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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coping tend to face change, distress, or threat by becoming internally focused, inner-blaming, inhibited, socially withdrawn, anxious, worrying, or working out issues by thinking them through.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

Constantino, M. J., Vîslă, A., Coyne, A. E., & Boswell, J. F. (2018). A meta-analysis of the association between patients’ early treatment outcome expectation and their posttreatment outcomes. Psychotherapy, 55(4), 473-485.

A concept similar to but distinct from client preferences is client expectations of outcomes. One of the first writers to discuss the importance of client expectations was Jerome Frank who argued that clients enter therapy demoralized, and that for therapy to be effective it must mobilize the client’s belief that treatment will work. Frank felt that outcome expectation is key to the process of remoralization for the client. Outcome expectations refer to clients’ personal predictions about how they will respond to treatment. Generally, problems may be signalled by clients who feel hopeless about the potential effectiveness of the therapy or therapist. But it is also possible for expectations to be unrealistically high, never met, and therefore disappointing. Clients may form outcome expectations before they start therapy, or the expectations may be shaped by early experiences in the therapy or with the therapist. Outcome expectations may develop, in part, based on how credible the therapy seems to the client, and or whether the therapist or therapy are consistent with the client’s preferences. Also, research indicates that higher realistic expectations likely leads to an improved therapeutic alliance, mainly because it facilitates collaboration of the client with the therapist. In this meta-analysis, Constantino and colleagues evaluated 72 studies (81 samples) of over 12,000 adult clients in which early outcome expectations were assessed and correlated with client outcomes at post-treatment. The overall effect of the meta-analysis was r = .18 (95% CI [.14, .22]), indicating a small, but statistically significant, positive effect. There were a few moderators of this relationship. The expectation – outcome correlation was larger for younger clients, and for therapies that used a treatment manual. Client diagnosis, treatment orientation, or treatment modality did not affect the correlation.

Practice Implications

Increasing a client’s expectation of a good outcome likely raises their hopes and goes some ways toward remoralizing the client. Therapists can assess their client’s outcome expectations early in therapy with a validated measure, and invite a discussion of these expectations. It may be useful to be aware of studies reviewed in the PPRNet blog, and to review with clients in a non-technical way the evidence for psychotherapy’s effectiveness. Although one should be inspiring about the potential outcomes of therapy for a client, therapists should not promise an unrealistic degree or speed of change. Therapists should express realistic confidence and competence in the psychotherapy that they are about to provide.

Author email: mconstantino@psych.umass.edu

Xu, H. & Tracey, T.J.G. (2016). Cultural congruence with psychotherapy efficacy: A network meta-analytic examination in China. Journal of Counseling Psychology, 63, 359-365.

Cultural congruence refers to providing psychotherapy that is consistent with the client’s cultural context in its description of the etiology of symptoms and in its therapeutic procedures. In general, congruence of treatments with clients’ expectation, preferences, and beliefs is related to greater psychotherapy efficacy. And specifically identifying culturally appropriate or adapted treatments is important because this is often related to better therapy outcomes for ethnic and racial minorities. Psychotherapy as a professional practice developed recently in China. Cognitive-behavioral, existential-humanistic, and psychodynamic therapies have taken their place along side indigenous therapies including Naikan therapy, Taoism cognitive therapy, and Morita therapy. Historically in China mental health problems were seen as a disturbance in ying-yang or a sin committed in a previous life. Healing practices included engaging in altruism or religious practices to achieve redemption. Xu and Tracey argue that Chinese culture strongly endorses an experiential and subjective orientation and is less aligned with analytic and objective orientations. Using this understanding, the authors expected that experiential-humanistic and indigenous therapies would be more congruent and therefore more effective than cognitive-behavioral education or psychodynamic therapy in alleviating mental health issues. In this meta analysis, Xu and Tracey reported on 235 studies conducted in China that compared the various treatments to a control condition or to each other. There were too few studies of psychodynamic therapy, so it was not included in the analyses. All treatments were effective compared to a control condition with large effect sizes (g = .85 to 1.18). However, whereas experiential-humanistic and indigenous therapies were equally effective, each was significantly more effective (g = .34) than cognitive-behavioral psychoeducation.

Practice Implications

The three modalities, experiential-humanistic, indigenous, and cognitive-behavioral psychoeducation were effective. However the two therapies that were more experiential and subjective in nature were more effective to reduce Chinese clients’ symptoms. When working with Chinese clients, therapists may achieve better outcomes if they work on more experiential components (e.g., feelings and therapeutic relationship) and focus on subjective experiences (e.g., introspection and reflection). The results of the meta analysis suggest that when working with Chinese clients interpersonal processes and emotions should be the clinical focus and take priority over dysfunctional cognitions and psychoeducation.

Miller, D.J., Spengler, E.S., & Spengler, P.M. (2015). A meta-analysis of confidence and judgement accuracy in clinical decision making. Journal of Counseling Psychology, 62, 553-567.

People can make errors in judgements based on decision making rules that are biased. Clinicians also may be prone to making such errors. In their Nobel Prize winning work, Kahneman and Tversky outlined a number of heuristics (i.e., mental shortcuts) that lead to cognitive biases, which in turn affect accuracy of decisions. For example, when making a differential diagnosis clinicians may: rely too heavily on only one piece of information which may be the most available (e.g., “I vividly remember a patient with conversion disorder who had the same history”); or ignore that a particular event (e.g., conversion disorder) is very rare; or seek confirming rather than disconfirming evidence (e.g., the patient has PTSD symptoms that can explain some symptoms). Complicating these biases is the tendency for clinicians to be over-confident. For example, in one study the average psychotherapist rated their performance as better than 80% of their peers, and no therapist rated him or herself in the lower 50^th percentile among peers. In their meta analysis, Miller and colleagues reviewed 36 studies of the relationship between clinician confidence ratings and accuracy of decisions among 1,485 clinicians. The authors were particularly interested in the overconfidence bias, which occurs when individuals report higher confidence in their judgments than is warranted by their actual accuracy. For example, studies have assessed the impact of clinician confidence on clinical accuracy in: detecting random responding on a psychological test, diagnosing a brain disorder verified by medical test using neuropsychological test data, predicting future violence and recidivism in offenders, and patient progress in psychotherapy. Most studies find that clinicians are quite confident in their judgments. But, is this confidence warranted? Miller and colleagues’ meta analysis found a significant but small (r = .15) association between confidence and accuracy. This suggests that clinician confidence is only slightly indicative of decision-making accuracy. The effect was a little larger for more experienced clinicians (r = .25), indicating that more experience and training resulted in somewhat more consistency between a clinician’s confidence and their clinical accuracy. Further, higher confidence leads to poorer accuracy when clinicians have to make repeated decisions without feedback, when feedback is not written, and when an event is rare.

Practice Implications

Clinicians, like everyone else, are sometimes subject to making errors when they only look at confirming evidence, when they rely only on their own memory rather than objective data, and when they are over-confident. Accuracy can be increased when clinicians use decision-making aids that provide quality corrective feedback. Aids to help in decision making might include the use of: objective standardized test data, repeated measurements with feedback to assess patient progress in psychotherapy, and actively looking for disconfirming evidence before making a clinical judgement. As the authors conclude, confidence is not a good substitute for accuracy.

Ehring, T., Welboren, R., Morina, N., Wicherts, J.M., Freitag, J., & Emmelkamp, P.M.G (2014). Meta-analysis of psychological treatments for posttraumatic stress disorder in adult survivors of childhood abuse. Clinical Psychology Review, 34, 645-657.

Post-traumatic stress disorder (PTSD) occurs at a very high frequency among those who experienced childhood physical and/or sexual abuse. As adults these individuals often request mental health services. Previous meta analyses of psychotherapies for PTSD have combined samples of those with PTSD due to childhood maltreatment and those due to trauma in adulthood. This meta analysis by Ehring and colleagues is the first specifically to look at treatment of PTSD in those with childhood abuse. Some argue that PTSD due to childhood abuse is different because of the high level of complex symptoms like emotion regulation problems, impulsivity, depression, dissociation, substance abuse, and others. And so treatments for PTSD related to childhood abuse may require different characteristics and may have different outcomes. Further, there is a long standing debate about whether trauma-focused treatments are appropriate for those with PTSD who have high levels of complex symptoms. There is concern for example that the focus on trauma memories may exacerbate symptoms like dissociation. Previous reviews showed that treatments targeting the trauma memory (i.e., focus on processing the memory and its meaning) had the largest effect on PTSD outcomes. This is likely because of the impact that memory processes (i.e., re-accessing memories, maladaptive attributions of memories) have on the maintenance of the disorder. Would these large treatment effects also be found in PTSD that resulted specifically from childhood abuse? (A note about meta analyses: meta analyses are the best way to synthesize a research area because this method combines the effect sizes from multiple studies into a single effect size. The findings of meta analyses are much more reliable than findings from any single study. See my November 2013 blog). Ehrling and colleagues conducted a meta analysis of 16 studies that included over 1200 participants with PTSD due to childhood abuse. Treatments included: trauma-focused cognitive behavioral therapy (CBT), non-trauma-focused CBT, eye movement desensitization and reprocessing (EMDR), and others. Psychological interventions were effective for PTSD related to childhood abuse, and the effects were large for both PTSD symptom severity and for other symptoms (i.e., depression, anxiety, dissociation). Psychological interventions were more effective that control conditions (i.e., wait lists or treatments as usual), and these effects were moderate. Effects remained large or moderate well into post-treatment follow-ups. Trauma focused treatments were more effective than non-trauma-focused treatments, and individual interventions were more effective than group-based interventions.

Practice Implications

Psychological interventions for PTSD in adults who experienced childhood abuse are effective in reducing symptom severity with moderate to large effects. Other symptoms like anxiety, depression, and dissociation also showed large positive changes in these individuals. Research shows that trauma-focused treatments are under-used in routine practice. This may be due to the concern that trauma-focused treatments may not be safe in some individuals with complex symptoms. Trauma-focused treatments may lead to higher effects than non-trauma focused treatments, indicating the potential importance of processing the trauma memory.

Mackenzie, C. S., Erickson, J., Deane, F. P., & Wright, M. (2014). Changes in attitudes toward seeking mental health services: A 40-year cross-temporal meta-analysis. Clinical Psychology Review, 34(2), 99-106.

Rates of treatment for mental disorders in developed countries have increased over time and this is largely due to the dramatic rise in the use of medications, such as antidepressants over the past 30 years. Concurrently the proportion of people receiving outpatient psychotherapy has declined. Despite the increase of pharmacological interventions, many mental health services in the US do not meet evidence based guidelines, and most people with mental disorders in the US and Canada are not receiving care. Barriers to accessing care include: lack of knowledge (not knowing where to get help); structural barriers (financial costs), and attitudes (stigma, belief that one should handle the problem oneself, and belief that treatment will not help). There is a great deal of evidence that negative attitudes about seeking and receiving help are the most consistent reasons related to low service utilization in Canada and the US. Efforts to reduce stigma, in part, have attempted to define mental illness as a medical or biological disorder likely with the intent of reducing blame of the individual for his or her problems. As Mackenzie and colleagues indicate, this coincided with an aggressive direct-to-consumer advertising of psychotropic medications for mental disorders. And so the perception that mental disorders are biological and that require biological treatments became entrenched in the population. However, as I summarized in the PPRNet October 2013 Blog endorsing neurobiological causes of mental illness is associated with seeing the disorder as persistent, unchangeable, and serious. This increases social distance, which is an aspect of stigma. In their meta analysis, Mackenzie and colleagues reviewed all published studies over the past 40 years that used the Attitudes Toward Seeking Professional Help Scale. They analysed 22 studies with a total sample size of 6,796. They used cross-temporal meta-analysis to correlate year of the study with total scores on the scale. The correlation was large and negative (r = -.53) indicating that participants’ help-seeking attitudes have become significantly more negative over time.

Practice Implications

Attitudes toward seeking mental health services have become increasingly negative over the past four decades, which is consistent with worsening public stigma about mental health. This has coincided with an increase in the use of psychotropic medications and a decline in psychotherapy during the same period, despite evidence that psychotherapy is as effective as medications and preferred by patients. As Mackenzie and colleagues suggest, it is possible that attitudes toward mental health care have become increasingly negative due to efforts to convince the public that mental disorders have a neurobiolobic etiology and require biological treatments. When appropriate, clinicians should not promote biological explanations at the expense of psychosocial explanations for mental disorders. Psychological explanations and treatments may result in patients experiencing a greater sense of optimism about change, and greater personal control over the treatments they receive.