Blog

The Psychotherapy Practice Research Network (PPRNet) blog began in 2013 in response to psychotherapy clinicians, researchers, and educators who expressed interest in receiving regular information about current practice-oriented psychotherapy research. It offers a monthly summary of two or three published psychotherapy research articles. Each summary is authored by Dr. Tasca and highlights practice implications of selected articles. Past blogs are available in the archives. This content is only available in English.

June 2019

Therapist Multicultural Competence and Cultural Adaptation of Psychotherapy

Soto, A., Smith, T.B., Griner, D., Rodriguez, M.D., & Bernal, G. (2018). Cultural adaptations and therapist multicultural competence: Two meta‐analytic reviews. Journal of Clinical Psychology, 74, 1907-1923.

There is emerging evidence that a client’s cultural experiences and background have an impact on the therapeutic alliance and on client outcomes. One means of adjusting psychotherapy is by cultural adaptations, which involve modification of treatment to consider language and culture in such a way that the treatment is more compatible with the client’s values. Cultural adaptation might incorporate holistic/spiritual concepts of wellness, and may include cultural rituals. Therapists could also align treatment goals and methods with the client’s culture. Domains of psychotherapy that psychotherapists can adapt to a client’s culture include: language of treatment, metaphors used in therapy, the person of the therapist (assigning a therapist with a similar cultural background), content discussed, concepts explored, goals of therapy, methods of interventions consistent with cultural values, and the context of treatment. Cultural competence refers to the therapist’s ability to engage and work effectively with diverse clients. These competencies include: awareness (ability to recognize cultural backgrounds, assumptions, and biases), knowledge (understanding of specific cultural groups and their history and experiences), and skills (ability to engage cultural groups and modify treatment to match cultural needs). In the first of two meta analyses, Soto and colleagues identified 99 studies of cultural adaptation that included data from almost 14,000 clients who were mainly Asian American, Hispanic/Latin American, or African American. The most frequent adaptations were for language of therapy, cultural values, and matching therapists with similar racial/ethnic backgrounds. Cultural adaptation had a significant, moderate, and positive effect to improve psychotherapy outcomes, d = 0.50 (se = 0.04; 95% CI, 0.42–0.58; p < 0.001). Even after adjusting for publication bias, the findings were significant but smaller d = 0.35 (95% CI, 0.27–0.43). All types of adaptation had a positive impact, but the biggest effect came with providing treatment in the native language of the client. Also, older clients benefitted most for cultural adaptation. In the second meta-analysis, the authors identified 15 studies of 2,640 clients on the effect of therapists’ level of multicultural competence. They found a significant and moderate association between therapist cultural competence and positive client outcomes, r = 0.24 (95% CI, 0.10–0.37; p < 0.001). However, only the client’s (and not the therapist’s) rating of therapist cultural competence was associated with better outcomes.

Practice Implications

The results of these meta-analyses clearly indicate that both cultural adaptations of psychotherapy and therapist cultural competence improve client outcomes. During the assessment phase, therapists should evaluate clients’ racial and ethnic backgrounds and the salient culturally-specific values and worldviews held by the client. Therapists could, whenever feasible, adapt their treatment to the client’s culturally-held values. Therapists might, if possible, arrange to provide therapy in the native language of the client – particularly for older clients. Cultural issues should be handled by therapists in a humble way. And therapists should keep in mind that it is the client’s experience, and not the therapist’s self-assessment, of cultural competence that is most relevant.

Author email: Alberto_Soto@brown.edu
Effects of Mental Health Interventions with Asian Americans

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
Therapists Differ in Their Effectiveness with Racial/Ethnic Minority Clients

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

May 2019

Positive Regard and Psychotherapy Outcome

Farber, B. A., Suzuki, J. Y., & Lynch, D. A. (2018). Positive regard and psychotherapy outcome: A meta-analytic review. Psychotherapy, 55(4), 411-423.

A concept similar to therapist empathy is the notion of therapist unconditional positive regard. Carl Rogers argued that the three factors of positive regard, empathy, and genuineness were the necessary and sufficient conditions for therapeutic change. Rogers’ pioneering work paved the way for the view that the relationship in psychotherapy was the critical factor in determining clients’ positive outcomes. Rogers defined unconditional positive regard as: the extent to which the therapist finds him- or herself experiencing a warm acceptance of each aspect of the client’s experience. It means caring for and prizing the client as a separate person. Other similar terms include: acceptance, non-possessive warmth, and therapist affirmation. Whereas empathy involves immersing oneself in the client’s internal frame of reference in order to truly understand the client’s experience, positive regard refers to unconditional acceptance of the attitudes held by the client and an expression by the therapist of the client’s inherent worthiness as a person. Often, empathy and positive regard go hand in hand, but not always. It is possible to empathize with a client’s pain (loss of a loved one), but not be accepting of aspects of the client’s behavior (coldness toward and disengagement from others). In this meta-analysis, Farber and colleagues reviewed 64 studies comprising 3,528 participants. The aggregated effect size of the association between positive regard and outcomes was small, g = .36, but statistically significant (95% CI: 0.28, 0.44). One of the key moderators of this association was severity of client psychopathology, such that positive regard had a significantly greater effect for clients with lower severity of psychopathology.

Practice Implications

The authors concluded that affirming clients may serve many important functions. Positive regard may strengthen a client’s sense of self and agency, and the belief in their ability to engage in a positive relationship. Positive regard likely reinforces clients’ engagement in therapy, increases self-disclosures, and facilitates the therapeutic alliance. Unconditional positive regard requires therapists to express positive feelings and attitudes to clients. This means communicating a caring, respectful positive attitude that affirms a client’s sense of self worth.

Author email: farber@tc.edu

April 2019

Therapeutic Alliance Rupture Repair

Eubanks, C. F., Muran, J. C., & Safran, J. D. (2018). Alliance rupture repair: A meta-analysis. Psychotherapy, 55(4), 508-519.

It is difficult to over-state the importance of developing and maintaining a therapeutic alliance in order for patients to experience a good outcome from psychotherapy. The alliance is the collaborative agreement between therapist and patient on the tasks and goals of therapy, and the emotional bond between therapist and patient. A previous meta-analysis found a moderate but highly reliable association between a good alliance and patient outcomes. The alliance is a trans theoretical construct – that is, it is important to all types of therapy regardless of theoretical orientation. Sometimes deteriorations in the alliance occur manifested by a disagreement on the goals, a lack of collaboration on the tasks, or a strain in the relational bond. Other terms for this phenomenon include weakenings, misattunements, challenges, resistances, enactments, and impasses. Such deteriorations can vary from minor tensions to major ruptures in the relationship. Tensions and ruptures in the alliance are common occurrences in therapy with some studies showing 50% of therapy cases experience at least a minor tension within the first six sessions of therapy. There are two main types of alliance tensions/ruptures. (1) Withdrawal tensions/ruptures occur when the patient moves away from the therapist, such as when the patient changes the subject, goes silent, and cancels appointments. These tensions/ruptures are more subtle and harder for therapists to detect. (2) Confrontation tensions/ruptures occur when the patient moves against the therapist, such as when the patient expresses dissatisfaction with or pressures or tries to control the therapist. These tensions/ruptures are more obvious, but also difficult for therapists to manage because of the feelings they evoke. In this meta-analysis, Eubanks and colleagues reviewed 11 studies representing 1,314 patients. They found that the association between rupture repair episodes and patient outcomes was on average moderately large r = .29, d = .62, 95% CI [.10, .47], p = .003.

Practice Implications

The research on alliance tensions/ruptures and repairs is still new but points to some important therapist practices that could improve patient outcomes. Therapists must be attuned to indications of tensions and ruptures in the therapeutic relationship. Therapists immediately need to attend to confrontation tensions/ruptures, in which patients express dissatisfaction or hostility. Similarly, therapists must address more subtle withdrawal tensions/ruptures, in which patients go silent, evade, or appease. Therapists can acknowledge the tension/rupture directly and nondefensively by inviting patients to explore their experience of the rupture. If necessary, therapists might change the tasks or goals of the therapy to better match the patient’s concerns. Therapists should empathize with a patient’s negative feelings about the therapy, and validate the patient for bringing up their concerns. If appropriate, therapists should take responsibility for their part in the tension/rupture and not blame the patient. Also, if the tension/rupture is a repetition of an interpersonal pattern for the patient (e.g., the patient tends to withdraw in relationships), then the therapist might consider carefully exploring the tension/rupture as it occurs in the therapy with the understanding that it is a repetitive pattern. Mainly, therapists need to anticipate that tensions and ruptures will occur in therapy, that they can be destabilizing for the therapist and therapeutic relationship, and so therapists need to recognize and know how to explore their own and their patient’s negative feelings.

Author email: catherine.eubanks@einstein.yu.edu
Goal Consensus and Collaboration in Psychotherapy

Tryon, G. S., Birch, S. E., & Verkuilen, J. (2018). Meta-analyses of the relation of goal consensus and collaboration to psychotherapy outcome. Psychotherapy, 55(4), 372-383.

A key element of the therapeutic alliance is for therapists and clients to collaboratively come to a consensus about what they will work on. Goal consensus is part of the agreement between therapist and client, and in part it defines what will be the tasks of therapy. The tasks of therapy (i.e., what a therapist and client do in therapy to alleviate the problems or address issues) follow from the goals and conceptualization of the problems. At times goal consensus is straight forward. The client wants to feel less depressed and the therapist proposes certain therapeutic actions to help the client to be relieved of their depressive symptoms. However at other times, despite an agreement on the main symptoms, the client may not agree with a therapist’s conceptualization and tasks of therapy. For example, a therapist might believe that the client’s history of abuse and/or their current problem with alcohol may underlie the depression, but the client does not want to address these underlying issues. In such an example, the therapist and client only barely agree on a goal, and may not agree on how to go about alleviating the symptoms. In some cases there is outright disagreement, a misunderstanding, or vagueness about the goals, and so there is no consensus and therefore no basis for a collaboration. Collaboration and goal consensus are pan-theoretical processes that apply to all forms of therapy. However, research in the past decade has focused almost exclusively on behavioral or cognitive therapy studies using homework compliance as the index of collaboration. Tyron and colleagues conducted a meta-analysis of 54 studies of the association between goal consensus and client outcomes and found a moderate and significant correlation, r = .24 with 95% CI [.19, .28]. They also reported similar findings from a meta-analysis of 53 studies of therapist and client goal collaboration and client outcomes, in which they found a moderate and significant effect, r = .29, 95% CI [.24, .34].

Practice Implications

These meta-analyses show a positive link between goal consensus and collaboration with psychotherapy outcomes. Therapists should clarify clients’ goals for therapy, and therapists should share their conceptualization of the clients’ issues or symptoms. This conceptualization will determine to some extent the tasks or methods of therapy. For some clients, this process may take time and require revisiting throughout the course of treatment. Collaborative work to establish the goals and focus of therapy may in and of itself be therapeutic for those clients who have long standing interpersonal problems. Therapists should seek input from clients about the formulation and treatment plans, and be prepared to adjust their intentions according to client preferences. Therapists could invite continuous client feedback about the goals and tasks of therapy and monitor client progress. Then therapists can use this feedback to modify their interpersonal stances and treatment methods.

Author email: gtryon@gc.cuny.edu

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June 2019

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May 2019

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April 2019

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