentions are epistemologi- cally private, and our most direct access to them is by asking therapists to reveal their thoughts. This sense of intention should be distinguished from sense of intent used in re- sponse mode coding (e.g., "Could you come closer?" has an interrogative form but a directive intent), which refers to the on-record meaning of utterances (Stiles, 1987). We use the former, private sense of intention in this article. As Hill and O'Grady (1985) pointed out, a systematic classification of intentions, thus conceived, may be useful for clarifying therapists' internal processes in teaching, clinical supervi- sion and practice, and research. Based on an initial list developed by Elliott and Feinstein (1978), a literature search, and a series of formal and infor- mal clinical studies, Hill and O'Grady (1985) constructed a