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Courtois, C. A. & Brown, L. S. (2019). Guideline orthodoxy and resulting limitations of the American Psychological Association’s Clinical Practice Guideline for the Treatment of PTSD in Adults. Psychotherapy, 56(3), 329-339.

Recently the American Psychological Association (APA) published clinical practice guidelines for the treatment of post-traumatic stress disorder (PTSD). The reaction from the clinical community that treats those with PTSD, client groups, and from many academic and research quarters was swift and negative. APA received almost 900 comments in their public consultations from many who felt the document was overly prescriptive, overly symptom-focused, and narrow in its recommendations. In this interesting inside look at the process, the Chair of the PTSD Practice Guidelines Committee (Christine Courtois) and a senior member of the Committee (Laura Brown) wrote a scathing commentary of the process imposed on them by APA that constrained the Committee’s access to information which affected their decisions. The Committee was bound by APA’s use of the Institute of Medicine (IOM) rules for developing practice guidelines. In other words, a psychological organization (APA) used a biomedical model to define what is relevant research, how to define treatment, what is an appropriate outcome, and how to decide on recommendations. As a result, the APA Committee reached several conclusions/decisions that were biased or premature. First, they defined PTSD only by its symptom presentation and not for the complex disorder that it is. In other words, PTSD was viewed almost exclusively from within a framework that defined it as only a fear-based response to a stressor. Such an approach downplays any developmental or attachment-related factors in the genesis or maintenance of PTSD. Second, the Committee was instructed to ignore a vast array of research on therapist factors, relationship factors, and client factors in psychotherapy. This runs counter to many clinicians’ views that one cannot engage in technical interventions related to PTSD symptoms without the patient experiencing a heightened sense of security in their relationship with the therapist. This also meant that the Committee largely ignored cultural and diversity factors. Third, the treatment recommendations focused on time-limited exposure-based interventions – which is a natural outcome of the first two decisions (i.e., seeing PTSD as only fear-based, ignoring issues of development, and ignoring relational factors in the treatment context). The authors were also disappointed that the APA ignored its own policy on evidence-based practice that puts equal weight on research, clinician expertise, and client factors when making clinical decisions. In the end the authors clearly were not confident in the narrow focus of the Clinical Practice Guideline, and they were concerned that clinicians, researchers, policy makers, and third party funders could misuse the Guideline to limit research, theory, and funding.

Practice Implications

In this extraordinary piece, the Chair and a senior committee member of the PTSD Practice Guideline Committee were highly critical of the process and outcome of APA’s effort to develop clinical practice guidelines for PTSD. The authors did not diminish the importance of exposure-based interventions for PTSD, however they did argue that these interventions must be offered only after clinicians take a sufficient amount of time to create a clinical context characterized by clients experiencing heightened safety in the therapeutic relationship, and to into account client preferences and culture. Further, clinicians should be highly sensitive to attachment-related insecurities and developmental traumas that may lengthen the treatment and that may have a complicating impact on the therapeutic relationship.

Norcross, J. C., & Wampold, B. E. (2019). Relationships and responsiveness in the psychological treatment of trauma: The tragedy of the APA Clinical Practice Guideline. Psychotherapy, 56(3), 391-399.

The American Psychological Association’s (APA) Clinical Practice Guideline for Posttraumatic Stress Disorder in Adults published in 2017 was met with a great deal of concern and criticism by the community of scholars and practitioners working with patients with PTSD. A key concern was that the APA used a biomedical model and not a psychological or contextual model in guiding their understanding of PTSD, their approach to what constitutes evidence, and to decisions about recommended treatments. In particular, the biomedical approach focuses almost exclusively on treatment methods, and down-plays the context of treatment (i.e., the relationship, patient factors, and therapist responsiveness). In this critique, Norcross and Wampold highlight the flaws in the APA Clinical Practice Guideline for PTSD, and the authors focus specifically on those variables that are known to predict patient outcomes but that were ignored by the Guideline. Norcross and Wampold highlighted that there exists numerous meta analyses that demonstrate that all bona fide psychotherapies work about equally well for trauma, and that the particular treatment method has little impact on PTSD outcomes. Yet, the restrictive review process undertaken by APA all but ignored this well-established finding. Also ignored was the research on the importance of the therapeutic relationship in the treatment of trauma. One review outlined nineteen studies that found that the therapeutic alliance was associated with or predicted reduction in PTSD symptoms. This is consistent with the general psychotherapy research literature, in which the alliance is the most researched and most reliable factor related to patient outcomes. Also missing from the PTSD Guideline was reference to a large body of research on therapist responsiveness to patient characteristics. Patients are more likely to improve if their therapists can adapt to the patient’s coping style, culture, preferences, level of resistance, and stage of change. In one study of cognitive-processing therapy (CPT; a treatment recommended by the APA Guideline), there were substantial differences between therapists in their patient’s PTSD symptom outcomes. That is, some therapists reliably were more effective than others, even though all therapists were trained in and supervised in providing the same manualized evidence-based treatment. Among the identified skills of the most effective CPT therapists were: a flexible interpersonal style, and an ability to develop and maintain a good therapeutic alliance across patients.

Practice Implications

There is growing consensus that the APA Clinical Practice Guideline for PTSD are based on dubious methodology and are of limited use to therapists and their patients with PTSD. Psychotherapists should practice a bona-fide therapy for PTSD, but should do so by taking into account the treatment context. In other words, more effective therapists are good at developing, maintaining, and repairing the therapeutic alliance across a range of patients. Effective therapists can also respond and adapt to patient characteristics such as level of resistance, coping style, culture, and stage of change. And so, even when providing a treatment based on the APA Guideline, therapists should nurture trust in the therapeutic relationship and be adaptive to their patients’ characteristics.

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

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

Davis, D. E., DeBlaere, C., Owen, J., Hook, J. N., Rivera, D. P., Choe, E., . . . Placeres, V. (2018). The multicultural orientation framework: A narrative review. Psychotherapy, 55(1), 89-100.

Many therapists have better outcomes with White or European clients than clients from diverse racial or ethnic minorities, and this might be due to racial and ethnic microaggressions that sometimes occur in therapy. Microaggression refer to intentional or unintentional brief commonplace verbal, behavioural, or environmental indignities that are experienced as derogatory or negative by racial and ethnic minority clients. A multicultural orientation refers to how the cultural worldviews, values, and beliefs of clients and therapists interact to co-create a relational experience in therapy. Therapist multicultural orientation has three elements. First, cultural humility, in which a therapist is able to maintain an interpersonal stance that is open to the client’s experience of cultural identity. Second, cultural opportunity, in which the therapist uses events in therapy to explore a client’s cultural identity in depth. Third, cultural comfort in which a therapist feels at ease, open, and calm with diverse clients. These elements are important in order to negotiate a therapeutic alliance (i.e. agreement on tasks and goals of therapy, and the emotional bond between client and therapist). In this narrative review, Davis and colleagues look at the small existing research on multicultural orientation and how that research can inform therapists’ practices. The authors found that in the two studies on the topic, greater therapist cultural humility was associated with better client outcomes. Several studies found that cultural humility was associated with a positive therapeutic alliance, and that therapist cultural humility was associated with fewer microaggressions as experienced by racial and ethnic minority clients. Finally, missed opportunities by therapists to explore the meaning of culture and identity were associated with negative client outcomes. Presumably, such missed opportunities meant that therapists did not recognize and repair cultural ruptures.

Practice Implications

The research on multicultural orientation suggests several practice implications. (1) Cultural humility requires therapists to explore their automatic cultural assumptions because if they remain unexplored they may be harmful to clients. (2) Therapists should overtly discuss the importance of cultural identities with clients in order to help both therapist and client develop a more complex understanding of the issues that bring the client to therapy. (3) A strong therapeutic alliance may require the therapist to incorporate their client’s cultural worldview and perspective when conceptualizing the client’s problems. (4) Depending on the client’s cultural worldview, therapists may consult with the client’s family and/or spiritual leaders when negotiating a culturally acceptable way of addressing the client’s problems. (5) Therapists need to identify for themselves when their values conflict with those of the client, and seek consultation or supervision when they do.

Stiles, W. B. & Horvath, A. O. (2017). Appropriate responsiveness as a contribution to therapist effects. In L. Castonguay and C. Hill (Eds.). How and why some therapists are better than others?: Understanding therapist effects (Ch. 4). Washington: American Psychological Association.

Appropriate responsiveness refers to therapists’ ability to adapt their techniques to the client’s requirements and circumstances. This might include planning treatment based on how the client is responding, using the client’s evolving responses to treatment as a guide to interventions, and adjusting interventions already in progress in light of subtle signs of client uptake. Appropriate responsiveness may depend on a client’s diagnosis, education, personality, stage of life, values, stage of therapy, among others. Responsiveness also depends on therapists’ skills, personality, theoretical orientation, and history of the therapeutic relationship. In this chapter, Stiles and Horvath review the literature on relationship variables that predict therapy outcomes and interpret these findings in the context of therapist responsiveness. To illustrate, previous research showed that therapists’ rigid adherence to a treatment manual was associated with worse client outcomes – or to state it differently, therapist adherence flexibility was associated with better outcomes. This flexibility is an indication of appropriate responsiveness on the part of the therapist. Stiles and Horvath also argue that most of the relationship variables that predict client outcomes reflect whether therapists appropriately respond to the circumstances of the client at a particular point in therapy. That is, evidence-based relationship factors like alliance, cohesion, empathy, goal consensus, positive regard, and others evaluate whether the therapist successfully tailored interventions and behaviors to the client’s unique personality and circumstances. For example, therapeutic alliance (the affective bond, and agreement on tasks and goals of therapy) indicates that the therapist selected interventions that were appropriate to the client, introduced them at the right time, and was attentive to and interested in the client’s progress. In support of this, the authors cite research showing that the therapeutic alliance is largely a function of the therapists’ responsiveness and not the client’s characteristics. That is, therapists are largely responsible for the quality of the therapeutic alliance.

Practice Implications

Research is increasingly indicating that therapists’ ability to respond appropriately to clients on a moment-to-moment basis is a key therapeutic factor. In other words, therapists who can build strong alliances, repair alliance ruptures, work for goal consensus and collaboration, manage countertransference, and be empathic are those who respond to the changing nature of client characteristics and needs in therapy. Supervision that provides feedback to therapists on these therapeutic factors, mastering a framework to guide interventions, client progress monitoring and feedback, and acquiring knowledge of client personality and cultural factors can sensitise therapists to their client’s changing requirements and allow them to respond therapeutically.