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Norcross, J.C. & Wampold, B.E. (2018). A new therapy for each patient: Evidence‐based relationships and responsiveness. Journal of Clinical Psychology, Online First, DOI: 10.1002/jclp.22678

Over the next several months, I will review in this blog results of a number of meta-analyses conducted recently on patient factors and relationship factors in psychotherapy. These factors provide evidence-based guidance to psychotherapists on how best to relate to and adapt to clients so that psychotherapy is more effective. This introductory article by Norcross and Wampold is an overview of the nine meta analyses related to transdiagnostic client factors to which therapists can adapt their interpersonal stances and treatment. The goal is to enhance treatment effectiveness by therapists tailoring therapy to individual client characteristics that are related to outcomes. Decades of research indicate that client transdiagnostic characteristics have more influence on outcomes than the particular treatment method, and likely more influence than the particular client diagnosis. The research indicates that giving the identical treatment to every client without adaptation to client characteristics is not an effective approach to providing psychotherapy. These meta analyses of client factors indicate that therapists should select different interventions and relational stances according to the client and the context. What are these client characteristics and therapist adaptations that are reliably related to outcomes? The client factors most strongly related to outcomes include therapist adaptations to: client culture/race/ethnicity (99 studies, g = .50); client preferences for type of therapy (51 studies, g = .28), client religion/spirituality (97 studies, g = .13 to .43), client stage of change (76 studies, g = .41), client reactance/resistance level (13 studies, g = .78), client coping style (32 studies, g = .53), and client attachment style (32 studies, g = .35). Over the next months, I will be reviewing in more detail these meta analyses of client factors and the practice implications of each so that therapists can use this evidence-base to help them to adapt to particular client characteristics.

Practice Implications

Practitioners will find that fitting the therapy to clients’ culture, stage of change, religion/spirituality, reactance/resistance, coping style, and attachment style will improve treatment outcomes. Doing so will have a greater impact on outcomes than the particular type of therapy provided or adapting treatment to the particular client diagnosis. The results of this large body of evidence suggests that therapists should no longer ask: “what is my theoretical orientation” but rather they should ask: “what relationship, adaptation, and approach will be most effective with this particular client”.

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.

Grenon, R., Carlucci, S., Brugnera, A., Schwartze, D., … Tasca, G. A. (2018). Psychotherapy for eating disorders: A meta-analysis of direct comparisons, Psychotherapy Research, DOI: 10.1080/10503307.2018.1489162

Eating disorders can cause a great deal of physical and mental impairment because of the severity of the symptoms and because of comorbid conditions like depression, anxiety, substance use, and others. Anorexia nervosa (AN) occurs in about 0.5% of the population, bulimia nervosa (BN) occurs in about 1.5% of the population, and binge-eating disorder (BED) occurs in about 3.5% of the population. Treatment guidelines include both cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) as front line interventions for BN and BED. However, results from previous meta analyses of psychological treatments for eating disorders were confounded by not focusing exclusively on randomized controlled trials, mixing studies of adult and adolescent samples, combining an array of outcomes rather than separately reporting primary (eating disorder symptoms) and secondary (interpersonal problems, depression) outcomes, and not distinguishing between bona fide psychotherapies (like CBT, IPT, psychodynamic therapy, and others) from non-bona fide treatments (like self help, behavioral weight loss supportive counseling). Grenon and colleagues conducted a meta analysis of psychotherapies for eating disorders to examine if: psychotherapy is effective compared to a wait list, if bona fide psychotherapy and non-bona fide treatment differ in outcomes, and if one type of psychotherapy (i.e., CBT) was more effective than other bona fide psychotherapies (like IPT, behavior therapy, psychodynamic therapy, dialectical behavior therapy). Their meta analysis included 35 randomized controlled trials of direct comparisons. Psychotherapy was significantly more effective than a wait-list control at post treatment, so that 53.89% of patients were abstinent of symptoms after psychotherapy compared to only 8.92% who were abstinent in the wait-list group. Bona fide psychotherapies (51% abstinent) were significantly more effective than non-bona fide treatments (40% abstinent) at post treatment, and dropout in bona fide psychotherapies (17.5%) was significantly lower than in non-bona fide treatment (29.1%). Further, the difference between CBT and other bona fide psychotherapies was not significant.

Practice Implications

Psychotherapy for eating disorders are effective for patients with BN or BED. There were too few studies of those with AN to come to any conclusions about their treatment. Patients with BN or BED are best treated with a bona fide psychotherapy that involves face to face psychological therapy like CBT, IPT, psychodynamic therapy, dialectical behavior therapy, or behavior therapy. Non-bona fide treatments like self help, behavioral weight loss, and supportive counseling should only be used as an adjunct to bona fide psychotherapy for eating disorders.

Jennissen, S., Huber, J., Ehrenthal, J.C., Schauenburg, H., & Dinger, U. (2018). Association between insight and outcome of psychotherapy: Systematic review and meta-analysis. The American Journal of Psychiatry. Published Online: https://doi.org/10.1176/appi.ajp.2018.17080847

For many authors, one of the purported mechanisms of change in psychotherapy is insight. In fact, the utility of insight for clients with mental health problems was first proposed over 120 years ago by Freud and Breuer. Briefly, insight refers to higher levels of self-understanding that might result in fewer negative automatic reactions to stress and other challenges, more positive emotions, and greater flexibility in cognitive and interpersonal functioning. Although insight is a key factor in some psychodynamic models, it also plays a role in other forms of psychotherapy. Experiential psychotherapy emphasises gaining a new perspective through experiencing, and for CBT insight relates to becoming more aware of automatic thoughts. Jennissen and colleagues defined insight as patients understanding: the relationship between past and present experiences, their typical relationship patterns, and the associations between interpersonal challenges, emotional experiences, and psychological symptoms. In this study, Jennissen and colleagues conducted a systematic review and meta analysis of the insight-outcome relationship, that is the relationship between client self-understanding and symptom reduction. They reviewed studies of adults seeking psychological treatment including individual or group therapy. The predictor variable was an empirical measure of insight assessed during treatment but prior to when final outcomes were evaluated. The outcome was some reliable and empirical measure related to symptom improvement, pre- to post- treatment. The review turned up 22 studies that included over 1100 patients mostly with anxiety or depressive disorders who attended a median of 20 sessions of therapy. The overall effect size of the association between insight and outcome was r = 0.31 (95% CI=0.22–0.40, p < 0.05), which represents a medium effect. Moderator analyses found no effect of type of therapy or diagnosis on this mean effect size, though the power of these analyses was low.

Practice Implications

The magnitude of the association between insight and outcome is similar to the effects of other therapeutic factors such as the therapeutic alliance. When gaining insight, patients may achieve a greater self-understanding, which allows them to reduce distorted perceptions of themselves, and better integrate unpleasant experiences into their conscious life. Symptoms may be improved by self-understanding because of the greater sense of control and master that it provides, and by the new solutions and adaptive ways of living that become available to clients.

Author email: Simone.Jennissen@med.uni-heidelberg.de

Munder, T., Fluckiger, C., Leichsenring, F, Abbass, A.A., Hilsenroth, M.J., … Wampold, B.E. (2018). Is psychotherapy effective? A re-analysis of treatments for depression. Epidemiology and Psychiatric Sciences, 1-7.

Based on a deeply flawed review in 1952, Hans Eysenck declared that psychotherapy was no more effective than custodial care for treating mental disorders. Later, he qualified this by stating that behaviour therapy was effective and other forms of psychotherapy were not. These statements touched off decades of angst and debate in the psychotherapy community, and also resulted in a great deal of research about psychotherapy’s effectiveness. By the 1970s the new research technique of meta-analysis was developed and was applied to psychotherapy research. In their seminal meta analysis of controlled studies, Smith and Glass found that psychotherapy was useful and with large effects compared to no treatment. And yet the debate continues. In 2018, Cuijpers argued that waitlist control groups (i.e., a common control condition in psychotherapy studies in which patients receive no treatment) are an inappropriate comparison leading to exaggerated estimates of the effects of psychotherapy. Recently, Munder and colleagues argued that waitlist controls are a way of estimating the natural course of the disorder (what would happen with no treatment) plus the effect of expecting to receive treatment (client expectations of receiving treatment tend to have a positive impact on symptoms). In fact, research shows that pre- to post-study effect sizes for the waiting period is approximately g = .40, or a medium effect. In other words, waiting for therapy in a study results in a moderate proportion of individuals getting better on their own without treatment. Therefore, Munder and colleagues argued that comparing psychotherapy to a waitlist control is appropriate and may be a conservative estimate of psychotherapy’s effects (i.e., psychotherapy has to outperform the effects of clients expecting treatment to help them). In their meta analysis, Munder and colleagues re-analysed 71 studies of psychotherapy for depression compared to a waitlist control condition. They found that the effect size in favour of psychotherapy was g = 0.75 (SE = 0.09) indicating a moderate to large effect. Psychotherapy was also more effective than care as usual (i.e., compared to another intervention that was not psychotherapy), g = 0.31 (SE = 0.11). There were no differences between types of psychotherapy (CBT, IPT, PDT, etc.) for depression outcomes.

Practice Implications

Despite various attempts during the history of psychotherapy to downplay or disparage its efficacy, research continues to show that psychotherapy is in fact effective. The average effect size compared to the natural history of depression is moderate to large (and that is likely an under-estimate). Again, there is no evidence that one type of psychotherapy is superior to another for treating depression. It is time for the field to move beyond questions of efficacy of psychotherapy and of the relative efficacy of different treatments, and look to understanding therapist interpersonal stances, client characteristics, and relationship factors that may improve outcomes from psychotherapy.