A 3-phase model of psychotherapy outcome is proposed that entails progressive improvement of subjectively experienced well-being, reduction in symptomatology, and enhancement of life functioning. The model also predicts that movement into a later phase of treatment depends on whether progress has been made in an earlier phase. Thus, clinical improvement in subjective well-being potentiates symptomatic improvement, and clinical reduction in symptomatic distress potentiates life-functioning improvement. A large sample of psychotherapy patients provided self-reports of subjective well-being, symptomatic distress, and life functioning before beginning individual psychotherapy and after Sessions 2, 4, and 17 when possible. Changes in well-being, symptomatic distress, and life functioning means over this period were consistent with the 3-phase model. Measures of patient status on these 3 variables were converted into dichotomous improvement-nonimprovement scores between intake and each of Sessions 2, 4, and 17. An analysis of 2 x 2 cross-classification tables generated from these dichotomous measures suggested that improvement in well-being precedes and is a probabilistically necessary condition for reduction in symptomatic distress and that symptomatic improvement precedes and is a probabilistically necessary condition for improvement in life functioning.

l Of course, any answer is dependent on a prospective design-in other words, the availability of measures of the patient's status before, during, and after treatment. Assessments of the effects of a treatment that are based on impressionistic, global, retrospective accounts of patients bear little relationship to assessments of change that are based on "before and after" measures.

Evidence suggests that a moderate amount of variance in patient outcomes is attributable to therapist differences. However, explained variance estimates vary widely, perhaps because some therapists achieve greater success with certain kinds of patients. This study assessed the amount of variance in across-session change in symptom intensity scores explained by therapist differences in a large naturalistic data set (1,198 patients and 60 therapists, who each treated 10-77 of the patients). Results indicated that approximately 8% of the total variance and approximately 17% of the variance in rates of patient improvement could be attributed to the therapists. Cross-validation and extreme group analyses validated the existence of these therapist effects.

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Adaptive treatment planning is a dynamic process that is dependent on valid, systematic assessments. The dosage and phase models provide theoretical bases for the development of such "patient-focused" information. Given an underlying mathematical regularity to the recovery process, growth modeling techniques can be used to determine an expected treatment response for every patient. By mapping the patient's actual status against such an expected change trajectory, it is possible to address the most clinically relevant question, "Is this treatment working?"