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Kolden, G.G., Austin, S.A., Wang, C-C., Chang, Y., & Klein, M. (2018). Congurence/genuineness: A meta-analysis. Psychotherapy, 55, 424-433.

More than 60 years ago Carl Rogers first described congruence or genuineness in the psychotherapy relationship as one of the necessary conditions for patients to improve. Congruence has two components. The intrapersonal component refers to mindful genuineness, personal awareness, and authenticity in relationships. The interpersonal component refers to the capacity to express ones’ internal experiences to another person. Rogers argued that patients often experience incongruence with regard to their internal states (they may avoid or fear the experience or expression of what they think or feel). He also stated that therapists’ congruence in the relationship with a patient is a pre-requisite for positive regard and empathy toward the patient. In this meta-analysis, Kolden and colleagues do a systematic review of the relationship between therapist congruence and patient outcomes. The review included 21 studies representing 1,192 patients. The weighted effect size for congruence and psychotherapy outcome was r = .23 (95% CI: .13, .32), representing on average a moderately large effect. Theoretical orientation did not affect the congruence – outcome association. However older therapists with more experience showed a significantly stronger congruence – outcome relationship. Also, therapy with younger patients was associated with a larger congruence – outcome relationship.

Practice Implications

Research continues to support fundamental therapeutic factors defined by Rogers many decades ago. In this case, congruence/genuineness (or the therapist’s ability to know their internal experience and communicate it respectfully to patients) is positively related to patient outcomes. This is especially true for older therapists (who may have a greater capacity for genuineness) and for younger patients – (for whom therapist genuineness may be particularly important). Patients who may have a greater need for and expectation of genuineness are likely to develop a stronger therapeutic alliance with a highly congruent therapist. Patients in a congruent therapeutic relationship learn that it is a safe space, that they matter as a person, and that the therapist is committed and accepting. All of which are precursors to a successful therapy.

Client Stage of Change Predicts Their Outcomes in Psychotherapy

Krebs, P., Norcross, J.C., Nicholson, J.M., & Prochaska, J.O. (2018). Stages of change and psychotherapy outcomes: A review and meta-analysis. Journal of Clinical Psychology, 74, 1964-1979.

Next to the therapeutic alliance, client stage of change is one of the most researched concepts in psychotherapy. The theory posits that clients come for treatment with varying levels of motivation, preparation, and capacity for behavior change. And their overall readiness for change influences the process and outcome of the psychotherapy they receive. Researchers have identified five stages that clients may go through during the change process, and they identified most effective therapist stances to help clients move from one stage to the next. Precontemplation is the stage in which the client has no intention of changing, and they may have been coerced into coming to therapy. During this stage therapists may help the client increase their awareness of the advantages of changing and the costs of not changing. Contemplation is the stage in which the client is aware that there is a problem, but has not yet made a commitment to take action. During this stage the client may face the sadness or anxiety related to letting go of behaviors that no longer work. Therapists may help a client to re-evaluate themselves should they change their behaviors. Preparation is a stage in which the individual is fully intending to take action, and they may make small behavioral changes. Therapists may help clients in this stage to act on their belief that they have the ability to change their behavior. Action is the stage in which clients modify their behaviors or environment to overcome their problems. Therapists may help clients at this stage by ensuring clients perceive adequate reinforcements for their efforts and resist the tendency to avoid problematic situations or feelings. Finally, the maintenance stage is the point at which clients have made desirable changes and now work to prevent relapse and consolidate gains. Therapists may help individuals during the maintenance phase to be prepared for or to avoid situations that may induce relapse. A key aspect of therapist stances related to client stages of change is exemplified by the process of motivational interviewing, in which the therapist works with the client’s resistance rather than taking a confrontational stance. In this meta-analysis, Krebs and colleagues systematically reviewed the literature on stages of change and summarize 76 studies with over 21,000 clients. The association between stage of change and client outcome was significant and moderate in effect size (d = 0.41; 95% CI: 0.34, 0.48). That is the stage of change at which the client starts has a measurable impact on their outcomes, with pre-contemplation being related to poorest outcomes, and action being related to best outcomes. These results were consistent across theoretical orientations. In a second meta-analysis, the authors found that tailored interventions to move clients to more advanced stages of change were significantly related to better outcomes, though the effects were small (d = 0.18; 95% CI: 0.16, 0.20).

Practice Implications

The stage of change theory is transtheoretical – that is, it operates across most therapeutic situations and clients. The findings of this meta-analysis indicate that therapists who know the client’s stage of change and who act accordingly will improve their client’s outcomes. Many therapists tend to believe that their clients are at the action stage, but this may not be the case. Treating someone who is contemplating change as if they are ready to make changes may be counter-therapeutic as it represents a mismatch of goals. Hence, therapists should work with clients to set realistic goals for therapy, and therapists should keep in mind that a patient who is not ready to change will not likely change if confronted. The best strategy may be to discuss with the client the risks and benefits of their behaviors, and help them make a decision of how or if to move forward with therapy.

Soto, A., Smith, T.B., Griner, D., Rodriguez, M.D., & Bernal, G. (2018). Cultural adaptations and therapist multicultural competence: Two meta‐analytic reviews. Journal of Clinical Psychology, 74, 1907-1923.

There is emerging evidence that a client’s cultural experiences and background have an impact on the therapeutic alliance and on client outcomes. One means of adjusting psychotherapy is by cultural adaptations, which involve modification of treatment to consider language and culture in such a way that the treatment is more compatible with the client’s values. Cultural adaptation might incorporate holistic/spiritual concepts of wellness, and may include cultural rituals. Therapists could also align treatment goals and methods with the client’s culture. Domains of psychotherapy that psychotherapists can adapt to a client’s culture include: language of treatment, metaphors used in therapy, the person of the therapist (assigning a therapist with a similar cultural background), content discussed, concepts explored, goals of therapy, methods of interventions consistent with cultural values, and the context of treatment. Cultural competence refers to the therapist’s ability to engage and work effectively with diverse clients. These competencies include: awareness (ability to recognize cultural backgrounds, assumptions, and biases), knowledge (understanding of specific cultural groups and their history and experiences), and skills (ability to engage cultural groups and modify treatment to match cultural needs). In the first of two meta analyses, Soto and colleagues identified 99 studies of cultural adaptation that included data from almost 14,000 clients who were mainly Asian American, Hispanic/Latin American, or African American. The most frequent adaptations were for language of therapy, cultural values, and matching therapists with similar racial/ethnic backgrounds. Cultural adaptation had a significant, moderate, and positive effect to improve psychotherapy outcomes, d = 0.50 (se = 0.04; 95% CI, 0.42–0.58; p < 0.001). Even after adjusting for publication bias, the findings were significant but smaller d = 0.35 (95% CI, 0.27–0.43). All types of adaptation had a positive impact, but the biggest effect came with providing treatment in the native language of the client. Also, older clients benefitted most for cultural adaptation. In the second meta-analysis, the authors identified 15 studies of 2,640 clients on the effect of therapists’ level of multicultural competence. They found a significant and moderate association between therapist cultural competence and positive client outcomes, r = 0.24 (95% CI, 0.10–0.37; p < 0.001). However, only the client’s (and not the therapist’s) rating of therapist cultural competence was associated with better outcomes.

Practice Implications

The results of these meta-analyses clearly indicate that both cultural adaptations of psychotherapy and therapist cultural competence improve client outcomes. During the assessment phase, therapists should evaluate clients’ racial and ethnic backgrounds and the salient culturally-specific values and worldviews held by the client. Therapists could, whenever feasible, adapt their treatment to the client’s culturally-held values. Therapists might, if possible, arrange to provide therapy in the native language of the client – particularly for older clients. Cultural issues should be handled by therapists in a humble way. And therapists should keep in mind that it is the client’s experience, and not the therapist’s self-assessment, of cultural competence that is most relevant.

Author email: Alberto_Soto@brown.edu

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

Beutler, L.E., Kimpara, S., Edwards, C.J., & Miller, K.D. (2018). Fitting psychotherapy to patient coping style: A meta‐analysis. Journal of Clinical Psychology, 74, 1980 – 1995.

This is another in a series of meta-analyses that assess client factors and their impact on outcomes. Researchers have been studying the impact of coping style in a number of different areas in social and clinical psychology for decades. Coping styles refers to characteristic ways of behaving in order to reduce discomfort and to adapt to changing circumstances. Everybody has preferred methods of coping, however when a coping style becomes extreme or rigid, then it can be pathological. Broadly speaking, researchers and clinicians categorize coping styles as internalizing or externalizing in nature and function. Those who primarily use internalizing coping tend to face change, distress, or threat by becoming internally focused, inner-blaming, inhibited, socially withdrawn, anxious, worrying, or working out issues by thinking them through. Those who primarily use externalizing coping tend to deal with stress by being externally focused, acting out, blaming others, confronting others, or using their social environment and support to manage their distress. Also, generally, one can define theories and practices of psychotherapy as those that are insight-oriented versus symptom-focused. Insight-oriented approaches emphasize that patients re-experience repressed emotions and develop self-understanding as a means of creating change. Symptom-focused approaches generally require patients to engage in new behaviors, new learning, or new perceptions followed and reinforced by social rewards. In this meta-analysis, Beutler and colleagues assess if patients with internalizing or externalizing coping styles achieve better outcomes if they received insight-oriented vs symptom-focused psychotherapy. That is, they assessed if patients matched to therapy focus based on their coping style might achieve better outcomes. They reviewed 18 studies including 57 types of treatment and almost 2,000 patients. Beutler and colleagues found that the mean therapy focus by coping style interaction was d = .60 for all studies (SE = 0.10; p < 0.001; CI 95% = 0.44–0.76). This suggests a medium to large effect in which matching therapy to coping style accounting for 23% of the variance in patient outcomes. Patients who use internalizing coping tend to do better in insight-oriented psychotherapy whereas those who use externalizing coping tend to do better in symptom-focused interventions.

Practice Implications

The results of this meta-analysis suggested that psychotherapists would do well to assess patients’ coping style during the intake assessment process and modify their treatments and interpersonal stances accordingly. Symptom-focused interventions, like those seen in behavioral or cognitive-behavioral therapies may work better for those with externalizing coping styles. On the other hand, insight or relationship-oriented interventions, like those seen in interpersonal or psychodynamic therapies, may be more apt for patients with internalizing coping styles. Despite this general rule, therapists should also be aware that client preferences, culture, and other transdiagnostic factors can effectively guide treatments and therapist stances.

Author email: larrybeutler@yahoo.com

Beutler, L. E., Edwards, C., & Someah, K. (2018). Adapting psychotherapy to patient reactance level: A meta‐analytic review. Journal of Clinical Psychology. Advance online publication.

This is another meta-analysis part of the Psychotherapy Relationships That Work series. In this study Beutler and colleagues looked at client resistance and its more extreme form, reactance. Resistance refers to a client avoiding to make changes advocated by the therapist, whereas reactance indicates not only that a client resists but also moves in a direction away from what the therapist is advocating. Social psychologists define resistance as a state of mind aroused by threat to one’s freedom and then attempts to restore one’s freedom. Resistance and reactance are relational concepts – that is, they are not only qualities of the client but defined by the therapeutic relationship. Therapists play a role in resistance by the degree to which they are directive, and by their ability to adjust their level of directiveness or control to the client’s characteristics. Therapist directiveness refers to the degree to which a therapist uses suggestion, interpretation, and assignments in therapy, such as: homework, setting topics, and leading the session. One way for a therapist to adjust their interpersonal stance is to reduce their level of directiveness with clients who are more resistant. In this meta-analysis, Beutler and colleagues reviewed 13 studies representing 1,028 clients. The aggregate effect size for the association between client reactance and therapist directiveness with client outcomes was d = 0.78 (SE = 0.1; p < .001; 95% CI: 0.60–0.97), which is large and significant. In other words, if a therapist adjusted their level of control by lowering it in the face of a resistant client, then client outcomes were better. The opposite was also true, if a therapist increased their directiveness for clients who were less resistant then those clients had better outcomes.

Practice Implications

The results indicate that if client resistance or reactance is not met with confrontation and control, but with acceptance and non-defensiveness, the client may have a better outcome. Resistant or reactant clients will likely do better in a therapy that is less directive, whereas clients with lower levels of resistance may do better with more directive interventions. Therapists may do well to assess routinely the level of a client’s resistance, and adjust their interventions accordingly. Highly resistant clients may need a more collaborative approach, and a transparent discussion that focuses on the impact of certain interventions and therapist interpersonal stances on the client’s sense of control and personal freedom in the therapy.