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Owen, J., Tao, K. W., Imel, Z. E., Wampold, B. E., & Rodolfa, E. (2014). Addressing racial and ethnic microaggressions in therapy. Professional Psychology: Research and Practice, 45(4), 283–290.

Overt forms of racism and prejudice still occur in society, and less overt forms are likely more prevalent. Microaggression are those less overt forms of racism and prejudice that may include direct and indirect insults, slights, and discriminatory messages. Specific types of microaggression are: microinvalidations (e.g., denying that racism exists), microassaults (e.g., direct racism but done in private), and microinsults (e.g., believing a group’s cultural norms are pathological). Microaggression are by definition ambiguous and subtle, and they may target culture, race, gender, sexual orientation, and other group identities. Microaggressions are associated with psychological distress in the recipient. Microaggressions can also occur in therapy if a patient perceives a therapist’s dismissing or negating messages about the patient’s culture, or if a therapist engages in culturally inappropriate interventions. Microaggressions represent a special type of therapeutic alliance rupture that could lead to negative patient outcomes. It is also possible that therapists and clients who address microaggressions after they occur are capable of repairing the alliance rupture and moving forward with a stronger relationship. However, there is very little research of the impact of client perceived microaggressions on the therapeutic alliance. In this unique study, Owen and colleagues asked 120 racial and ethnic minority university counselling centre patients treated by 33 different therapists (23 of whom were White) to rate their experience microaggressions, to indicate if the microaggression was discussed, and to rate the therapeutic alliance. In total, 53.3% of patients experienced a microaggression in therapy, and of those patients, 68.4% were treated by a racial or ethnic minority therapist. Clients who reported fewer microaggressions also reported stronger therapeutic alliances (r = .28, p = .01). Of the patients who reported a microaggression, only 24% (13 patients) reported that the microaggression was discussed by the therapist. Of these 13 patients, almost all (12 patients) reported that the discussion was successful. Therapist and patient dyads who successfully discussed the microaggression: (1) had alliance scores comparable to patients who did not experience a microaggression, and (2) had alliance scores that were significantly higher than dyads who experienced but did not discuss the microaggression.

Practice Implications

Microaggressions appear to be ubiquitous in daily life and in psychotherapy – no therapist is immune. More than 53% of patients in this study reported a microaggression, despite what was likely their therapists’ good intentions. Microaggression are a special case of therapeutic alliance ruptures, which are known to be associated with poor patient outcomes. Therapists must develop a strong multicultural orientation and take a culturally humble stance with clients from a different culture or group. This involves therapists being attuned to the possibility of committing a microaggression, inviting patients to alert the therapist should a microaggression occur, and being open to clarifying misunderstandings and owning missteps.

Mental Health Disorders Increase Health Care Utilization in Adults with Chronic Disease

Sporinova B, Manns B, Tonelli M, et al. (2019). Association of mental health disorders with health care utilization and costs among adults with chronic cisease. JAMA Network Open. Published online: 2(8):e199910. doi:10.1001/jamanetworkopen.2019.9910

Chronic diseases like diabetes, heart disease, chronic obstructive pulmonary disease (COPD), chronic kidney disease are common and represent a major burden on the individual and on society. So much so that chronic diseases represent about 60% of global disease burden. There is also a documented association between mental and physical health, such that mortality in cancer, diabetes, and following a heart attack is significantly higher in those with depression. The cost of chronic disease to the Canadian economy represents about 60% of the annual health care budget, and depression alone has a $32.3 billion impact on the Canadian economy. In this economic study, Sporinova and colleagues sought to quantify the impact of having a mental disorder on health care utilization and cost for those with chronic diseases. The study used a large data base of adults from Alberta, Canada who had at least one chronic disease including asthma, COPD, heart failure, myocardial infarction, diabetes, epilepsy, and chronic kidney disease. Mental disorders were defined as a concurrent diagnosis of depression, schizophrenia, or substance use disorder. Factors like sex, income, and rural residency were controlled in the analyses. Of the cohort with a chronic illness, 15.8% had a mental disorder, with depression as the most common mental disorder at 11.2%. People with chronic illness and a mental disorder tended to be younger, women, with a lower socio-economic status, and they tended to die at a higher rate during the study period. The mean total 3-year health costs of those with a chronic illness was $20,210 (95% CI: $19,674, $20,750) Canadian dollars, whereas for those with a concurrent mental disorder the cost was significantly higher at $38,250 (95% CI: $36,476, $39,935). Higher costs were driven by greater hospitalizations, prescription drug use, and physician visits. Costs were higher for older people, and for those with more than one mental disorder.

Practice Implications

The results clearly indicated that an important proportion of those with chronic illnesses were also diagnosed with a mental disorder. Further, a diagnosis of a mental disorder drove up the burden of the chronic illness significantly, both for the individual and for the health care system. Past research indicated improved medical outcomes when treating depression in medical patients. And so, although the physical symptoms of chronic illness may appear prominent, clinicians must treat mental health problems when they exist concurrently, if they want to improve patient medical and mental health outcomes.

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

Reese, R. J., Duncan, B. L., Bohanske, R. T., Owen, J. J., & Minami, T. (2014). Benchmarking outcomes in a public behavioral health setting: Feedback as a quality improvement strategy. Journal of Consulting and Clinical Psychology, 82(4), 731-742.

Psychotherapy has demonstrated its efficacy in randomized controlled trials. But do these findings in highly controlled studies translate to everyday practice in publicly funded agencies that treat low income clients? Previous research in the US showed that outcomes of treatment-as-usual in public behavioural health agencies are generally not positive, so that only 20 to 35% of clients reliably improved. One approach to improving outcomes is to transport specific evidence-based treatments into practice settings. For example, research on applying CBT for panic and depression in a publicly funded agency resulted in similar outcomes to those achieved in randomized controlled trials. However, an alternative strategy of improving outcomes is to use continuous outcome monitoring, which involves repeated (weekly) measurement of client outcomes with reliable scales, and feedback to therapists on the client’s status relative to previous sessions and relative to other similar clients. Research has demonstrated that this strategy improves client outcomes and reduces the number of clients who deteriorate. In this study, Reese and colleagues examined the outcomes of a large public behavioural health service in the U.S. that treats low-income individuals. The service implemented repeated outcome monitoring of clients with feedback to therapists. Over 5,000 clients mainly with depression, mood, and anxiety disorders were treated by 84 therapists who were licensed at the masters degree or higher. The clients completed the Outcome Rating Scale (a measure of symptom outcome) prior to each session, and the Session Rating Scale (a measure of the therapeutic alliance) after each session. Therapists received two days of training on how to use these measures and on the continuous feedback they were provided in order to improve their treatment of clients and their outcomes. Outcomes from this public behavioural health service were compared to previous large studies in publicly funded settings that implemented specific evidence-based treatments. The findings were similar, with about 42% showing reliable pre- to post-treatment improvement. The results of implementing continuous outcome monitoring with feedback for depressive symptoms were also large and positive (d = 1.34). These effects were similar to benchmarks established in randomized controlled trials of specific psychotherapies.

Practice Implications

Continuous outcome feedback enables therapists to identify clients who are not benefiting
from a given treatment, so that clinicians may collaboratively design different interventions or change their interpersonal stances. The inclusion of outcome monitoring and feedback in this publicly funded psychotherapy system, resulted in outcomes that were: better than what is often seen in such public service settings, equivalent to those public systems that implemented specific evidence based treatments, and similar to those reported in highly controlled randomized trials. The authors concluded that adding routine outcome monitoring and feedback is a viable alternative to transporting specific evidence based treatments to publicly funded psychotherapy programs. The measures used in this study are available free for individuals to use at: betteroutcomesnow.com.

Author email: jeff.reese@uky.edu

Pybis, J., Saxon, D., Hill, A., & Barkham, M. (2017). The comparative effectiveness and efficiency of cognitive behaviour therapy and generic counselling in the treatment of depression: Evidence from the 2nd UK National Audit of psychological therapies. BMC Psychiatry, 17, 215. DOI 10.1186/s12888-017-1370-7

Over a decade ago the United Kingdom (UK) invested large sums of public dollars to fund the Increasing Access to Psychotherapy (IAPT) program. In IAPT, most patients receive cognitive behavioral therapy (CBT) as first-line treatment for depression or anxiety, and may receive generic counseling as second line treatment. One of the admirable aspects of IAPT is that the program consistently assesses outcomes, makes its data available for analyses, and publishes yearly reports on their outcomes. In this very large study, Pybis and colleagues assess whether CBT and generic counseling have different outcomes for patients with depression or anxiety. Over 33,000 patients who received treatment at one of 103 sites were in the study. Most patients (about 23,000) receiving CBT, and the others (about 10,000) receiving generic counseling. Two-thirds of the patients were female, most (84%) were white British, and the mean age was 41 (SD = 13.86). CBT focused on changing negative thoughts and behaviors in order to improve depressive symptoms. Generic counselling was harder to define, though the authors described these therapists as practicing in an integrative manner by bringing skills from training in different forms of psychotherapy. Generic counseling therapists did not focus on giving advice or opinions, but rather on helping clients understand themselves better. Pre- to post-treatment effect sizes for CBT (0.94 [0.92, 0.95]) and generic counseling (0.95 [0.92, 0.98]) were equivalent for depression outcomes. In CBT 50.4% of patients reliably improved, whereas 49.6% reliably improved if they received generic counseling. The average number of sessions attended by patients in the two treatments (CBT = 8.9 [6.34]; counseling = 7.5 [5.54]) were also equivalent. However, there were significant site effects. That is, a moderate and significant amount of patient outcomes (15%) could be accounted for by the site at which they received treatment (i.e., some sites or clinics had better outcomes than others).

Practice Implications

Generic counseling as provided in the IAPT in the UK was as effective as structured CBT for reducing symptoms of depression. However, almost half of patients did not improve in either treatment. Generic counseling was likely a label used to describe integrative psychotherapy that followed principles from a variety of psychotherapies that were based on psychological principles. There were much larger site/clinic effects than treatment modality effects, so that clients in some clinics had better than clients who received treatment in other clinics. This is consistent with research on therapist effects that show that some therapists are more effective than others, regardless of their orientation. This research suggests that training therapists to be more effective by improving their facilitative interpersonal skills may yield better outcomes for clients.

Cologan, J., Schweiter, R.D., & Nolte, T. (2017). Therapist reflective functioning, therapist attachment style, and therapist effectiveness. Administration Policy and Mental Health, DOI: 10.1007/s10488-017-0790-5.

Differences between therapists account for about 8% of patient outcomes, which is a moderate effect and therefore an important factor. Constructs such as therapist personality characteristics and facilitative interpersonal skills may play a key role in how effective therapists can be with their clients. An important therapist quality might be reflective functioning, or mentalization. Reflective functioning refers to the ability to conceptualize, identify, and understand mental states in oneself and in others, and how mental states affect behaviour and functioning.  For example, reflective functioning is the basis for predicting others’ behaviors, understanding social nuances and others’ intentions, and also one’s own behaviors and internal experiences. Fundamentally for a therapist, reflective functioning is necessary for empathy, which is a key therapeutic quality. Another key issue for therapists might be their own attachment security, or their characteristic ways of relating to others in interpersonal relationships. Securely attached therapists (those who have a positive view of self and others in relationships) may be able to develop a better therapeutic alliance with clients. Insecurely attached therapists (those who are avoidant in relationships or who are preoccupied in relationships), may struggle to a greater extent with developing and maintaining an alliance. In this study, Cologan and colleagues assessed reflective functioning and attachment security in 25 therapists from different theoretical orientations who treated 1001 adult clients who mostly had problems with depression or anxiety. Client outcomes were measured pre and post treatment. On average clients experienced a reduction in their symptoms after psychotherapy. Clients of therapists with higher levels of reflective functioning experienced better outcomes. Therapist attachment insecurity did not have a direct effect on client outcomes.

Practice Implications

As with other studies, therapists in this study varied in their outcomes, so that some had better outcomes than others. Level of therapist reflective functioning (ability to mentalize) accounted for a large proportion of this difference. Therapists who had greater skills with understanding their own and clients’ behaviors in terms of mental states (intentions, motivations, psychological and emotional needs, internal conflicts) likely were better able to empathize and develop an alliance with their clients. These are skills that therapists can learn with practice, consultation, personal therapy, and training.