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Nehrig, N., Prout, T.A., & Aafjes-van Doorn, K. (2019). Whose anxiety are we treating, anyway? Journal of Clinical Psychology. Online first publication.

Evidence-based practice (EBP) in psychotherapy is defined by the American Psychological Association as the deliberate integration of: (1) the research evidence, (2) clinician expertise in making treatment decisions, and (3) client characteristics, preferences, and culture. The EBP statement was meant to supplant an older model of prescriptive psychotherapy practice that resulted in the creation of lists of empirically-supported treatments (EST). The ESTs were defined as: (1) manualized therapies, (2) shown to be efficacious in randomized controlled trials, (3) for patients with a specific diagnosed mental disorder. However, manualized therapies are not necessarily more effective than non-manualized treatments, and patients in randomized controlled trials may not represent those typically seen by therapists in everyday practice. Although EBPs are the current standard by which psychotherapists should practice, many therapists and organizations focus almost exclusively on the first of the EBP criteria (the research evidence of ESTs) to the exclusion of the second and third criteria (clinician expertise, and patient characteristics, preferences, and culture). In this review article, Nehrig and colleagues speculated about why this is the case by asking: “whose anxiety are we treating?” They argued that manualized therapies identified as ESTs reduce therapists’ anxiety caused by: uncertainty about treatment outcomes, the emotional toll of providing psychotherapy to people who are suffering, and the negative emotions (anxiety, despair, cynicism) that sometimes arises in therapists from the work. Nehrig and colleagues argued that ESTs provide therapists with a sense of control and certainty, while limiting therapists’ attention on relational challenges in the work of therapy. However, this emphasis on ESTs comes at a cost for therapists and patients. Therapists may not focus on developing skills to manage the relational challenges inherent in providing psychotherapy, greater certainty may reduce therapists’ engagement in sufficient self-reflection, and therapists may attend only to patients’ symptoms and not to the patient as a whole person. Nehrig and colleagues also discuss the preference for ESTs among institutions, insurance companies, and government funders of psychotherapy. ESTs reduce anxiety in these contexts because ESTs are seen by managers as methods to enhance accountability and standardization of treatment, to uphold standards of care, and to reduce potential liability. The short-term nature of most ESTs also assuages economic concerns for institutions and funders who wish to manage costs. However, this emphasis on short term manualized treatment also reduces psychotherapy from a complex interpersonal process with inherent uncertainty to one that resembles a clear-cut medical procedure that encourages top-down decision-making about clinical practice.

Practice Implications

Anxiety about the complexity of psychotherapy can cause therapists, institutional managers, and government funders to place greater value on ESTs rather than on clinical expertise of the therapist and patient characteristics. Patient characteristics, preferences, and culture are related to developing the therapeutic alliance and to patient outcomes. Astute therapists can learn to adjust their interventions to these patient characteristics, which may mean using clinical judgement to alter or deviate from a prescriptive manual. An EBP approach that integrates research, clinical expertise, and patient characteristics allows therapists to take into account transtheoretical factors known to affect outcomes like the therapeutic alliance, repairing alliance ruptures, empathy, and to use their clinical expertise to adjust their interpersonal stances to relevant patient characteristics, preferences, and culture.

Karver, M. S., De Nadai, A. S., Monahan, M., & Shirk, S. R. (2018). Meta-analysis of the prospective relation between alliance and outcome in child and adolescent psychotherapy. Psychotherapy, 55(4), 341-355.

Over the past decades there has been increasing research on the efficacy of psychotherapy for children and adolescents, but outcomes have not always been positive. Treatment of children and adolescents comes with challenges that are unique from those experienced in therapy of adults. For example, unlike most adults, children and adolescents may not be the ones to choose to attend therapy - that decision is often made by adults in their lives. Furthermore, psychotherapists must also develop and maintain a collaborative relationship with parents, on whom the therapist and child/adolescent rely in order to be able to engage in treatment. Because of the unique characteristics of working with children and adolescents, negotiating, developing, maintaining, and repairing the therapeutic alliance is potentially complex. The therapeutic alliance is defined as an agreement on tasks of therapy, an agreement on goals of therapy, and the relational bond between therapist and client. In this meta-analysis, Karver and colleagues reviewed 28 studies of psychotherapy with children and adolescents. The mean age was about 12 years, most children/adolescents had internalizing problems, but others had problems with externalizing behaviors, and substance abuse. Almost two thirds of the studies involved a version of behavior or cognitive behavioral therapy. The therapeutic alliance was measured from the perspective of the client, therapist, and/or the parent. The overall mean effect size of the alliance-outcome relationship was small to moderate: r = .19 (p < .01, 95% confidence interval [CI] [0.13, 0.25]). Larger effect sizes were seen in those therapies of children and adolescents with internalizing disorders (r = .19), and when the therapist – parent alliance was measured and correlated with outcomes (r = .30). In other words, a positive alliance was most important for internalizing disorders, and for the relationship between therapist and parent.

Practice Implications

The findings of this meta-analysis indicate that the therapeutic alliance, especially with the parent, is important to the outcomes of children and adolescents in psychotherapy. Clinicians should not only develop an alliance with the youth, but also with the parent/caregiver. Therapists should also consider measuring the alliance regularly during therapy as a means of heading off any ruptures (with the youth or the parent) that might endanger the therapy. The authors recommended using the Therapeutic Alliance Scale for Children – Revised with children/adolescents, and the Working Alliance Inventory with parents.

Hill, C. E., Knox, S., & Pinto-Coelho, K. G. (2018). Therapist self-disclosure and immediacy: A qualitative meta-analysis. Psychotherapy, 55(4), 445-460.

Different writers and theorists in psychotherapy have disagreed on the need for or the wisdom of therapists disclosing about themselves during therapy. Recently, however, both humanistic therapists and some psychodynamic therapists tend to see therapist self-disclosure or immediate discussion of the therapeutic relationship more positively. Therapist self-disclosure is a therapist statement that reveals something personal about the therapist (“That makes me angry too”). On the other hand, immediacy refers to comments about and processing the therapeutic relationship by client and therapist in the here and now (“You said that people inevitably let you down, I wonder if you expect that I will let you down too”). Immediacy, also known as metacommunication, is particularly useful to address therapeutic alliance ruptures. In this qualitative meta-analysis, Hill and colleagues (2018) examined research that studied the effects of therapist disclosures and immediacy on subsequent client processes right after the disclosure or immediacy occurred. The authors included in their review 21 studies with a total sample of 184 cases. Five studies with 99 cases looked specifically at the effect of therapist disclosure. Therapist self-disclosure occurred relatively infrequently in 0% to 4% of all therapist responses. The most frequently occurring subsequent processes after therapist disclosure included an enhanced therapy relationship (reported in 64% of studies), greater client insight (reported in 46% of studies), and improved client mental health (reported in 45% of studies). Negative effects of therapist disclosure included negative client feelings or reactions (reported in 30% of studies) and impaired therapeutic relationship (reported in 16% of studies). Fifteen studies with 78 cases looked specifically at immediacy. Therapists used immediacy more extensively in between 12% to 38% of cases. The most frequently occurring subsequent processes following immediacy included an enhanced therapy relationship (reported in 40% of studies), and increased client self-disclosure (reported in 40% of studies). Negative effects of immediacy included a negative impact for the therapist (reported in 11% of studies) that referred to a heightened sense of therapist vulnerability.

Practice Implications

Reviews and theoretical guidelines stress that therapists should sparingly and deliberately use self-disclosure and immediacy. In fact, this review by Hill and colleagues indicated that therapist self-disclosure is relatively rare, whereas immediacy might be more common. Therapists might consider self-disclosure when the client is feeling alone and in need of support. But, as Hill and colleagues indicate, therapists must be thoughtful and strategic about self-disclosure, therapists should disclose only personally resolved material, and therapists must focus their disclosures exclusively on the client’s needs. On the other hand, immediacy may be a useful strategy to negotiate and address problems in the therapeutic relationship by talking about interactions and intentions in the relationship (i.e., metacommunicate about the relationship). Therapists have to consider that immediacy may require lengthy processing, and therapists should be attentive to the role of countertransference and seek consultation in order to be sure to act in the best interest of the client.

Author email: cehill@umd.edu

Fonagy, P., Lemma, A., Target, M., O'Keeffe, S., Constantinou, M., Ventura Wurman, T., . . . Pilling, S. (2019). Dynamic interpersonal therapy for moderate to severe depression: A pilot randomized controlled and feasibility trial. Psychological Medicine, 1-10. Online first publication. doi:10.1017/S0033291719000928

Most psychotherapies are equally effective when it comes to treating depression. However, no single therapy is uniformly effective, so that about 50% of patients might improve when it comes to symptom reduction. So, although there is a large evidence base for treatments like CBT, therapists and patients need access to a range of available treatments. There is less research on psychodynamic therapies, although a number of trials and meta-analyses indicate their effectiveness to treat depression. In the United Kingdom (UK), the health system may offer a stepped care program that provides patients with low intensity guided self-help based on a CBT model followed by more intensive treatment with CBT or IPT if patients did not benefit from self-help. The UK health system rarely offers Dynamic Interpersonal Therapy (DIT), and DIT has never been studied in a randomized controlled trial within the UK health system. Fonagy and colleagues designed this randomized controlled trial to test the efficacy of DIT when compared to the CBT-oriented self-help program as offered in the UK. The study also included a smaller randomized sample of those who received the intensive version of CBT for depression. In total, 147 participants with moderate to severe depression were randomly assigned to DIT, CBT guided self-help, or the intensive version of CBT. The DIT is informed by attachment theory and by mentalization theory, and it views depressive symptoms as responses to interpersonal difficulties or perceived attachment threats. The results of the trial showed a significantly greater effect of DIT compared to guided self-help with regard to depressive symptoms, overall symptom severity, social functioning, and quality of life at post-treatment. The patients receiving DIT maintained these gains up to 1-year post-treatment. Over half of DIT patients showed clinically significant improvements, but only 9% who received the CBT-based guided self-help achieved such improvement. There were no significant differences on any of the outcomes between DIT and the more intensive version of CBT.

Practice Implications

One of the benefits of DIT, according to the authors, is that it offers a treatment manual and curriculum that enables those without a lot of background in psychodynamic therapies to deliver it. This makes DIT potentially widely-applicable in publicly funded health systems like in the UK, Canada, and others. DIT may offer yet another effective option of psychotherapy to therapists and their patients who experience depressive symptoms. The study also points to the limits of offering only guided self-help to those with moderate to severe depression.

Author email: p.fonagy@ucl.ac.uk

Huey, S. J. & Tilley, J. L. (2018). Effects of mental health interventions with Asian Americans: A review and meta-analysis. Journal of Consulting and Clinical Psychology, 86, 915-930.

Do existing mental health interventions work well for patients of Asian descent? Interventions delivered in the typical way in which they were devised may not be as effective as intended when it comes to culturally diverse groups like Asian Americans. The clinical trials in which the treatments were developed typically are almost exclusively made up of White participants, and most evidence-based treatments do not consider cultural considerations. Culturally responsive psychotherapies that are consistent with the cultural norms, values, and expectations of patients may be more effective. That is, if an evidence-based treatment is not culture specific, it may not be as effective as intended. Even when culture is taken into account in evidence-based treatments, the accommodation tends to be for African American or Hispanic/Latino patients, and not for Asian American patients. Asian American and East Asian heritage is often influenced by Confucian values that emphasize interpersonal harmony, mutual obligations, and respect for hierarchy in relationships. This may mean that patients of Asian descent may be less committed to personal choice, more attuned to others, and more socially conforming. This may lead to cultural differences in cognitive processing and emotional reactions to interpersonal contexts. In this meta-analysis, Huey and colleagues assessed if the effects of evidence-based treatments will be bigger if the treatments were specifically tailored for Asian Americans. Their review included 18 studies with 6,377 participants. Samples included Chinese Americans, Cambodian Americans, Korean Americans, Vietnamese Americans, and other Asian groups. Problems treated included depression, PTSD, smoking, and other concerns. About half of the studies were of CBT, and most (91%) were culturally tailored in some way either for an Asian subgroup or tailored for minorities in general. The mean effect size for evidence-based treatments versus control groups was d = .75, SE = .14, p < .001, indicating a moderate to large effect. Treatments tailored specifically for Asian subgroups (e.g., Chinese Americans) showed the largest effects (d = 1.10), whereas treatment with no cultural tailoring or non-Asian tailoring showed the smallest effects (d = .25).

Practice Implications

Existing psychological treatments are efficacious for Asian Americans, with moderate effects. However, treatments specifically adapted for Asian American subgroups showed the largest effects, indicating that specific cultural adaptations could substantially improve the effectiveness of psychotherapy. Asian Americans face challenges in terms of using and engaging in treatments. Developing culturally specific interventions to improve acceptability of treatment may be one way to make the most therapeutic impact on one of the largest growing racial groups in North America.

Author email: hueyjr@usc.edu

Hayes, J. A., Owen, J., & Bieschke, K. J. (2015). Therapist differences in symptom change with racial/ethnic minority clients. Psychotherapy, 52(3), 308-314.

There is ample research showing that therapists differ in their outcomes with clients. Some therapists consistently have better outcomes than others, and some therapists consistently have worse outcomes. One study estimated that as many as 5% of therapists are reliably harmful, with many more being neither harmful or helpful. Fortunately, there is evidence that some “super-shrink” therapists are reliably helpful. There is also research showing the existence of ethnic disparities in mental health problems and their treatment. The minority stress theory suggests that members of cultural minority groups face problems like discrimination, oppression, and prejudice that affect their mental health. When racial/ethnic minority (REM) individuals do experience mental health problems they may be reluctant to seek help from a therapist of European descent. This may be due to cultural mistrust or doubts about cultural sensitivity. Recently, writers have been discussing the importance of therapist cultural competence in treating REM clients. In this study by Hayes and colleagues, the authors looked at 36 therapists and 228 clients. Clients were students at a university counselling centre seen an average of 5.42 times, and about 65% of clients were of European descent. The therapists were in training in a doctoral counseling program, and they each treated at least 4 clients: two REM and two non-REM clients. Since each therapist had both REM and non-REM clients, the authors were able to estimate the effect of the therapist on client outcomes, and also to see if therapists differed in their ability to treat REM and non-REM clients. In this study, cultural competence was defined as differences in client outcomes within each therapist depending on client culture or race. Overall, about 39% of clients achieved reliable positive change in general symptom distress. Almost 9% of the variance in client outcome was attributable to therapists. Further, the client’s race/ethnicity explained 19% of the variance in treatment outcome attributed to therapists. In other words, which therapist a client saw had moderate impact on whether the client improved, and this was partly due to the client’s REM status.

Practice Implications

In this sample of training therapists and student clients, some therapists were more effective than others, and some of this difference was due to the client’s racial/ethnic heritage. The results suggest that therapists’ cultural competence is a component of overall competence. The findings speak to the need for multicultural training for therapists. Some authors discuss the importance of cultural humility among psychotherapists, which is an interpersonal stance that is other-oriented rather than self-focused, and characterized by respect and lack of superiority toward a client’s cultural background and experience. Client perception of their therapist as culturally humble will improve the therapeutic alliance and the client’s outcomes.

Author email: jxh34@psu.edu