RECOVER YOUR BALANCE: EFFECTIVENESS RESEARCH OF POSITIVE PSYCHOTHERAPY

The present study examines whether Positive Psychotherapy (PPT) fulfills the three common efficacy factors of psychotherapy postulated by Grawe et al. (1994) and in doing so takes the therapists’ assessment of the common factors, the length of professional experience of therapists and multiple times of measurement into account. 207 outpatients (66 males, 41 females) and their therapists - who were trained in PPT - evaluated the fulfillment of the three common factors after an individual therapy session. Results provide support for the effectiveness of PPT: patients and therapists both assessed PPT to fulfill the three common efficacy factors. However, patients perceived all three factors to be fulfilled to an even higher degree than therapists did. Additionally, two of the common factors were judged to be more fulfilled when the treating therapist had more rather than less professional experience. Lastly, patients experienced therapy as even more effective over time. The verification of the effectiveness of Positive Psychotherapy via an explicit measurement of the common efficacy factors leads to a gain of knowledge and has important implications for psychotherapists practicing and teaching PPT alike. Furthermore, the present study provides new and interesting approaches for future research.


Introduction
Psychotherapy research is considered by many authors as a "fundamental aspect of psychotherapeutic services" (e.g.Lambert, 1991, p. 1) and is held to be necessary to improve treatment outcomes and treatment guidelines of psychotherapy (Angus et al., 2014) (Elkins, 2012;Grawe, 1992).Additionally, psychotherapy research is also of interest to patients (McLeod, 2001), as patients' positive valuation of therapy -including the belief that psychotherapy is efficacious and likely to be of help to them -goes along with increased motivation for therapy (Rosenbaum & Horowitz, 1983).On top of that, there has been increasing pressure from health insurances, funding bodies and other stakeholders to demonstrate effectiveness of psychotherapeutic services (McLeod, 2001;Peseschkian et al., 1999;Presslich-Titscher & Datler, 1994).All of the above led to a rise of research on psychotherapy over the past 70 years (Fuertes & Nutt Williams, 2017).This research can generally be divided into four phases, depending on the particular research question under investigation (Grawe, 1992).During the first phase research concentrated on demonstrating the effectiveness of psychotherapy in general, while the second phase centered on comparing psychotherapy directions and thus on identifying the most effective one.The third phase, on the other hand, took a more prescriptive approach by examining which form of therapy was indicated for which patient.In the 1990s, process research came more and more into focus, and with it the question of how psychotherapy works and what exactly makes psychotherapy effective (Grawe, 1997;Hank & Krampen, 2008;Mattejat, 2011).
Concerning that last research question, Grawe, Donati and Bernauer (1994) -based on a large empirical examination of psychotherapy effectivenesspostulated that three common efficacy factors were crucial for the effectiveness of every psychotherapy: motivational clarification, active help to solve problems and therapeutic support and relationship.According to them, motivational clarification refers to fathoming the threatening meaning of a particular situation or event or the implications of a patient's goal.The second common factor of active help to solve problems refers to the patient's concrete experience of learning how to deal with situations previously experienced as difficult or anxiety-provoking (Grawe, 1997).Finally, Grawe et al. (1994) defined the third common factor of psychotherapy as the extent to which the patient feels understood by the therapist and can accept the therapist's support.According to the model, the effectiveness of psychotherapy depends on the extent to which these three common factors are activated by concrete therapeutic procedures (Grawe et al., 1994).
These common efficacy factors sensu  & Tritt, 1998;Peseschkian et al., 1999).Using a battery of psychometric test that was decided on in consultation with Grawe, Peseschkian and colleagues were able to show that "PPT fulfills the […] principles postulated by Grawe [et al. (1994)] for the effectiveness of psychotherapy" (Peseschkian & Remmers, 2020, p. 29).The importance and impact of that effectiveness study is highlighted by the award for outstanding work in the field of medical quality assurance it received (Peseschkian et al., 1999).Yet, it should be noted that the researchers at that time could only infer the fulfillment of the three common efficacy factors from the patients' results on various psychometric tests since there was no instrument available to specifically measure the common efficacy factors postulated by Grawe et al. (1994).Now, over 20 years later, this has changed as Krampen (2002) developed the Session Questionnaire for General and Differential Individual Psychotherapy (STEP).This instrument was designed in order to allow for an economic measurement of the three common efficacy factors according to Grawe et al. (1994).The STEP questionnaire refers to the patient's experience of an individual therapy session as well as the associated external perception and evaluation of his or her therapist (Krampen, 2002) Therefore, the present study aims at examining whether PPT fulfills the three common efficacy factors postulated by Grawe et al. (1994) when explicitly surveyed via the STEP questionnaire.Additionally, the present research also takes the therapists' evaluation of the common efficacy factors, differences in the professional experience of therapists and multiple times of measurement into account, allowing for a more sophisticated exploration of the activation pattern of common efficacy factors in PPT.Following the work of Peseschkian and colleagues, in order to maximize generalizability of results, a naturalistic setting was chosen in that the STEP questionnaire was administered to 210 outpatients that were treated by therapists trained in PPT.Thus, this study poses a continuation of the research conducted by Peseschkian and colleagues in 1998 and 1999 and provides further evidence for the effectiveness of PPT.

Subjects and study design
The study sample consisted of outpatients treated at the psychotherapy practice Akademie an den Quellen in Wiesbaden, Germany, between 2014 and 2019.
Patients were asked to fill out the STEP questionnaire directly following a regular therapy session.They completed the STEP questionnaire at different stages of therapy, consequently, the sample was a mixture of patients at the beginning of therapy as well as at advanced stages of therapy.Sessions to be evaluated were selected randomly and patients were not told about the planned evaluation in advance in order to prevent biases.
In total, 210 patients participated in the study of whom 54 completed the questionnaire twice, 17 filled it out thrice and 5 answered it four times.The average time between two measurements was 7 months.The present study poses a clinical study in which no control group was planned (quasi-experimental study or nonrandomised design; Schramm et al., 2004).
After scanning the data for potential outliers, 207 patients were included in the statistical analysis for the first time of measurement.Thus, this sample included 66 males and 41 females between 18 and 78 years (average age = 44).The outlier analysis of the sample with two measures resulted in 52 patients (11 males, 41 females, average age = 43).As the sizes of the samples with three and four measures are both very small, these samples were not analyzed separately.
For the statistical analyses of the general effectiveness of psychotherapy in the practice, all measures were analyzed together as the STEP questionnaire is designed specifically to evaluate the therapy session just conducted and, therefore, multiple measurements by the same person should also be considered for assessing the general effectiveness of a form of psychotherapy.After having excluded statistical outliers, the resulting sample, including multiple measures of the same person, consisted of 282 patients (86 male, 196 female, average age = 44).On average, patients had been treated in the practice for 9.9 months when they completed the STEP questionnaire.Diagnoses of patients included depression (52.9%), stress disorders (26.8%), anxiety disorders (14.3%), psychological and behavioral factors associated with disorders or diseases classified elsewhere (15.0%), somatoform disorders (7.5%), personality disorders (6.8%), and others (22.1%).

Therapists
A total of 21 psychotherapists participated in the present study, all of whom worked at the psychotherapy practice Akademie an den Quellen in Wiesbaden, Germany, throughout the time of the study.All therapists were trained in psychodynamic psychotherapy and PPT.19 of them were psychotherapists in training at Wiesbadener Akademie für Psychotherapie (WIAP) where psychotherapeutic training based on PPT is provided.The other two psychotherapists both are lecturers at WIAP: one is certified as master trainer in PPT, while the other is qualified in Integrative Therapy sensu Petzold (1993), an approach very similar to PPT concerning the fundamental structure and conception of human beings.

Therapy Sessions
All patients included in the present study received weekly 50 minute-sessions of PPT.PPT  ).PPT is characterized by conflictcenteredness and resource-orientation as well as the integration of approaches from the main psychotherapy directions (ebd.).PPT focuses on the capacities of the patient and wants to help the patient to discover his or her potential for self-help.Disorders, conflicts and symptoms are seen as 'a capacity to react to conflicts' (ebd., p. 12), and are considered to be part of the wholeness of the patient just like his or her resources, capacities and potentials.

Measures
The Session Questionnaire for General and Differential Individual Psychotherapy [Stundenbogen für die Allgemeine und Differentielle Psychotherapie] (STEP; Krampen, 2002) constitutes an economic and standardized questionnaire to assess the common efficacy factors of psychotherapeutic processes distinguished by Grawe et al. (1994) from the perspective of patients and their therapists.The items of the questionnaire directly relate to the experience of an individual therapy session by the patient, constituting the patient version (STEPP), as well as his or her therapist's external perception of the session and of the patient's experience, forming the therapist version (STEPT).
Both versions are designed as parallel in terms of content and comprise 12 complementary items each.Five items measure the experienced (patient version STEPP) or perceived (therapist version STEPT) motivational clarification of the patient (STEP-C), four items assess the experienced or perceived active help to solve problems (STEP-P) and three items evaluate the therapeutic relationship (STEP-R), respectively for the specific therapy session.
For the STEPP the patients use a 7-step answer scale to rate how applicable the respective statements are to their experiences.The reliabilities for the three scales of the patient version lie between Cronbach's  = 0.76 and Cronbach's  = 0.89.For the STEPT the therapists assess content-analogous questions related to their perception of the patients' experience and behavior on a 7-step answer scale.The reliabilities for the three scales of the therapist version range from Cronbach's  = 0.78 to Cronbach's  = 0.91.Thus, all scales show good internal consistencies (Field, 2013).
Because of the different amounts of items of the three scales, the maximally achievable values vary.For the STEP-C a total score of 35 can be reached, for the STEP-P a maximal assessment of 28 is possible and for the STEP-R the maximal score is 21.

PPT fulfills the three common efficacy factors
The statistical analysis of the dataset including all measures revealed that in comparison to the norms published by Krampen (2002) the mean values of all subscales were in the average range (see Table 1).
When taking into account random fluctuations, however, the mean values of STEPP-P and STEPT-P tended to be in the below average to average range.As the deviations from the average range are rather small (see Table 1), overall, both scales can still be considered to be lower average.It is noteworthy though that both scales concern the active help to solve problems -from the patients' and the therapists' point of view.Therefore, this could imply that therapists practicing and teaching PPT should pay special attention to this common factor in order to ensure its fulfillment.
Additionally, in consideration of random fluctuations, the mean value of STEPP-R tended to be average to above average, suggesting that patients perceive the common factor therapeutical relationship to be especially strongly fulfilled by PPT (see Table 1).
All things considered, it can be stated that PPT activates the three common efficacy factors distinguished by Grawe et al. (1994), both from the patients' point of view and according to the therapists' assessment, and is thus perceived to be effective.

Patients experience therapy as more effective than their therapists think
Interestingly, patients' evaluations differed significantly from the therapists' assessments on all subscales and at all times of measurement (see Table 2 and Figure 1).Thus, on average, the patients experienced all three common efficacy factors as significantly more fulfilled than their therapists perceived them to do.
Although divergence in patients' and therapists' evaluation of a therapy session is neither alarming nor unusual and is described as a generic problem of process research by Hartmann et al. ( 2013), the differences in the assessments of the STEP questionnaire are generally not as uniform and consistent across all scales as was the case in the present survey.Usually, it can be observed that at times the patients and at other times the therapists perceive the common efficacy factors as more fulfilled and that the direction of divergence between the scales also differs within the same sample (Krampen, 2002).
One possible explanation for this unusually uniform divergence in terms of higher values of the patients' assessments evident in the present study is that the therapists have a more advanced understanding of the three common factors and base their assessments of them on their professional knowledge of how they should be fulfilled in a psychotherapy, leading to higher expectations and, thus, a more critical evaluation.The patients on the other hand compare the psychotherapy situation to their past personal experiences resulting in more positive assessment.A similar explanation was suggested by Horvath (2000) concerning the divergence of patients' and therapists' assessment of the therapeutical alliance.Fitzpatrick et al. ( 2005) applied Horvath's assumption to the three dimensions of task collaboration, goal collaboration and patient-therapist bond.Therefore, it seems plausible that this pattern may also be applicable to the three common factors of psychotherapy defined by Grawe et al. (1994).

Therapists' professional experience plays a role
As two therapists with many years of professional experience (average professional experience = 20.56 years) as well as 19 psychotherapists in training (average professional experience = 3.50 years) participated in the present study, the influence of professional experience of the treating therapist on the assessment of the common efficacy factors could also be examined.The statistical analysis of the dataset including all measures showed that the common factor problem solving was perceived by both patients and therapists as being significantly more fulfilled if the treating therapist had more rather than less professional experience.As it had been those two scales (STEPP-P and STEPT-P) that tended to be in the below average to average range when compared to the norm values, another norm comparison was conducted for therapists with much and for therapists with little professional experience, separately.This analysis Claudia Christ et al.
revealed that the patients' and therapists' assessment for experienced therapists was in the average range, even when taking into account random fluctuations.The mean values for therapists with less professional experience, on the contrary, tended to be below average to average.As the analyzed dataset includes 248 measures from therapists with little professional experience, but only 34 measures of more experienced therapists, it seems plausible that the effect of therapists' professional experience led to the overall classification of STEPP-P and STEPT-P as below average to average, that was reported earlier.
In addition, patients of therapists with many years of professional experience rated the therapeutic relationship to be significantly more fulfilled than patients of less experienced therapists.The therapists themselves, however, showed no significant difference in their assessment of this common factor.With regard to motivational clarification, therapists and patients agreed that no difference was seen in the fulfillment of this common factor depending on the therapist's amount of professional experience (see Table 3 and Figure 2).When comparing the results of the present study with the comparative results reported in the manual of the STEP questionnaire (Krampen, 2002), the findings are only partially corresponding.
Coinciding with the present findings, Krampen's (2002) analyses also revealed significantly higher values regarding problem solving for therapists with more professional experience, both from the therapists' and the patient's point of view.However, the patients' and therapists' ratings of motivational clarification were also higher for more experienced therapists, which was not true for the present survey.Moreover, in the comparative analyses the patients' assessment of the therapeutic relationship showed no significant differences depending on the professional experience of the therapist, whereas this was the case in the present survey.Although it should be considered that the comparative analyses reported in the manual are based on rather small samples only, a more differentiated and in-depth exploration of the influence of therapists' professional experience on each of the three common factors seems desirable and germane.The agreement on the direction of the effects -always in the sense of better ratings of the common factors for therapists with more professional experiencehowever, indicates that therapeutical work can be taught and learned.

Patients experience therapy as even more effective over time
Since for 52 patients two measurements were conducted, it was also possible to investigate whether and how the patients' and therapists' assessment of the three common efficacy factors of psychotherapy developed over time.It was noteworthy that the patients' evaluation changed significantly in that they perceived all three common factors to be even more strongly fulfilled over time.Thus, patients perceived therapy to be even more effective over time.However, no such effect was observed among the therapists: they always perceived therapy as equally effective for the patients (see Table 4 and Figure 3).

Conclusions
The aim of the present study was to examine the fulfillment of the three common efficacy factors of psychotherapy by PPT.Using the STEP questionnaire (Krampen, 2002) to explicitly measure the common factors postulated by Grawe et al. (1994), the results at hand provide support for the effectiveness of PPT in the sense that patients as well as therapists perceived PPT to fulfill the three common efficacy factors.The finding that patients and therapists assessed active help to solve problems to be fulfilled only at a lower average could be resolved by taking into account the professional experience of the treating therapist which was identified as especially relevant for the fulfillment of this common efficacy factor.The professional experience also played a role for patients' evaluation of the therapeutic relationship.This provides evidence for the teachability and learnability of therapeutic work, especially concerning the active help to solve problems and the therapeutic relationship.Furthermore, patients judged all three common factors to be fulfilled to an even higher degree than therapists did.Lastly, it could be found that patients experienced therapy as even more effective over time while no such trend was detected in therapists' assessments.
To the authors' knowledge this paper poses the first examination of the fulfillment of the three common efficacy factors as measured by the STEP questionnaire in PPT.Therefore, it provides important and new support for the effectiveness of PPT.Additionally, because of taking into account the therapist's assessment, the length of the therapist's professional experience and multiple times of measurement, it allows for deeper insights into the patterns of activation and makes it possible to identify relevant aspects of the fulfillment of the common factors.A particularly important finding in this context is the influence of professional experience on the fulfillment of active help to solve problems as this highlights the importance of giving special consideration to this common factor in the training of ongoing psychotherapists.
In addition to providing meaningful answers concerning the effectiveness of PPT, the present findings also open up further questions and thus provide important and interesting approaches for future research.For one thing, there should be closer examination of what factors play a role for the differences in assessment between patients and therapists and whether the potential explanation The present results should always be interpreted by taking into account that this study is also not without limitations.Therefore, it should be noted that the absence of a control group limits the causal conclusions that can be drawn from the study on the effectiveness of PPT.In addition, the chosen naturalistic design reduces the internal validity of the study (Howard et al., 1996).However, this limitation was accepted as the study aimed at examining the effectiveness of PPT under naturalistic conditions emphasizing external validity and generalizability of the findings (Howard et al., 1996;Leichsenring & Rüger, 2004).Nonetheless, due to the abovementioned reasons a replication of the study under more controlled conditions seems desirable for future research.
All in all, the present paper provides important evidence for, as well as further insights into, the effectiveness of PPT as measured by the common efficacy factors sensu Grawe et al. (1994).It can thus be seen as a continuation of the research of Peseschkian and colleagues (1998; 1999).The present findings are highly relevant for future psychotherapy research as well as for psychotherapists practicing and teaching PPT all around the globe.
Notes.N = 282, STEPP-C/STEPT-C = patient/therapist version of motivational clarification scale, STEPP-P/STEPT-P = patient/ therapist version of active help to solve problems scale, STEPP-R/ STEPT-R = patient/therapist version of therapeutic relationship scale, a = average, ba = below average, aa = above average.Claudia Christ et al.

Figure 2 .
Figure 2. Comparison of patients' and therapists' mean scores of STEP scales motivational clarification (STEP-C), active help to solve problems (STEP-P) and therapeutical relationship (STEP-R) for therapists with much vs. little professional experience.

Figure 3 .
Figure 3.Comparison of patients' and therapists' mean scores of STEP scales motivational clarification (STEP-C), active help to solve problems (STEP-P) and therapeutical relationship (STEP-R) for first vs.second measurement.
. Its relevance results from the contribution that

Table 1 .
T norm values, Cronbach's , standard deviations (SD) and confidence intervals (CI) for all STEP scales.

Table 2 .
Means (M), standard deviations (SD), t-and p-values of t-tests for comparison of patients' and therapists'assessment of the STEP scales.

Table 3 .
Means (M), Standard deviations (SD), t-and p-values of t-tests for comparison of much versus little professional experience of the treating therapist.

Table 4 .
Means (M), Standard deviations (SD), t-and p-values of t-tests for comparison of first versus second time of measurement.
19 THE GLOBAL PSYCHOTHERAPIST.Volume 1. Number 2. July 2021 Claudia Christ et al. suggested by the authors proves to be true.Moreover, future research should try to illuminate how the growing professional experience of psychotherapists translates into increased fulfillment of two of the common factors.Lastly, it seems interesting to explore how and to what extent patients' assessment of the three common factors increases over time.