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Curran, J., Parry, G.D., Hardy, G.E., Darling, J., Mason, A-M., Chambers, E. (2019). How Does therapy harm? A model of adverse process using task analysis in the meta-synthesis of service users’ experience. Frontiers in Psychology, 10:347. doi: 10.3389/fpsyg.2019.00347

Forty to 60% of patients do not recover after a course of psychotherapy, and approximately 5% to 8.2% are worse off. In the National Health Service in the UK, 5% of patients reported lasting bad effects of therapy. Although these appear to be small percentages, they represent a large number of patients. In Canada for example, over 1 million Canadians use psychotherapy each year, so 5% would represent 50,000 individuals. Therapists, for their part are poor at identifying patients who deteriorate in therapy. In this meta-synthesis of qualitative research, Curren and colleagues aimed to derive a model based on patients’ experiences of the factors that lead to negative outcomes. They conducted a narrative review of qualitative research findings and of patients’ testimony from a number of sources. They noted eight domains identified by patients that are associated with adverse events in psychotherapy. First, contextual factors refer organizational issues that affect access to or choice of therapy, cultural validity of the therapy, and lack of information about services. Second, pre-therapy factors refer to poor pre-therapy contracting between therapist and patient, and therapists that focus on symptoms rather than the client as a person. Third, therapist factors refer to therapist inflexibility, and therapists’ financial interests that influence their decisions about therapy. Fourth, client factors refer to client lack of understanding of therapy, fear, and demoralization. Fifth, relationship factors refer to a poor relational fit between therapist and patient, therapists perceived as shaming, therapists misusing power, and clients not feeling heard or understood. Sixth, therapist behaviors refer to boundary violations, rigidly applying techniques, therapist acting out, and therapist passivity. Seventh, therapy process refers to the type of therapy offered not matching patient needs, and patients not agreeing with the techniques. Eighth, endings refer to short term therapies that “open a can of worms” without resolution, and the client feeling abandoned.

Practice Implications

Therapists would do well to ensure that the patient’s voice is heard when it comes to preferences and cultural validity of the treatment. In particular, therapists should not rigidly apply techniques focused exclusively on symptom reduction. Instead, therapists should see patients’ problems within their interpersonal and cultural context and focus on outcomes related to the quality of life of patients. Therapists must attend to developing and maintaining the therapeutic alliance (agreement on tasks and goals of the therapy, and the relational bond with patients). Any signs of disruptions or tensions in the alliance should be identified and repaired. Patients require information about the therapy, what it entails, and how it will end before signing on to a course of treatment. Organizations must remove barriers to accessing treatment and provide therapies that represent a range of orientations and foci to meet patients’ needs.

Huey, S. J. & Tilley, J. L. (2018). Effects of mental health interventions with Asian Americans: A review and meta-analysis. Journal of Consulting and Clinical Psychology, 86, 915-930.

Do existing mental health interventions work well for patients of Asian descent? Interventions delivered in the typical way in which they were devised may not be as effective as intended when it comes to culturally diverse groups like Asian Americans. The clinical trials in which the treatments were developed typically are almost exclusively made up of White participants, and most evidence-based treatments do not consider cultural considerations. Culturally responsive psychotherapies that are consistent with the cultural norms, values, and expectations of patients may be more effective. That is, if an evidence-based treatment is not culture specific, it may not be as effective as intended. Even when culture is taken into account in evidence-based treatments, the accommodation tends to be for African American or Hispanic/Latino patients, and not for Asian American patients. Asian American and East Asian heritage is often influenced by Confucian values that emphasize interpersonal harmony, mutual obligations, and respect for hierarchy in relationships. This may mean that patients of Asian descent may be less committed to personal choice, more attuned to others, and more socially conforming. This may lead to cultural differences in cognitive processing and emotional reactions to interpersonal contexts. In this meta-analysis, Huey and colleagues assessed if the effects of evidence-based treatments will be bigger if the treatments were specifically tailored for Asian Americans. Their review included 18 studies with 6,377 participants. Samples included Chinese Americans, Cambodian Americans, Korean Americans, Vietnamese Americans, and other Asian groups. Problems treated included depression, PTSD, smoking, and other concerns. About half of the studies were of CBT, and most (91%) were culturally tailored in some way either for an Asian subgroup or tailored for minorities in general. The mean effect size for evidence-based treatments versus control groups was d = .75, SE = .14, p < .001, indicating a moderate to large effect. Treatments tailored specifically for Asian subgroups (e.g., Chinese Americans) showed the largest effects (d = 1.10), whereas treatment with no cultural tailoring or non-Asian tailoring showed the smallest effects (d = .25).

Practice Implications

Existing psychological treatments are efficacious for Asian Americans, with moderate effects. However, treatments specifically adapted for Asian American subgroups showed the largest effects, indicating that specific cultural adaptations could substantially improve the effectiveness of psychotherapy. Asian Americans face challenges in terms of using and engaging in treatments. Developing culturally specific interventions to improve acceptability of treatment may be one way to make the most therapeutic impact on one of the largest growing racial groups in North America.

Author email: hueyjr@usc.edu

Truijens, F., Zühlke‐van Hulzen, L., & Vanheule, S. (2018). To manualize, or not to manualize: Is that still the question? A systematic review of empirical evidence for manual superiority in psychological treatment. Journal of Clinical Psychology. Advance online publication. 

In 2010 Webb and colleagues published a meta-analysis in which they showed that the association between adherence to a psychotherapy manual and treatment outcome was close to zero. The same was true for therapist competence in delivering the manualized psychotherapy – almost no relationship to client outcome. Psychotherapy manuals typically specify the theoretical basis for an intervention, the number and sequencing of treatment sessions, the content and objective of sessions, and the procedures of each session. National institutes in the US and the UK have promoted manuals as a means to define what is evidence-based psychotherapy. By doing so these institutes assume that psychotherapy that is manualized is more effective that non-manualized treatment. However, detractors have argued that: (1) strict adherence to manuals may reduce therapists’ ability to individualize treatment to client needs and characteristics; (2) manuals are often designed for single disorders but clients tend to have many comorbid conditions; and (3) it is impossible for clinicians to gain competence in all different manuals for the various client conditions they may encounter. In this systematic review, Truijens and colleagues ask: does the use of manuals increase therapy effectiveness? To answer this question they conducted three different systematic reviews. First, they reviewed six studies that directly compared manualized versus non-manualized versions of a psychotherapy within the same study. One study showed manuals were superior, three showed no difference, and two studies showed that non-manualized therapies were more effective. Second, they reviewed eight meta-analyses that compared the pre- to post-treatment effect sizes of manualized therapies and of non-manualized therapies versus no-treatment control conditions. Three meta-analyses concluded that manualized therapies were superior, four meta-analyses did not find differences, and one observed non-manualized treatments to be superior. Third, the authors reviewed 15 additional studies to those reviewed by Webb and colleagues in their original meta-analysis. Overall, Truijens found similar results that support the conclusion that the level of adherence to psychotherapy manuals is not substantially related to better treatment outcomes.

Practice Implications

Although treatment manuals may be helpful for training purposes and to ensure validity in psychotherapy research, there is actually little consistent evidence that adhering to a manual results in better client outcomes. Some have argued that rigid adherence to a treatment manual can be harmful to clients. Therapists may need to take a flexible stance when applying research-supported therapeutic principles and interventions. Such a stance adjusts therapy to take into account client characteristics like level of resistance, coping style, attachment style, and others. Truly evidence-informed approaches incorporate what we know about client characteristics, therapeutic relationship factors, and therapist factors to promote positive outcomes in psychotherapy clients.

Davis, D. E., DeBlaere, C., Owen, J., Hook, J. N., Rivera, D. P., Choe, E., . . . Placeres, V. (2018). The multicultural orientation framework: A narrative review. Psychotherapy, 55(1), 89-100.

Many therapists have better outcomes with White or European clients than clients from diverse racial or ethnic minorities, and this might be due to racial and ethnic microaggressions that sometimes occur in therapy. Microaggression refer to intentional or unintentional brief commonplace verbal, behavioural, or environmental indignities that are experienced as derogatory or negative by racial and ethnic minority clients. A multicultural orientation refers to how the cultural worldviews, values, and beliefs of clients and therapists interact to co-create a relational experience in therapy. Therapist multicultural orientation has three elements. First, cultural humility, in which a therapist is able to maintain an interpersonal stance that is open to the client’s experience of cultural identity. Second, cultural opportunity, in which the therapist uses events in therapy to explore a client’s cultural identity in depth. Third, cultural comfort in which a therapist feels at ease, open, and calm with diverse clients. These elements are important in order to negotiate a therapeutic alliance (i.e. agreement on tasks and goals of therapy, and the emotional bond between client and therapist). In this narrative review, Davis and colleagues look at the small existing research on multicultural orientation and how that research can inform therapists’ practices. The authors found that in the two studies on the topic, greater therapist cultural humility was associated with better client outcomes. Several studies found that cultural humility was associated with a positive therapeutic alliance, and that therapist cultural humility was associated with fewer microaggressions as experienced by racial and ethnic minority clients. Finally, missed opportunities by therapists to explore the meaning of culture and identity were associated with negative client outcomes. Presumably, such missed opportunities meant that therapists did not recognize and repair cultural ruptures.

Practice Implications

The research on multicultural orientation suggests several practice implications. (1) Cultural humility requires therapists to explore their automatic cultural assumptions because if they remain unexplored they may be harmful to clients. (2) Therapists should overtly discuss the importance of cultural identities with clients in order to help both therapist and client develop a more complex understanding of the issues that bring the client to therapy. (3) A strong therapeutic alliance may require the therapist to incorporate their client’s cultural worldview and perspective when conceptualizing the client’s problems. (4) Depending on the client’s cultural worldview, therapists may consult with the client’s family and/or spiritual leaders when negotiating a culturally acceptable way of addressing the client’s problems. (5) Therapists need to identify for themselves when their values conflict with those of the client, and seek consultation or supervision when they do.

Totura, C.M.W., Fields, S.A., & Kraver, M.S. (2018). The role of the therapeutic relationship in psychopharmacological treatment outcomes: A meta-analytic review. Psychiatric Services, 69, 41-47.

There is evidence to suggest that pharmacological treatments are effective for a wide range of disorders. However, a high level of adherence to taking psychotropic medications is necessary in order for them to have a chance of working. Medical interventions in general do not work well when patients are non-adherent to the regimen, and non-adherence is a significant problem in medicine. Treatment adherence is particularly problematic in those with a mental health condition. Low adherence may have to do with problems with the medications themselves, like unpleasant side effects. And low adherence also may be due to issues related to mental health impairment, like low motivation and problems with reasoning. A particular issue in mental health treatment is the manner in which patients receive the medication. Unlike some medical interventions, psychotropic medications are often taken by patients on their own and away from the clinic or hospital. In psychotherapy, we know that a good therapeutic alliance improves outcomes partly because a good alliance provides a context within which psychological interventions can work (i.e., clients may be more adherent to the treatment recommendations) and partly because the alliance itself may be therapeutic. In this meta analysis, Totura and colleagues examine if there is an association between the therapeutic alliance and mental health outcomes for patients who receive pharmacological interventions for their mental illness symptoms. Eight studies of 59 samples representing over 1,000 patients were included. Four studies were of pharmacological treatment for affective disorders, two for schizophrenia, and two for mixed diagnoses. The results indicated a statistically significant and moderate effect: z = .30 (CI=.20, .39, SE=.048, z=6.192, p=.05), such that greater therapeutic alliance predicted better mental health outcomes among patients receiving pharmacotherapy.

Practice Implications

Higher quality of the physician-patient relationship was related to better mental health treatment outcomes for patients taking pharmacotherapy. The therapeutic alliance appears to be just as import in pharmacological treatment as it is in psychotherapy. It is possible that a good alliance with the provider may increase patient adherence, which may lead to better outcomes. It is also possible, however, that the alliance itself is therapeutic. That is, negotiating an alliance and repairing alliance tensions may lead to positive changes in patients’ ability to cope with emotions and to make the most of their social supports. The results also suggest the importance of training physicians in communication skills to improve therapeutic relationships.

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.