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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

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

Morales, K., Keum, B. T., Kivlighan, D. M., Jr., Hill, C. E., & Gelso, C. J. (2018). Therapist effects due to client racial/ethnic status when examining linear growth for client- and therapist-rated working alliance and real relationship. Psychotherapy, 55(1), 9-19.

Racial and ethnic minority (REM) clients tend to have less access to health care services, are less likely to seek services for mental illness, and may receive lower quality care. It is also possible that REM clients may be treated differently by psychotherapists, so that REM clients may have a different experience from non-REM clients of the therapeutic alliance (i.e., the collaborative agreement on tasks and goals of therapy, and the bond with the therapist). The alliance is a well-known factor that is related to client outcomes. If there is such a difference in how REM and non-REM clients experience the alliance, it is likely because of the therapist’s ability to establish and grow the alliance. Previous research showed that therapists and not clients are largely responsible for the alliance – outcome association. Research also demonstrated that some therapists are less effective with REM than with non-REM clients, possibly because of the differing experiences of and development of the therapeutic alliance. In this study, Morales and colleagues measured the therapeutic alliance after every session of therapy for 144 clients seen in a counselling center, almost half of whom were REM clients. The clients saw one of 19 therapists, so that each therapist (10 of whom were REM therapists) saw at least two REM and two non-REM clients. So, the researchers were able to see how each therapist developed a therapeutic alliance differently with REM and non-REM clients. The study found that higher therapeutic alliance between therapists and clients early in therapy was associated with clients remaining in therapy longer, and that the therapeutic alliance statistically significantly increased across sessions. However, therapists varied significantly in the alliance growth depending on whether they were treating REM or non-REM clients. Some therapists showed significant growth in the alliance with REM clients but not with non-REM clients, whereas other therapists showed significant growth in the alliance with non-REM but not with REM clients.

Practice Implications

There were significant differences between therapists in how they were able to develop a therapeutic alliance with racial and ethnic minority (REM) clients vs non-REM clients. The authors speculated that this difference might be due to the therapists’ level of multicultural orientation. A multicultural orientation is a way of being with clients that consists of cultural humility, using opportunities to examine culture, and cultural comfort. Having a multicultural orientation likely increases the level of therapeutic alliance and promotes its growth over time. Research shows that a client benefits when the therapist integrates the client’s cultural narrative into the psychotherapy.

Author email: kmorales@umd.edu

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.

Truijens, F., Zühlke‐van Hulzen, L., & Vanheule, S. (2018). To manualize, or not to manualize: Is that still the question? A systematic review of empirical evidence for manual superiority in psychological treatment. Journal of Clinical Psychology. Advance online publication. 

In 2010 Webb and colleagues published a meta-analysis in which they showed that the association between adherence to a psychotherapy manual and treatment outcome was close to zero. The same was true for therapist competence in delivering the manualized psychotherapy – almost no relationship to client outcome. Psychotherapy manuals typically specify the theoretical basis for an intervention, the number and sequencing of treatment sessions, the content and objective of sessions, and the procedures of each session. National institutes in the US and the UK have promoted manuals as a means to define what is evidence-based psychotherapy. By doing so these institutes assume that psychotherapy that is manualized is more effective that non-manualized treatment. However, detractors have argued that: (1) strict adherence to manuals may reduce therapists’ ability to individualize treatment to client needs and characteristics; (2) manuals are often designed for single disorders but clients tend to have many comorbid conditions; and (3) it is impossible for clinicians to gain competence in all different manuals for the various client conditions they may encounter. In this systematic review, Truijens and colleagues ask: does the use of manuals increase therapy effectiveness? To answer this question they conducted three different systematic reviews. First, they reviewed six studies that directly compared manualized versus non-manualized versions of a psychotherapy within the same study. One study showed manuals were superior, three showed no difference, and two studies showed that non-manualized therapies were more effective. Second, they reviewed eight meta-analyses that compared the pre- to post-treatment effect sizes of manualized therapies and of non-manualized therapies versus no-treatment control conditions. Three meta-analyses concluded that manualized therapies were superior, four meta-analyses did not find differences, and one observed non-manualized treatments to be superior. Third, the authors reviewed 15 additional studies to those reviewed by Webb and colleagues in their original meta-analysis. Overall, Truijens found similar results that support the conclusion that the level of adherence to psychotherapy manuals is not substantially related to better treatment outcomes.

Practice Implications

Although treatment manuals may be helpful for training purposes and to ensure validity in psychotherapy research, there is actually little consistent evidence that adhering to a manual results in better client outcomes. Some have argued that rigid adherence to a treatment manual can be harmful to clients. Therapists may need to take a flexible stance when applying research-supported therapeutic principles and interventions. Such a stance adjusts therapy to take into account client characteristics like level of resistance, coping style, attachment style, and others. Truly evidence-informed approaches incorporate what we know about client characteristics, therapeutic relationship factors, and therapist factors to promote positive outcomes in psychotherapy clients.