Blog

The Psychotherapy Practice Research Network (PPRNet) blog began in 2013 in response to psychotherapy clinicians, researchers, and educators who expressed interest in receiving regular information about current practice-oriented psychotherapy research. It offers a monthly summary of two or three published psychotherapy research articles. Each summary is authored by Dr. Tasca and highlights practice implications of selected articles. Past blogs are available in the archives. This content is only available in English.

November 2017

Therapist Multicultural Orientation and Client Outcomes

Hayes, J. A., Owen, J., Nissen-Lie, H. A. (2017). The contribution of client culture to differential therapist effectiveness. In L. G. Castonguay and C. E. Hill (Eds.) How and why are some therapists better than others? Understanding therapist effects (Ch. 9). Washington: American Psychological Association.

Some therapists may have better client outcomes because they are more adept at working with clients of different cultures. In this chapter, Hayes and colleagues define culture as referring to a group of people who share common history, values, beliefs, symbols, and rituals. The cultural groups to which one may belong include those based on: gender, religion, ethnicity, disability status, sexual orientation, race, and age, among others. Research suggests that culturally adapted therapy is more effective than unadapted therapy for racial minority clients. This may be due to more effective therapists being able to explain clients’ mental health problems and provide a rationale for specific therapy interventions that is congruent with the client’s beliefs. The most common model of multicultural therapy is multicultural competence, which is defined by having knowledge of various cultural groups, skills to navigate cultural processes, and self-awareness of personal bias. However, Hayes and colleagues argue for a multicultural orientation model in which a therapist is humble, respectful, and open to addressing culture in therapy. Whereas multicultural therapy is about acquiring knowledge, multicultural orientation refers to a way of being with clients. Hayes and colleagues review the research literature that indicates that therapists with cultural expertise are those who acknowledge when they do not have specific knowledge about a culture, have a high tolerance for not knowing, and at the same time recognize that cultural socialization affect clients’ mental health. A multicultural orientation is intended to bolster and support current therapeutic practices. For example, therapists may recognize that they need to better understand clients’ heritage when deciding whether or not to challenging a deeply held core belief related to the clients’ culture. In support of this, Hayes and colleagues review the research that indicates that: (1) client perception of therapist humility is related to client outcomes, especially for clients with a strong cultural identity; (2) clients who perceived that their therapist missed opportunities to discuss cultural issues in session had worse therapy outcomes; (3) clients who perceived therapists as culturally oriented experienced the therapy as more credible; and (4) therapist cultural comfort was related to better client outcomes.

Practice Implications

The authors suggest that therapists ask open-ended questions to clients regarding their cultural identity, such as asking the role that religion and spirituality play in their lives. This would allow therapists to learn about client cultural identity in the client’s own words. It is particularly important for therapists to maintain a stance of humility and cultural comfort, and to attend to opportunities to work productively with cultural issues in therapy in order to improve their clients’ outcomes.

October 2017

Therapists’ Appropriate Responsiveness to Clients

Stiles, W. B. & Horvath, A. O. (2017). Appropriate responsiveness as a contribution to therapist effects. In L. Castonguay and C. Hill (Eds.). How and why some therapists are better than others?: Understanding therapist effects (Ch. 4). Washington: American Psychological Association.

Appropriate responsiveness refers to therapists’ ability to adapt their techniques to the client’s requirements and circumstances. This might include planning treatment based on how the client is responding, using the client’s evolving responses to treatment as a guide to interventions, and adjusting interventions already in progress in light of subtle signs of client uptake. Appropriate responsiveness may depend on a client’s diagnosis, education, personality, stage of life, values, stage of therapy, among others. Responsiveness also depends on therapists’ skills, personality, theoretical orientation, and history of the therapeutic relationship. In this chapter, Stiles and Horvath review the literature on relationship variables that predict therapy outcomes and interpret these findings in the context of therapist responsiveness. To illustrate, previous research showed that therapists’ rigid adherence to a treatment manual was associated with worse client outcomes – or to state it differently, therapist adherence flexibility was associated with better outcomes. This flexibility is an indication of appropriate responsiveness on the part of the therapist. Stiles and Horvath also argue that most of the relationship variables that predict client outcomes reflect whether therapists appropriately respond to the circumstances of the client at a particular point in therapy. That is, evidence-based relationship factors like alliance, cohesion, empathy, goal consensus, positive regard, and others evaluate whether the therapist successfully tailored interventions and behaviors to the client’s unique personality and circumstances. For example, therapeutic alliance (the affective bond, and agreement on tasks and goals of therapy) indicates that the therapist selected interventions that were appropriate to the client, introduced them at the right time, and was attentive to and interested in the client’s progress. In support of this, the authors cite research showing that the therapeutic alliance is largely a function of the therapists’ responsiveness and not the client’s characteristics. That is, therapists are largely responsible for the quality of the therapeutic alliance.

Practice Implications

Research is increasingly indicating that therapists’ ability to respond appropriately to clients on a moment-to-moment basis is a key therapeutic factor. In other words, therapists who can build strong alliances, repair alliance ruptures, work for goal consensus and collaboration, manage countertransference, and be empathic are those who respond to the changing nature of client characteristics and needs in therapy. Supervision that provides feedback to therapists on these therapeutic factors, mastering a framework to guide interventions, client progress monitoring and feedback, and acquiring knowledge of client personality and cultural factors can sensitise therapists to their client’s changing requirements and allow them to respond therapeutically.
Therapeutic Alliance in the Treatment of Adolescents

Murphy, R. & Hutton, P. (2017). Therapist variability, patient reported therapeutic alliance, and clinical outcomes in adolescents undergoing mental health treatment: A systematic review and meta-analysis. The Journal of Child Psychology and Psychiatry, doi:10.1111/jcpp.12767.

The therapeutic alliance refers to the affective bond between therapist and client, and their agreement on the tasks and goals of therapy. The alliance is a well-known predictor of outcomes in adult psychotherapy with a mean alliance-outcome correlation of r = .28. Less is known about the role of the alliance in the treatment of adolescents. Some reviews indicate that the alliance-outcome relationship in children and adolescents is weaker than observed among adults, but these reviews may have been flawed since they included both children and adolescents in the same review, and the number of studies they reviewed was small. A large rigorous systematic review of adolescents’ perceptions of the alliance can provide insight into their experience of psychological treatment and inform routine mental health practice. In their meta analysis, Murphy and Hutton reviewed studies of clinical samples of adolescents between the age of 12 – 19 who received psychological treatment. The authors made sure that the measures of alliance and outcomes were reliable, they excluded studies of those with medical and neurocognitive problems, and included only studies with adolescents (i.e., excluding studies with primarily children). Twenty-seven studies with almost 3,000 participants were included. Main presenting problems of adolescent patients were: substance use, eating disorders, behavioral difficulties, and a range of mood and anxiety disorders. The mean weighted effect size of the alliance-outcome relationship among studies of psychological treatment of adolescents was r = .29 (95% CI: 0.21, 0.37; p < .001) indicating a moderate effect.

Practice Implication

This is the largest meta analysis of the alliance-outcome relationship in the psychological treatment of adolescents with mental health problems. The alliance was moderately associated with outcomes, and so therapeutic alliance may be a reliable predictor of clinical progress in the treatment of adolescents. The findings suggest that those working with adolescents should routinely assess the alliance after each session in order to evaluate if they need to address relational barriers to positive outcomes. For example, if the alliance markedly declines from one session to the next, then clinicians should address potential problems in their relationship with the adolescent client, renegotiate goals, or renegotiate the tasks of therapy.

September 2017

Does it Matter Which Therapist a Client Gets?

Barkham, M., Lutz, W., Lambert, M., & Saxon, D. (2017). Therapist effects, effective therapists, and the law of variability. In L.G. Castonguay and C.E. Hill (Eds.) How and why are some therapists better than others? Understanding therapist effects. Washington, DC: American Psychological Association.

Psychotherapy research has often focused on the differences between treatment types (CBT, interpersonal psychotherapy, psychodynamic therapy), which has overshadowed research on what makes for an effective therapist. Psychotherapists represent the most costly important component of psychotherapy, and only recently has research begun to catch up to the importance of therapist effects. The term “therapist effects” refers to differences between therapists (i.e., variability) in their clients’ outcomes. In this chapter, Barkham and colleagues review some of the research on effective therapists. Best estimates of therapist effects suggest that differences between therapists account for about 8% of client outcomes – which is considered a medium effect and larger than the variance accounted for by the type of therapy that a client receives. Psychotherapy research often tries to control for therapist effects by training therapists to adhere to a manual, however adherence to a manual does not substantially reduce therapist effects, and adherence is not related to patient outcomes. The implication is that which therapist a client sees matters to the client’s mental health outcomes. The best research on the topic indicates that about 20% of therapists are substantially better than the average therapist, and 20% are substantially worse than the average. (The good news is that 60% of therapists [the average] are equally and positively effective). In that study of 119 therapists, the least effective therapists had about 40% of their clients recover, whereas the most effective therapists had about 76% of their clients recover. In other words, the better therapists were almost twice as effective as the worse therapists. In a re-examination of previous data, Barkham and colleagues looked at whether other variables, like client symptom severity, played a role in therapist effects. They found that differences among therapists was higher as client baseline severity increased. That is, the gap between better and worse therapists increased when client symptoms were more severe and complex. Good therapists were better equipped to handle more complex cases.

Practice Implications

There are important differences between therapists in their effectiveness, and this makes a difference to clients. It is particularly important for clients with more severe symptoms to be matched with more effective therapists. Previous research indicates that the level of therapist interpersonal skills (alliance, empathy, warmth, emotional expression, verbal skills) can account for significant proportion of therapist effects, and so training therapists in these interpersonal skills will improve client outcomes. Also, therapists who receive continuous reliable feedback throughout therapy about their client’s symptom levels can also drastically reduce client drop-outs and the number of clients who get worse during treatment.

February 2017

The Importance of Psychosocial Factors in Mental Health Treatment

Greenberg, R.P. (2016). The rebirth of psychosocial importance in a drug-filled world. American Psychologist, 71, 781-791.

In this thoughtful piece, Greenberg reviews the research on psychosocial factors that affect mental health treatment outcomes – including for medications and in psychotherapy. There has been an important shift in the last few decades to view mental disorders, including depression, as biologically based. For example, surveys indicate that the public’s belief in biological causes of mental illness rose from 77% to 88% during a 10 year period. During the same period the belief in the primacy of biological treatment for mental disorders rose from 48% to 60%. Further, 20% of women and 15% of men in the US are currently taking antidepressant medications. Some of these trends are due to direct to consumer marketing of medications by the pharmaceutical industry, which saw a 300% increase in sales in antidepressants. Some of these trends are also due to Federal agencies like the National Institute of Mental Health that vigorously pursued an agenda of biological research. But what is the evidence for a purely biological view of mental health? Greenberg notes that the evidence is poor. For example, no one has been able to demonstrate that a chemical imbalance actually exists to explain depressive symptoms – which undermines the reason for using medications to treat depression. Further, research on the efficacy of antidepressant medications shows that they perform only slightly better than a placebo pill, prompting a former editor of The New England Journal of Medicine to declare that this difference is unlikely to be clinically meaningful. The placebo effect is essentially a psychosocial effect. It refers to: the patient’s experience of a caring relationship with a credible professional, and the patient’s expectations and hopes of getting better. Placebo is a very real phenomenon that also has an impact on purely medical interventions like surgeries. In psychotherapy trials, relational/contextual factors like therapeutic alliance, expectations, therapist empathy, and countertransference likely account for more of the client’s outcomes than the particular therapeutic technique that is used. In both psychotherapy and medication treatments for depression, it appears that the more patients perceived their doctors as caring, empathic, open, and sincere, the greater their symptom improvement. There is also good evidence that psychotherapy is as effective and antidepressants for mild to moderate depression, and that antidepressants are slightly superior for chronic depression. However, even the latter should be interpreted carefully and within the context that patients prefer psychotherapy, their adherence to medications is poorer, side effects are worse for medications, and drop out rates are lower for psychotherapy.

Practice Implications

Patients benefit from antidepressant medications, but perhaps not exactly for the reasons that they are told. Psychosocial factors likely account for a large proportion of the effects of many medically-based interventions for mental disorders. Psychosocial factors are actively used in many psychotherapies, and therapists’ qualities like their ability to establish an alliance, empathy, and professionalism account for a moderate to large proportion of why patients get better.

May 2016

Common Factors Across 5 Therapies for Suicidal Patients with Borderline Personality Disorder

Sledge, W., Plukin, E.M., Bauer, S., Brodsky, B.,... Yoemans, F. (2014). Psychotherapy for suicidal patients with borderline personality disorder: An expert consensus review of common factors across five therapies. Borderline Personality Disorder and Emotion Dysregulation, 1:16. doi:10.1186/2051-6673-1-16.

Treating patients with suicidal ideation and borderline personality disorder (BPD) can cause significant anxiety, concern, anger, and guilt in clinicians. Strong emotional reactions can lead to risky therapeutic interventions, poor clinical decisions, and professional burn out. The outcome of therapy can have serious consequences for such patients. Recently, a panel of 13 experts reviewed the efficacy of the most common treatments for suicidal ideation in BPD. As part of the review, they identified the common factors that may be useful for all clinicians who work with these clients. The five therapies they reviewed included the following. Dialectical behavior therapy, which emphasizes the role of emotional dysregulation and impulsivity in suicide. Treatment includes distress tolerance, emotional regulation, interpersonal effectiveness, and mindfulness. Schema therapy decreases suicide risk by challenging negative thoughts with cognitive and behavioral techniques while using the therapeutic relationship to improve the patient’s capacity to attach to others. Mentalization based therapy works toward improving the patient’s capacity to keep in mind the patient’s own mind and the mind of the other. This encourages new perspectives on relationships and emotion regulation. Transference focused psychotherapy views suicidal behavior in BPD as related to distorted images of the self and others. The treatment emphasizes gaining greater awareness of self in relation to others, and integrating a more realistic experience of the self. Good psychiatric management is an integrative approach that uses both psychodynamic and behavioral concepts. The approach sees BPD as a problem with interpersonal hypersensitivity, but the management tends to be more pragmatic than theoretically based. The expert panel defined six common factors among these treatments. (1) Negotiation of a frame for treatment – in which roles and responsibilities of therapist and patient are defined before the start of treatment, including an explicit crisis plan. (2) Recognition of the patient’s responsibilities within therapy. (3) The therapist having a clear conceptual framework for understanding the disorder that then guides the interventions. (4) Use of the therapeutic relationship to engage the patient and to address suicide actively and explicitly. (5) Prioritizing suicide as a topic whenever it comes up in the therapy. (6) Providing support for the therapist through supervision, consultation, and peer support.

Practice Implications

Suicidal ideation in patients with BPD can have serious consequences for the patient and can be highly stressful for the clinician. This expert panel identified six common features of most major treatment approaches to suicidal ideation in BPD. Even if clinicians are not explicitly trained in any one of the approaches, ensuring that these six factors are present in their work will improve the likelihood that their patients will experience a good outcome.

This month...

Type of Research

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November 2017

Practice Implications

October 2017

Practice Implications

Practice Implication

September 2017

Practice Implications

February 2017

Practice Implications

May 2016

Practice Implications

Psychotherapy Practice Research Network (PPRNet)