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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.

Steel, C., Macdonald, J., & Schroder, T. (2017). A systematic review of the effect of therapists’ internalized models of relationships on the quality of the therapeutic relationship. Journal of Clinical Psychology. Advance online publication.

Therapists likely respond differently to different clients, due to their own personal characteristics and unconscious processes.Relational theory suggests that the therapist’s particular qualities combine with the client’s particular qualities to form a unique interpersonal context. The interpersonal context of therapy may be influenced by client and therapist internalized patterns of relating which are likely formed in early childhood. The attachment theory concept of internal working models is one way to understand therapists’ internalized patterns of relating. Internal working models are like templates that help one to predict how relationships with others work. Internal working models of self indicate the quality of one’s self-concept. In this systematic review, Steel and colleagues examined a total 22 studies and asked: do therapists’ secure attachments and positive internal working models affect the quality of the therapeutic relationship with clients? There were too few studies on the specific concepts to conduct meta analyses to aggregate effect sizes, so the authors simply reviewed the literature. Eighteen of 22 studies showed an association between therapist internalized relational models/attachment security/self concept and the therapeutic relationship. Three of four studies that looked specifically at therapist attachment found that therapist secure attachment was associated with a more positive therapeutic relationship. Among these studies, all forms of therapist attachment insecurity were associated with poorer relationship quality with clients and with lower levels of therapist empathy. Four of five studies that examined the effects of internal working models of self indicated that greater therapist negative self-concepts (i.e., self-criticism, neglecting of self, hostility towards self) was associated with a poorer therapeutic alliance with clients. 

Practice Implications

Therapist effects (i.e., the differences between therapists) are emerging as important predictors of client outcomes. It is possible that therapists’ views of others and of self (i.e., internal working models) contribute to these differences. However, there are relatively few studies that examine psychotherapists’ views of self and of others and the impact on therapy. The research that does exist suggests important issues for therapists to consider. Therapists that are insecurely attached (i.e., are dismissive of the importance of relationships or are overly preoccupied with relationships) may have problems in developing positive therapeutic relationships and may be perceived as less empathic by clients. Therapists who have an overly negative view of their self (i.e., self critical, self neglecting) may struggle with developing a therapeutic alliance with clients. The findings suggest that clinicians need to be aware of their internalized relational models. The process of recognizing, reflecting on, and extricating from maladaptive interpersonal patterns and self-concepts may require supervision and/or personal therapy.

Author email: katiecatherinesteel@gmail.com

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.

McFarquhar, T., Luyten, P., & Fonagy, P. (2018). Changes in interpersonal problems in the psychotherapeutic treatment of depression as measured by the Inventory of Interpersonal Problems: A systematic review and meta-analysis. Journal of Affective Disorders, 226, 108-123.

Interpersonal problems are commonly reported by depressed people. Interpersonal problems are seen by many as both a cause of depressive symptoms and as a result of depression. Depression may be the result of lacking basic human needs like social supports, stable relationships, and intimacy. One of the most important ways of assessing interpersonal problems is with the Inventory of Interpersonal Problems (IIP). The IIP is based on a circumplex model of two independent dimensions: affiliation (friendliness vs hostility) and status (dominance vs submissiveness). Greater problems in any of these domains or any combination of these domains may lead to interpersonal distress that result in or are the result of depression. Many psychotherapies target interpersonal problems in their treatment of depression: Interpersonal Psychotherapy (IPT), Short Term Dynamic Psychotherapy (STDP), and Emotion Focused Therapy (EFT). In this meta-analysis, McFarquhar and colleagues evaluated whether psychotherapy for depression is related to changes in interpersonal distress and whether specific types of interpersonal problems at baseline are related to treatment outcomes for depression at post-treatment. The authors looked at both randomized and non-randomized trials of psychotherapy for adults with depression. They found 10 studies that met inclusion criteria, six of which were randomized controlled trials. Psychotherapy for depression resulted large positive changes in interpersonal problems (overall pre- to post-treatment ES g=0.74, 95% CI=0.56–0.93). Unfortunately, there were too few studies (k = 3) that met meta-analytic criteria to do an analysis of pre-treatment interpersonal distress as a predictor of depression outcomes. However, of 8 studies that looked at this question, six showed that higher interpersonal distress was associated with poorer outcomes for depression at post-treatment.

Practice Implications

Given that interpersonal problems both cause and are caused by depressive symptoms, targeting relationship difficulties (lack of social support, conflict in relationships, low intimacy, relationship avoidance) in psychotherapy should be a priority. This meta-analysis showed that interpersonal distress improves after psychotherapy for depression, and there was some evidence that higher interpersonal problems at the outset may reduce the effects of the therapy for depressive symptoms.

Murphy, R. & Hutton, P. (2017). Therapist variability, patient reported therapeutic alliance, and clinical outcomes in adolescents undergoing mental health treatment: A systematic review and meta-analysis. The Journal of Child Psychology and Psychiatry, doi:10.1111/jcpp.12767.

The therapeutic alliance refers to the affective bond between therapist and client, and their agreement on the tasks and goals of therapy. The alliance is a well-known predictor of outcomes in adult psychotherapy with a mean alliance-outcome correlation of r = .28. Less is known about the role of the alliance in the treatment of adolescents. Some reviews indicate that the alliance-outcome relationship in children and adolescents is weaker than observed among adults, but these reviews may have been flawed since they included both children and adolescents in the same review, and the number of studies they reviewed was small. A large rigorous systematic review of adolescents’ perceptions of the alliance can provide insight into their experience of psychological treatment and inform routine mental health practice. In their meta analysis, Murphy and Hutton reviewed studies of clinical samples of adolescents between the age of 12 – 19 who received psychological treatment. The authors made sure that the measures of alliance and outcomes were reliable, they excluded studies of those with medical and neurocognitive problems, and included only studies with adolescents (i.e., excluding studies with primarily children). Twenty-seven studies with almost 3,000 participants were included. Main presenting problems of adolescent patients were: substance use, eating disorders, behavioral difficulties, and a range of mood and anxiety disorders. The mean weighted effect size of the alliance-outcome relationship among studies of psychological treatment of adolescents was r = .29 (95% CI: 0.21, 0.37; p < .001) indicating a moderate effect.

Practice Implication

This is the largest meta analysis of the alliance-outcome relationship in the psychological treatment of adolescents with mental health problems. The alliance was moderately associated with outcomes, and so therapeutic alliance may be a reliable predictor of clinical progress in the treatment of adolescents. The findings suggest that those working with adolescents should routinely assess the alliance after each session in order to evaluate if they need to address relational barriers to positive outcomes. For example, if the alliance markedly declines from one session to the next, then clinicians should address potential problems in their relationship with the adolescent client, renegotiate goals, or renegotiate the tasks of therapy.