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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

Pomerville, A., Burrage, R.L., & Gone, J.P. (2016). Empirical findings from psychotherapy research with indigenous populations: A systematic review. Journal of Consulting and Clinical Psychology, 84, 1023-1038.

Indigenous people around the world have a higher incidence of mental illness compared to other ethnic or racial groups. These higher rates may be related to the historical effects of colonization and to current discrimination. Despite this, there is very little empirical research on psychotherapy provided to Indigenous peoples. Psychotherapy, as commonly practiced, has Eurocentric values by emphasizing individuality, independence, rationality, assertiveness, and by sometimes taking an ahistorical present-centered focus. These values may conflict with some Indigenous cultures that emphasize community, interdependence, mysticism, modesty, and the historical context of current functioning. Hence, psychotherapy as typically defined may require adaptations when used with Indigenous groups. In their review, Pomerville and colleagues examine what is currently known about psychotherapy with Indigenous populations. The populations studied in the existing research includes Indigenous peoples of the US, Australia, Canada, Pacific Islands, and New Zealand. There were no psychotherapy studies prior to 1986, and only 23 studies since then. Most studies emphasized some form of cultural adaptation of the treatment. The majority of studies focused on substance abuse, with only a few on anxiety and depression. Only two studies were controlled outcomes studies (i.e., randomized controlled trials considered by many to provide the best evidence from a single study). Research on individual therapy for Indigenous adolescents is completely lacking. The authors concluded that the efficacy of novel or adapted treatments or the generalizability of existing empirically supported treatments to Indigenous people are currently unknown.

Practice Implications

The virtual absence of controlled outcome trials of psychotherapies for Indigenous populations is serious gap in the practice of mental health interventions. This state of the research is particularly problematic given the high rates of mental illness and alarming rates of suicide among adolescents in Indigenous populations. Some studies found discontent among Indigenous communities with the current application of empirically supported treatments, and others argue that Indigenous healing be given the same legitimacy despite no controlled outcome research. On the other hand some authors favour training cultural competence among clinicians who practice standard empirically supported treatments. Pomerville and colleagues suggest that in the absence of evidence, tailoring psychotherapy to address the needs of Indigenous clients by taking into account specific practices of their communities may improve retention and outcomes.

Falkenström, F., Grant, J., & Holmqvist, R. (2016): Review of organizational effects on the outcome of mental health treatments. Psychotherapy Research, DOI: 10.1080/10503307.2016.1158883

Many psychotherapists treat patients within organizational contexts. These contexts might include university clinics, hospitals, primary care centers, community health centers, or even shared or group private practices. Psychotherapy researchers are often concerned with patient outcomes and predictors of outcomes like patient, therapist, or relationship variables. However, rarely do psychotherapy researchers consider the effects of the larger organizational context within which the psychotherapy is provided. On the other hand, many organizational psychology researchers are interested in organizational culture and management practices but seldom link these directly to patient outcomes. Is there an effect of the organizational context (i.e., culture and climate) on patient outcomes, and can we understand its effects in order to improve outcomes? Falkenstrom and colleagues review this literature. Organizational culture refers to shared norms, beliefs, and expectations in an organization or unit. These can be affected by hierarchical structure (i.e., perceived power differences between professions), managerial principles and styles (e.g., rigid vs lax styles, supportive and active vs undermining, micro-managing, or disengaged), and by technology. Various organizations appear to engender different cultures such that the staff can be more or less committed to the organization strategies and to the work itself. This is the basis of the well known expression: “culture eats strategy for breakfast”. Organizational climate refers to the overall sense of psychological security in a work environment. This may have an impact on workers’ attitudes and performance, and may also affect their willingness to report errors and to problem solve. In their review, Falkenstrom and colleagues found only 19 studies that directly assessed the effects of organizational context on patient mental health outcomes. Differences between organizations appeared to account for between 6% and 60% of patient outcomes. This is a very wide range that may be the result of many differences between studies (i.e., different patient populations, different definitions of outcomes, different definitions and measurements of organizational variables, etc.). However, even at 6%, this represents what most researchers would call a medium and meaningful effect. For example, Falkenstrom and colleagues reviewed specific studies and found that organizational climate (i.e., low conflict, low emotional exhaustion, and high cooperation and job satisfaction) were related to better psychosocial functioning in children placed in state custody. Several other studies showed that high staff turnover, low levels of support from leadership, and low mutual respect among professionals was associated with poorer mental health outcomes for a variety of patient populations. One study found that an intervention to improve organizational culture and climate resulted in improving mental health outcomes among children and adolescents.

Practice Implications

There are surprisingly few studies that look at the relationship between organizational culture and patient outcomes. Although limited, most of the studies point to the effects of organizational culture and climate on staff and on patient outcomes. With increased emphasis on quality control in mental health care, it makes sense for managers, practitioners, researchers and patient groups to carefully consider an organization’s managerial practices, leadership, culture, and climate when looking to improve patient outcomes.

Elliott, R.E., Greenberg, L.S., Watson, J. Timulak, L., & Briere, E. (2013). Research on humanistic-experiential psychotherapies. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6th Edition (pp. 495-538). New York: Wiley.

Humanistic or experiential psychotherapies (HEP) include: person centred therapy, gestalt therapy, emotion-focused therapy, existential psychotherapy, and others. Elliott and colleagues argue that each of these approaches share the characteristic of valuing the centrality of an empathic and therapeutic relationship. That is, an authentic relationship between patient and therapist provides the client with a new and emotionally validating experience. HEP methods that deepen client emotional experiences occur within an empathic relationship, and interpersonal safety is key to enhancing a client’s attention for self awareness and exploration. Despite the long history of research in HEP, these treatments are often used as “control” conditions in outcome studies of psychotherapies – that is, to control for “non-specific” or relationship factors. Elliott and colleagues conducted meta analyses on the effectiveness of humanistic-experiential therapies. Overall, they included 199 studies of over 14,000 patients. Pre to post treatment effect sizes were large (d = .95), indicating a positive effect HEP across a wide range of clients. (A note on effect sizes: Cohen’s d < .20 represents a negligible effect; d = .20 to .49 is a small effect; d = .50 to .79 is a moderate effect; and d > .80 is a large effect). Compared to a wait-list control (62 studies), the positive effect of HEP was significant with a moderate effect size for the difference (d = .76).  There were 135 studies that compared HEP to other active forms of psychotherapy. The difference between HEP and non-HEP therapies were trivial and non significant (d = .01). In the 76 studies that compared HEP to cognitive behavioral therapy (CBT), those who received CBT had better outcomes, but the effects were negligible (d = .13). The authors reported that there is enough evidence to indicate that HEP are efficacious for depressive disorders, substance misuse, and relationship problems; and HEP are probably efficacious for anxiety and psychotic disorders.

Practice Implications

The research on outcomes of humanistic-existential psychotherapies (HEP) provides support for the effectiveness of these therapies for a variety of disorders, and provides further support for the importance of the facilitative and relationship factors that help patients get better. Empathy, genuineness, positive regard each comes with research support to indicate their importance to patient outcomes.  Elliot and colleagues conclude that the education of psychotherapists is incomplete without greater emphasis on HEP and its facilitative components.

Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month from the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, you can read the Handbook table of content and sections of the book on Google Books.

Bohart, A.C. & Wade, A.G. (2013). The client in psychotherapy. In M. Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behavior change (6^th ed.), pp. 219-257. Hoboken, NJ: Wiley.

Last month I blogged about the section in Bohart and Wade’s (2013) chapter that focused on client attachment. This month I focus on other factors like severity of distress and comorbidity, and level of motivation. Some authors argue that client factors predict 30% of variance in outcomes. That accounts for more of psychotherapy outcome than therapist effects and therapeutic techniques combined. Severity of symptoms of anxiety and depression and functional impairment caused by this distress leads to poorer client prognosis. Further, individuals with more severe symptoms need more sessions to show improvement. Some research shows that those with greater symptoms change more than those with fewer symptoms. However, even though those with higher levels of distress show the most change, they are less likely to achieve recovery in which they return to a normal level of functioning. In most cases, clients with comorbid problems are less likely to do well. For example, comorbidity for personality disorder or substance abuse negatively impact outcome. Client motivation is also related to psychotherapy outcomes. Motivation can be internal (those that arise from the individual’s intrinsic interests or values) or external (those that arise from external rewards or punishments). Generally, internal motives (i.e., greater readiness to change) are better predictors of sustained behaviour change. The stages of change model describes readiness to change as occurring in progressive stages that include: (1) precontemplation, in which clients are not internally motivated; (2) contemplation in which clients move to the next stage where they recognize a problem but are not ready to take action; and (3) preparation for action in which clients are more internally motivated to change. The next two stages of the model do not speak to motivation but to action and maintenance of change. Norcross looked at clients’ readiness to change prior to therapy and its relationship to outcome. Greater readiness to change was moderately and significantly associated with better treatment outcomes.

Practice Implications

The results on severity and comorbidity suggest that providers and policy makers must consider increasing the number of treatment sessions to take into account clients who have greater initial severity and comorbidities, especially for those with comorbid personality disorders. Results related to motivation indicate that when client motivation to work in therapy comes from within and they show progress in their readiness to change, they are more likely to do well. Therapists need to find ways of mobilizing clients’ internal reasons for change. Motivational interviewing may be one means of doing so.

Swift, J.K., Greenberg, R.P., Whipple, J.L., & Kominiak, N. (2012). Practice recommendations for reducing premature termination in therapy. Professional Psychology, 43, 379-387.

As discussed in a previous blog entry, Swift and Greenberg (2012) found that almost 20% of adult individual therapy patients drop out of therapy. Dropping out is generally defined as clients unilaterally terminating psychotherapy prior to benefitting fully and against their therapist recommendation. In this paper, Swift and colleagues review five methods with the best research evidence to reduce premature termination. (1) Providing education about duration and course of therapy. Research indicates that 25% of clients expect to recover after only two sessions of therapy, 44% after four sessions, and 62% expect to recover after 8 sessions. However the research literature indicates that it takes 13 to 18 sessions for 50% of clients to recover. Further, although some clients improve quickly and maintain that, some clients may feel worse before they get better, especially if the symptoms are related to painful feelings or events. So aligning client expectations about the length of treatment and the course of treatment may reduce dropping out. This education should be research based to increase the credibility of the information. (2) Providing role induction. Clients who are naıve to therapy may start not knowing what behaviors or roles are most appropriate on their part and could feel lost or like they are doing things wrong. Role induction refers to providing clients with some pre-treatment education or orientation about appropriate therapy behaviors. This could be done by video, verbally, or in writing. A meta analysis found that pre-therapy role induction increases attendance and reduces drop outs. (3) Incorporating client preferences. Client preferences include wants or desires concerning the type of treatment that is to be used, the type of therapist one would like to work with, and the roles and behaviors that are to take place in therapy. A recent meta analysis found that clients who had their preferences accommodated were almost half as likely to drop out of treatment prematurely compared with clients whose preferences were not taken into account. (4) Strengthening early hope. Although it is important that clients do not hold unrealistic expectations (i.e., recovery after only two sessions), it is also important that they have a general hope that therapy can help them get better. Research evidence shows that expectations for change explain as much as 15% of the variance in therapy outcomes. (5) Fostering the therapeutic alliance. The therapeutic alliance involves agreeing on goals and tasks of therapy, and a positive bond between client and therapist. A rupture in the alliance has been associated with dropping out of therapy, and a previous meta analysis found that a stronger alliance was associated with fewer drop outs.

Practice Implications

Therapists can do 5 things that are research supported to reduce patient drop outs. (1) Provide education about duration and course of therapy.  Practicing clinicians can help their clients to develop realistic expectations about duration and recovery prior to the start of therapy. Clinicians working with a more severely disturbed population or working from an orientation that espouses longer treatment durations may want to alter the education they provide to better fit their clients. (2) Provide role induction. Clinicians can provide education about the “jobs” of both the client and the therapist, such as who is expected to do most of the talking and who will be responsible for structuring or directing sessions. This type of induction should also include a discussion of the rationale for the approach that will be used. (3) Incorporate client preferences. Accommodating client preferences does not mean the therapist should automatically use the client’s preferred methods. Often clients are unaware of what treatment options are available or best suited for their particular problems. Instead, therapists should consider sharing their knowledge about the particular disorder and the nature of different approaches to the treatment of those problems with clients. Clients can then share their preferences regarding those treatment options with the therapist and work collaboratively toward a decision about which approach might be best. (4) Strengthen early hope. Therapists should express confidence that the therapy will work for their patient. Knowing the research evidence on the efficacy of psychotherapy will increase the therapist’s credibility in making such statements. (5) Foster a therapeutic alliance. Efforts to foster the therapeutic alliance should occur early on in therapy when the risk of premature termination is high, and as also therapy progresses. Early efforts should focus on making sure there is an agreement on the goals and tasks before jumping to treatment interventions.

Author email: Joshua.Keith.Swift@gmail.com