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Castonguay, L.G., Barkham, M., Youn, S.J., & Page, A. (2021). Practice-based evidence: Findings from routine clinical settings. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 6.

Practice-based evidence refers to research that is conducted as part of routine clinical practice. Often these studies do not impose strict research conditions like randomization of patients, and so they produce findings that are more relevant to psychotherapy as practiced real-world. In studies from practice-research networks, clinicians are often involved in the design and implementation of the study. Our Psychotherapy Practice-Research Network (PPRNet) is an example of a collaboration between researchers and clinicians to produce practice-based evidence. In a large survey, we found that most clinicians regardless of theoretical orientation wanted more research on the therapeutic relationship and on professional development. And so PPRNet developed a research program on training psychotherapists to identify and repair therapeutic alliance ruptures and microaggressions. In this chapter, Castonguay and colleagues review some of the key findings from practice research networks. First, White patients report better outcomes than Black patients in routine care, and these differences were linked back to the clinicians. That is, therapists varied in their effectiveness with racial and ethnic minority patients. Second, patients benefit when clinicians monitor the therapeutic alliance and outcomes on a session-to-session basis using reliable and valid measures. Noticing when a patient’s ratings of the alliance decline from one session to the next, might indicate a problem in the therapeutic relationship. Third, when monitoring the alliance, therapists should also rate the alliance. If a therapist’s ratings of the alliance are higher than their patients, then this may be a sign that the therapist is not paying attention to problems in the alliance. Fourth, developing and maintaining a strong therapeutic alliance likely will improve patient outcomes. Fifth, a reliable and valid assessment of client’s past and current interpersonal difficulties is likely to improve a therapist’s treatment plan for that patient.

Practice Implications

Doing research in clinical practices is not as well controlled as clinical trials research. But practice-based evidence is more relevant to how psychotherapy is done in the real world with real patients. The research is not so clear about why some therapists are more effective with racial and ethnic minority (REM) patients. However, complementary research suggests that some therapists who have a previously high level of multicultural orientation (cultural humility, open to conversations about culture, and cultural comfort) are more effective with REM patients. Also monitoring the therapeutic alliance with a valid scale on a session-to-session basis leads to better outcomes. Such monitoring will alert the therapist to resolve an alliance rupture if a patient’s ratings decrease from one session to the next. If therapists also rate the alliance and find that their scores are higher than their patient’s, then this may alert the therapist to a potential problem. Finally, knowing if a patient has current and past interpersonal problems can inform a therapist to focus on how those problems affect current symptoms and to talk about how those problems manifest themselves in the therapeutic relationship.

Constantino, M.J., Boswell, J.F., & Coyne, A.E. (2021). Patient, therapist, and relational factors. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 7.

Race refers to socially constructed perceptions of physical attributes shared by a group of people, whereas ethnicity refers to a group of people's shared cultural values,

attitudes, and behaviors. By extension, racial identity represents a sense of belonging that stems from a perception that one shares a heritage with a particular racial group. In this part of the chapter, Constantino and colleagues review the psychotherapy research on these important patient factors. The research suggests that racial and ethnic minority (REM) patients have more difficulty accessing therapy, and that the quality of mental health treatment that they receive is lower than for White patients. REM patients may be at greater risk for premature termination from therapy than White patients. One solution might be to match REM patients to therapists with similar identities. A meta-analysis of 52 studies found that patients significantly preferred a therapist of the same race or ethnicity (d = .32), and patients perceived therapists of the same race or ethnicity more positively. However, the same study found little benefit for patient outcomes of matching therapists and patients on their racial or ethnic identities. The exception was for African American patients who experienced significantly better outcomes when treated by a same race/ethnicity therapist, but the effect was small (d = 0.19).

Practice Implications

The mental health disparities and higher dropout rates experienced by racial and ethnic minority (REM) patients should be a cause of concern for all psychotherapists. As reported in the next blog entry, some therapists are significantly less effective when working with REM vs White patients, and some therapists are more effective when working with REM patients. Overall, the findings suggest that specific therapist behaviors and practices affect REM patients’ mental health outcomes. One way to improve these outcomes is to assess a patient’s cultural identity and to culturally adapt treatment to aspects of patients’ cultural backgrounds. Another approach is for therapists to develop multicultural competence and a multicultural orientation that includes cultural humility, openness to conversations about culture, and cultural comfort.

Barkham, M. & Lambert, M.J. (2021). The efficacy and effectiveness of psychological therapies. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 5.

Psychological therapies are culturally bound practices with certain values built into them. For example, common therapies prize independence in patients and rapport in the therapeutic relationship. However, some cultures may value community rather than independence, and respect rather than rapport. In this part of the chapter, Barkham and Lambert ask: what is the effect of a conventional psychotherapy that is based on the values of a dominant culture when applied to a different ethnic or racial group? In one small meta-analysis of 9 and 16 studies, culturally adapted interventions were significantly more effective than unadapted interventions g = 0.52 (95% CI [0.15, 0.90]) and resulted in close to 5 times greater odds of remission. Adaptation usually refers to incorporating some cultural practices into the therapy, adapting the language of the therapist, or providing a therapist who is from the same culture as the patient. Similarly, there is research on the effects of a multicultural competency and multicultural orientation of the therapist. These competencies refer to therapists who learn about a patient’s culture, use culturally relevant treatment strategies, and are aware of their own assumptions and biases regarding the patient’s culture. A meta-analysis of 18 studies reviewed the impact of a therapist’s multicultural competence on various aspect of therapy. Therapist multicultural competence accounted for 37% of the working alliance, 52% of patient satisfaction, 38% of a patient’s perception of therapist competence, and 34% of depth of the session. However, therapist multicultural competence accounted for only 8% of patient outcomes. More recently, some authors have discussed the importance of multicultural orientation, which refers to a therapist’s cultural humility as an attitude towards the patient’s culture, a therapist’s willingness to explore the patient’s racial and cultural identities, and the therapist’s comfort with cultural diversity.

Practice Implications

The research on the impact of psychotherapy on diverse patient populations is still rather small, but some practice implications can be gleaned. Adapting therapies to the patient’s culture and identity likely will improve patient mental health outcomes. The adaptation might include incorporating cultural practices, metaphors, and values into the therapy, and providing therapy in the language of the patient, or finding a therapist from the same cultural background as the patient. Similarly, there is evidence that therapists who are multiculturally competent (learn about the patient’s culture and checks their own biases) can provide a deeper therapeutic experience for their patients. Emerging research on therapist multicultural orientation suggests that a therapist’s cultural humility, willingness to engage in cultural conversations, and comfort with diverse cultures may lead to better experiences of therapy for their patients.

Barkham, M. & Lambert, M.J. (2021). The efficacy and effectiveness of psychological therapies. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 5.

Meta-analyses are not perfect, but they are the best way to summarize findings from a research field. In psychotherapy research, for example, meta-analyses aggregate effect sizes across a number of studies by producing a mean effect compared to a control condition. In this part of the chapter, Barkham and Lambert review the research on the efficacy of psychotherapies. The very first meta-analysis of psychotherapies was conducted by Smith and Glass in 1977 in which they aggregated effects of 475 studies that compared treated versus untreated groups. They reported a standard mean effect size of 0.85 in favor of psychotherapy, which is equivalent to a treated person being better off than 80% of untreated people. That sounds impressive, but it turned out to be an over-estimate of the effects of psychotherapy. Later studies took a more conservative approach by removing lower quality studies (small samples, poorly designed), which resulted in an average effect size of 0.67 when psychotherapy was compared to control conditions. Some meta-analyses went even further by excluding studies with wait-list control groups. It turns out that using a wait-list control (people who get no treatment) may inflate the effects of therapy because people waiting for treatment sometimes get worse, which by comparison makes the patients who get therapy look even better. These meta-analyses also controlled for publication bias (the likelihood that some negative or unflattering studies were never published). By taking all these possible sources of bias into account, the overall effect size of psychotherapy drops to about 0.31 (95%CI [0.24, 0.38]). Nevertheless, even when taking such a conservative approach to the research findings, one can conclude with some certainty that psychological therapies are effective to improve mental health conditions.

Practice Implications

The research over the years has demonstrated two important things about psychotherapy. First, psychotherapy is effective for many mental health problems, even if the effects are smaller than we once thought. The success rate for psychotherapy in treated persons is about 60% compared to 40% for untreated people (or to put it another way, therapists must treat 3 to 5 patients for one to recover). And these effects of psychotherapy are as large as one gets from many common medical interventions. Second, the effects of psychotherapy have not changed in the past 50 years. That is, new developments in psychological therapies and technologies have not moved the needle on patient outcomes since the 1970s.

Barkham, M. & Lambert, M.J. (2021). The efficacy and effectiveness of psychological therapies. In In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 5.

In this part of the chapter, Barkham and Lambert review the debate about which psychotherapy is most effect for a particular disorder. This is a debate that has been ongoing since the middle of the last century. The current status of this debate centers around questions like how big are the differences between treatments, are these differences clinically meaningful, and if the specific interventions of a particular therapy are not the cause of change, then what are? It turns out that the early estimations of differences in therapies favoring CBT were over-blown. This was caused by combining effects across different studies that did not directly compare the treatments in question (the technical explanation is that comparing the effects of CBT vs a wait list control group in one study to the effects of psychodynamic therapy to a control group in another study introduces a whole host of confounds that make interpreting the differences in effects across studies unreliable). When subsequent researchers conducted meta-analyses of the effects of psychological therapies and only included studies in which bona-fide therapeutic approaches were directly compared to each other in the same study, then the differences between therapeutic approaches were small and clinically irrelevant (and even those small effects were be wiped out by controlling for the researchers’ allegiance [i.e., the effect caused by the researchers’ preference of one therapy over another]). Another way to consider the question is to assess the effects of the specific interventions of a therapy. That is, if CBT is effective because of its cognitive or behavioral components, then removing a component of CBT should reduce its effectiveness. These are often referred to dismantling studies. However, reviews of these types of studies indicate that removing components of treatment seem to have little or no impact on patient outcomes. That is, the effect of a therapy seems to have little to do with the specific intervention associated with the therapy (e.g., cognitive restructuring, exposure and response prevention). In fact, by far the largest predictors of patient outcomes are the factors common across most therapies: the therapeutic alliance, therapist empathy, goal consensus, therapist interpersonal skills, cultural adaptation of therapies, and others.

Practice Implications

This research domain is far from perfect, and the debate over which therapy is better unfortunately will likely continue for some time. However, clinically and from a public health perspective, this is not a useful debate and hopefully with time it will fade. Much more useful questions likely center around how we can improve therapist skills in those factors that lead to better patient outcomes. That is, regardless of theoretical orientation, can we train therapists to verbally express emotions and empathy, improve their capacity to develop and maintain the therapeutic alliance, and adapt their interventions to the patient’s culture, characteristics, and preferences?

Barkham, M. & Lambert, M.J. (2021). The efficacy and effectiveness of psychological therapies. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 5.

For decades now, researchers have been trying to address the question of how many sessions of therapy is optimal for the average patient. In this part of the chapter, Barkham and Lambert review some of the research related to the question: how much therapy is necessary? Early research noted that it took about 13 sessions for 50% of patients to achieve clinically significant change, and 50 sessions was necessary for 75% of patients to achieve significant change. In other words, the number of sessions need to be doubled for another 25% of patients to improve. (Of note, half of patients did not improve after 13 sessions). Such research suggests a dose-response relationship, such that more therapy sessions result in more patients getting better – but the rate of return slows considerably with more sessions. The problem with this approach to estimating how many sessions are necessary is that it assumes that all patients improve at a consistent rate across sessions, but that may not be the case. Other researchers suggest that patient rate of change is individual, and that when a patient achieves a good enough level of change, they will terminate therapy. The research area is complicated by several factors. First, much of the research was conducted in university counselling centers with therapists in training, student patients, and bounded by the semester system. So, by definition, the therapy is time-limited and patients may be homogenous with regard to symptom severity. Second, some of the data in meta-analyses come from randomized controlled trials that by necessity represent brief treatments. Third, different modes of delivery in different countries appear to have an impact on how many sessions are delivered and what kind of therapy is offered. Fourth, patient severity at baseline may be related to longer treatments and slower rates of change.

Practice Implications

Although the dose-response research has been used in some settings to arbitrarily select treatment length offered to all patients, the results of this research may not be reliable. Predetermined fixed treatment lengths are likely not appropriate for patients. For example, greater patient severity at the start of treatment, and comorbidity and complexity of problems will likely result in such patients requiring a higher number of treatment sessions. A one-size-fits-all approach to determining how many sessions are offered to patients will likely negatively affect the most vulnerable of patients.