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Swift, J. K., Callahan, J. L., Cooper, M., & Parkin, S. R. (2018). The impact of accommodating client preference in psychotherapy: A meta‐analysis. Journal of Clinical Psychology, 74(11), 1924-1937.

Here is another in a series of meta analyses looking at client factors that predict psychotherapy outcomes. In 2006 the American Psychological Association defined evidence-based practice in psychology as composed of 3 pillars: (1) the integration of the best available research combined with (2) clinical expertise in the context of (3) client characteristics including client preferences. Client preferences can be grouped into three broad categories. First, activity preferences refer to activities that a client hopes they and their therapists will engage in during treatment. For example, some clients may prefer homework between sessions, or therapists who interpret, or may prefer a type of therapy modality like group, couple, or individual treatment. Second, treatment preferences include client’s wishes for certain types of therapy approach like CBT, psychodynamic, interpersonal psychotherapy, peer-support, or others. Third, therapist preferences include a client’s desire for the type of therapist with which they would like to work. This might include preferences based on demographics, therapist personality, interpersonal style, culture, and so on. Studies that measure the impact of clients receiving their preferences may simply ask clients what they prefer, or might use a questionnaire of preferences. Some research found that clients are willing to give-up up to 40% in the treatment’s efficacy in order to ensure that they worked with a therapist with whom they would have a good relationship. In this meta-analysis, Swift and colleagues reviewed 53 studies that examined the association between client preferences and psychotherapy outcomes. In 28 studies that included data from 3,237 clients, the overall effect of client preference on psychotherapy drop out was statistically significant, such that clients who were not matched or not given a choice of treatment preference were 1.79 times more likely to drop out compared to those who did get their preference (95% CI: 1.44, 2.22; p < .001). In 53 studies of over 16,000 clients, the overall effect of clients receiving their preference on outcomes was also statistically significant (d = 0.28, 95% CI [0.17, 0.38], p < .001). Receiving a preferred treatment or therapist was associated with better client outcomes.

Practice Implications

The results of this body of research suggests that therapists will do well to attempt to accommodate client preferences in psychotherapy, unless they are impractical, or therapeutically or ethically counter-indicated. One can ask clients about their preferences for activities of therapy, therapist style and characteristics, and treatment type.  Some of these decisions may require clients to be educated about their options, and so agencies may consider adopting decision aids. At the very least therapists should initiate a discussion with clients about what the client wants and what they can reasonably expect to receive. These discussions may occur at the beginning of treatment and revisited part way through as well. Therapists may also consider using more structured valid assessments of client preferences to help with this task.

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

Reich, C.M. & Berman, J.S. (2018). Are psychotherapies with more dropouts less effective? Psychotherapy Research. Online first publication.

The client dropout rate in clinical studies is about 20%, and almost double that in regular clinical practice. A dropout is a unilateral decision on the part of the patient to discontinue treatment after the first session. This is often viewed as a treatment failure, but it is possible that some patients feel better enough to not continue with therapy, and others may have practical constraints like transportation or childcare difficulties. In three meta analyses, Reich and Berman ask: (1) do those who drop out experience more distress than completers to begin with?, (2) do completers have better outcomes than drop outs?, and (3) do less effective treatments also have more drop outs? In general, the studies included different types of psychotherapy but most were CBT (~75%), most therapists had a masters or doctoral degree (~33%) but many studies also included student therapists (~25%), client problems included depression (~17%), anxiety (25%), or other disorders, and most studies were randomized controlled trials (~61%). To answer the first question the authors conducted a meta analysis of 76 studies. Clients who dropped out of therapy were in more distress prior to beginning treatment than individuals who completed the treatment (d= − 0.14, 95% CI [− 0.08, − 0.20], p < .001). The effect was small but significant. Younger and male clients tended to be in more distress at pre-treatment. To answer the second question, the authors conducted a meta analysis of 43 studies. Clients who dropped out of therapy were significantly more distressed following therapy than individuals who completed treatment (d = .0.56, 95% CI [.0.37, 0.70] p < .001). This was a moderately large and significant effect. To answer the third question, the authors completed a meta regression of data in 34 studies. Overall, treatments with more drop outs also had completers with worse outcomes at post treatment, β = -.37, SE = 0.17, p < .05. Also, when treatments were shorter in length, greater overall dropout was associated with even worse outcomes for treatment completers, β = − 1.28, SE = 0.35, p < .001.

Practice Implications

These meta analyses support the notion that on average those who drop out do so because they do not find the treatment to be helpful. Patients who drop out tend to be more distressed to begin with, and are more likely to be young and male. An intriguing finding was that those treatments with more drop outs also tended to be less effective for those who completed the therapy. In other words, effective treatments also tended to maintain more patients. Previously, writers suggested clinically useful methods to reduce premature termination from psychotherapy. These include: providing patients with information about duration of therapy and how change occurs, educating patients about therapist and patient roles, taking into account patient preferences when deciding on treatment methods and therapist stances, strengthening early hope, fostering the therapeutic alliance, and assessing and discussing treatment progress on an ongoing basis.

Hayes, J. A., Gelso, C. J., Goldberg, S., & Kivlighan, D. M. (2018). Countertransference management and effective psychotherapy: Meta-analytic findings. Psychotherapy, 55(4), 496-507.

This is another meta analysis from the Psychotherapy Relationship That Work series that will be published in a book by Norcross and Wampold in 2019. Psychotherapists’ unresolved personal conflicts and the cognitive, emotional, or behavioural manifestations of these conflicts in therapy are called countertransference. Countertransference can result in reactions within the therapist that negatively affect their relationship with patients and patient outcomes. Successfully managing these reactions may be an important aspect of positive outcomes in psychotherapy. The old view of countertransference, dating back to Freud, was that countertransference was detrimental to therapy, and therapists had to work to keep their personal reactions out of therapy. More contemporary views see therapist countertransference as inevitable and as providing potentially important information about the patient. In their model of countertransference management, Hayes and Gelso identified five aspects managing countertransference. 1) Origins of countertransference refer to therapists gaining an understanding of their unresolved issues from their past that can interact with patient characteristics in therapy (therapist unresolved family issues, low professional self esteem). 2) Triggers refer to specific issues within the patient that stimulate a specific unresolved issue in the therapist (the patient is competitive and the therapist has a fragile professional self esteem). 3) Manifestations refer to therapist cognitive, behavioural, or affective reactions to triggers and origins (the therapist puts the competitive client in his or her place). 4) Effects refer to the impact of countertransference manifestations on the therapy process or outcome (patient who is put in his or her place drops out or goes silent). 5) Management refers to therapists’ strategies to manage countertransference, including self awareness, self care, consultation and supervision, or personal therapy. In this series of meta analyses, Hayes and colleagues found that: (1) countertransference reactions are associated with poorer therapy outcomes (r = -.16, p = .02, 95% CI [-.30, -.03], d = -0.33, k = 14 studies, N = 973); (2) therapists’ management of countertransference reduces countertransference reactions (r = -.27, p = .001, 95% CI [-.43, -.10], d = -0.55, k = 13 studies, N = 1,065); and (3) successful countertransference management is related to better therapy outcomes (r = .39, p = .001, 95% CI [.17, .60], d = 0.84, k = 9 studies, N = 392 participants).

Practice Implications

The research on countertransference management is still in its early stages but results are promising. Therapists’ ability to identify unresolved issues within themselves, how these issues interact with specific patient behaviors and clinical presentations, and management of therapist reactions are important to their work. The work of psychotherapy is fraught with emotional challenges and potential pitfalls for the therapist. Every therapist will experience confusing or challenging emotional reactions to a client. Better understanding and management of these reactions and their manifestations will not only lead to better patient outcomes, but also to greater therapist personal well-being and work satisfaction.

Norcross, J. C., & Lambert, M. J. (2018). Psychotherapy relationships that work III. Psychotherapy, 55(4), 303-315.

Relationship factors in psychotherapy are some of the most important predictors of patient outcomes. They outweigh factors like the type of therapy provided in determining whether patients get better after psychotherapy. In this second overview article, Norcross and Lambert provide a review of 17 meta-analyses of relationship factors in psychotherapy that contribute to positive outcomes. Like the review of patient factors also found in this blog and E-Newsletter, this article briefly outlines those evidence-based relationship factors that reliably predict patient outcomes in psychotherapy. The therapeutic relationship refers to how the therapist and patient relate to each other, or their interpersonal behaviors. By contrast, techniques or interventions refer to what is done by the therapist. Practice guidelines typically focus on interventions or therapeutic orientation. As the authors argue, what is missing from treatment guidelines are the person of the therapist and the therapeutic relationship – evidence for which is backed up by 5 decades of research. Even in studies of highly structured manualized psychotherapy for a specific disorder in which efforts were made to reduce the effect of individual therapist, up to 18% of outcomes (a moderate to large effect) could be attributed to the person of the therapist. By contrast somewhere between 0% and 10% of outcomes (a small to moderate effect) is attributable to specific treatment methods. So, which therapeutic relationship factors are reliably related to patient outcomes? These include: the therapeutic alliance in individual therapy (306 studies, g = .57) couple therapy (40 studies, g = .62), and adolescent psychotherapy (43 studies, g = .40), collaboration (53 studies, g = .61) and goal consensus (54 studies, g = .49), cohesion in group therapy (55 studies, g = .56), therapist empathy (82 studies, g = .58), collecting and delivering client feedback or progress monitoring (24 studies, g = .14 to .49), managing countertransference (9 studies, g = .84), and repairing therapeutic alliance ruptures (11 studies, g = .62) among others. Over the next few months, I will be reviewing these meta analyses in more detail to discuss how therapists can use this evidence base to improve their patients’ outcomes.

Practice Implications

The research as a whole indicates that therapists should make the creation and cultivation of the therapeutic relationship a primary goal of therapy. Factors such as managing the therapeutic alliance, repairing alliance ruptures, engaging in ongoing progress monitoring, managing countertransference and others should be used to modify treatments and interpersonal stances in order to maximize outcomes. When seeking out professional development and training, practitioners should focus on evidence-based relationship factors (managing the alliance, judicious self disclosure, managing emotional expression, promoting credibility of the treatment, collecting formal feedback, managing countertransference) in addition to focusing on evidence-based treatments.

Levy, K.N., Kivity, Y., Johnson, B.N., & Gooch, C.V. (2018). Adult attachment as a predictor and moderator of psychotherapy outcome: A meta‐analysis. Journal of Clinical Psychology. Online first publication, DOI: 10.1002/jclp.22685.

Adult attachment refers to characteristic ways people manage their emotions and relationship styles. Securely attached individuals adaptively and flexibly experience emotions and they are able to give and receive love and support to others. Insecure attachment can be sub-categorized as avoidant or anxious attachment. Those who are anxiously attached tend to up-regulate their feelings so that they may feel easily overwhelmed, and they tend to be preoccupied with relationship loss. Those with avoidant attachment styles tend to down-regulate their emotions so that they have difficulty experiencing or expressing feelings, and they might dismiss the importance of relationships as a means of protecting themselves. John Bowlby, the founder of attachment theory, argued that psychotherapy had the potential to serve as a secure base from which individuals might explore themselves and relationships. He also described the therapist as a temporary attachment figure with which the patient might develop an emotional bond to promote change and for a corrective experience. In this meta-analysis, Levy and colleagues looked at whether attachment dimensions can change in psychotherapy and whether they can predict improvement in patient symptoms pre- to post-therapy. (A note on meta analysis. It is a method of systematically reviewing a research literature, combining the effect sizes in that literature, and summarizing these effects. Because meta analyses usually contain many studies, their results are much more reliable than the results of any single study, and so they provide the most solid basis for making practice recommendations). In this meta analysis, Levy and colleagues included 36 studies, totaling 3,158 clients. Higher client attachment security (or lower attachment insecurity) at the start of therapy was associated with better outcomes by post-treatment (r = 0.17, p < 0.001, 95% CI = [0.13, 0.22], k = 32). Also, greater improvement in attachment security (change in attachment security from pre- to post-treatment) predicted better outcomes (r = 0.16, p < 0.001, 95% CI = [0.07, 0.25], k = 15). When looked at separately, higher levels of either attachment anxiety or attachment avoidance were associated with poorer outcomes, and change in either type of attachment insecurity was associated with better outcomes. These effects appeared to be consistent regardless of the type of therapy (non-interpersonal vs interpersonal therapies).

Practice Implications

Although attachment insecurity is associated with poorer outcomes, change in attachment insecurity is possible with psychotherapy and this change is associated with better symptom outcomes. Therapists should expect longer and more challenging treatment with patients who are anxiously attached. Anxiously attached individuals may appear engaged early in therapy, but they are quick to anger, feel rejected, and become overwhelmed. Such individuals may benefit from help to contain their emotional experiences by repeating the treatment frame and increasing structure. They may also benefit from interpersonally-oriented therapy focused on reducing their preoccupation with relationship loss. Avoidantly attached individuals may appear aloof, but they may be easily overwhelmed by demands for closeness. Therapists may have to carefully balance the amount of interpersonal space or demands in treatment with these clients so that they remain in therapy.