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Firth, N., Saxon, D., Stiles, W. B., & Barkham, M. (2019). Therapist and clinic effects in psychotherapy: A three-level model of outcome variability. Journal of Consulting and Clinical Psychology, 87(4), 345–356.

Patients vary in their outcomes from receiving psychotherapy. That is some patients receive more benefit than others or receive benefit more quickly than others. Previous research indicates that factors like higher symptom severity and socioeconomic deprivation are factors that lead to poorer outcomes. There is also evidence that some therapists are more effective than others so that 5% to 10% of patient outcomes depend on which therapist the patient sees. There is also research showing that the location of the clinic may reflect systematic differences in patient outcomes. This may be due to differences in clinic patient populations, to therapist recruiting practices, resource allocation, and accessibility. Research in population health suggest that local neighborhoods affect physical health. In this large study of over 26,000 patients receiving psychological therapy in the United Kingdom (UK) health system, Firth and colleagues estimated how much of patient outcomes were due to differences among patients, differences among therapists, and difference among clinics. Patients received person-centred, psychodynamic, cognitive-behavioral, or supportive therapies. Drop-out rates from therapy was 33%. Average age of patients was 38.4 years (SD = 12.94) and 69.3% were women. Most patients experienced anxiety (71.8%) and/or depression (54%). There were 462 therapists in the study working at 30 clinics throughout the UK. Up to 58.4% of patients who provided post-treatment data (i.e., completed therapy) showed reliable and clinically meaningful improvement, but there were large differences in patient improvement rates across the clinics (range: 23.4% to 75.2%) and across therapists (6.7% to 100%). Patient severity explained a large proportion of therapist differences. That is, whereas many therapists were effective with less severely symptomatic patients, relatively fewer therapists were effective with more severely symptomatic patients. Patient unemployment, location of the clinic in a more economically deprived area, and the proportion non-White patients in the area explained most of the differences between clinics. Patients who were employed and living in an economically advantaged neighborhood composed of mostly White residents had better outcomes.

Practice Implications

We know from previous research that some therapists are more effective than others and these differences are more pronounced with more severely symptomatic patients. However, this study suggests that larger social factors like racism, systematic bias, and microaggressions also play a role in patient outcomes. Economic deprivation likely affects the level of funding and resources allocated to some clinics. Psychotherapists and funding sources need to take into account the broader socioeconomic, ethnic/racial, and geographic context in which the patient lives when planning and offering services to patients.

De Smet, M. M., Meganck, R., De Geest, R., Norman, U. A., Truijens, F., & Desmet, M. (2020). What “good outcome” means to patients: Understanding recovery and improvement in psychotherapy for major depression from a mixed-methods perspective. Journal of Counseling Psychology, 67(1), 25–39.

Many researchers consider the randomized controlled trial (RCT) as the best research design for testing medical and psychological treatments. However, critics of the design point to its limitations. For example, in order to collect homogenous samples of patients, researchers may exclude those with complex comorbidities. As a result, patient samples in RCTs may not represent patients one might see in real clinical practice. Also, researchers, and not patients, tend to define the meaning of what is a “good outcome” in these studies. It is possible that researchers and patients may not share the same definition of what it means to have a good outcome from psychotherapy. One key statistical and measurement method that researchers use to define outcomes is the reliable change index, which calculates the degree of change on a symptom scale from pre-treatment to post-treatment relative to the unreliability of the measurement. Using this method, researchers classify patients as “recovered” (reliably changed and passing a clinical cut-off score), “improved” (reliably changed but remaining in the clinical range), “not improved”, or “deteriorated”. However, this commonly used approach does not indicate whether the changes are actually meaningful to the patients. In this study, De Smet and colleagues interviewed patients from a randomized controlled trial of time-limited psychotherapy (16 sessions of CBT vs psychodynamic therapy) for depression who were classified as “recovered” or “improved” at post-treatment based on the reliable change index of a commonly used depression self-report scale. The authors asked how the patients experienced their depression symptom outcome, and what changes the patients valued since the start of therapy. In the original treatment trial of 100 patients, 28 were categorized as “recovered” and 19 patients were categorized as “improved”. During the post-therapy interview, the “recovered” and “improved” patients typically reported a certain degree of improvement in their symptoms. However, the patients categorized as “improved” reported that their gains were unstable from day to day, some reported having relapsed, and half did not feel that they improved at all. None of the “recovered” patients indicated that they felt “cured” of depression. Patients identified three domains of change that they experienced and valued. First, they felt empowered – that is, they had increased self-confidence, greater independence, and new coping skills. Second, they found a personal balance – that is, they had better relationships with loved ones, felt calmer, and had greater insight into their problems. Third, patients tended to identify ongoing struggles despite positive changes in the other domains – that is, certain key problems remained unresolved. “Improved” patients, and even some in the “recovered” group, indicated that their core difficulties had not been altered by the therapy.

Practice Implications

Although measurement of symptom change can give a clinician a general sense of how the patient is doing with regard to their symptoms and whether the patient is on track, such measurement may not capture the complexity of patients’ experiences of the therapy and any broader changes they may value. Patients in this trial, especially those classified as “improved”, had varied experiences. Aside from symptom reduction, clinicians should assess what their patients may value, such as: better relationships, greater self-understanding, more self-confidence, and feeling calmer. Most patients, including some who “recovered”, felt that they were engaged in an ongoing struggle, even after therapy. These findings suggest that addressing some of the core difficulties patients face may require longer term psychotherapy.

Kolden, G.G., Austin, S.A., Wang, C-C., Chang, Y., & Klein, M. (2018). Congurence/genuineness: A meta-analysis. Psychotherapy, 55, 424-433.

More than 60 years ago Carl Rogers first described congruence or genuineness in the psychotherapy relationship as one of the necessary conditions for patients to improve. Congruence has two components. The intrapersonal component refers to mindful genuineness, personal awareness, and authenticity in relationships. The interpersonal component refers to the capacity to express ones’ internal experiences to another person. Rogers argued that patients often experience incongruence with regard to their internal states (they may avoid or fear the experience or expression of what they think or feel). He also stated that therapists’ congruence in the relationship with a patient is a pre-requisite for positive regard and empathy toward the patient. In this meta-analysis, Kolden and colleagues do a systematic review of the relationship between therapist congruence and patient outcomes. The review included 21 studies representing 1,192 patients. The weighted effect size for congruence and psychotherapy outcome was r = .23 (95% CI: .13, .32), representing on average a moderately large effect. Theoretical orientation did not affect the congruence – outcome association. However older therapists with more experience showed a significantly stronger congruence – outcome relationship. Also, therapy with younger patients was associated with a larger congruence – outcome relationship.

Practice Implications

Research continues to support fundamental therapeutic factors defined by Rogers many decades ago. In this case, congruence/genuineness (or the therapist’s ability to know their internal experience and communicate it respectfully to patients) is positively related to patient outcomes. This is especially true for older therapists (who may have a greater capacity for genuineness) and for younger patients – (for whom therapist genuineness may be particularly important). Patients who may have a greater need for and expectation of genuineness are likely to develop a stronger therapeutic alliance with a highly congruent therapist. Patients in a congruent therapeutic relationship learn that it is a safe space, that they matter as a person, and that the therapist is committed and accepting. All of which are precursors to a successful therapy.

Client Stage of Change Predicts Their Outcomes in Psychotherapy

Krebs, P., Norcross, J.C., Nicholson, J.M., & Prochaska, J.O. (2018). Stages of change and psychotherapy outcomes: A review and meta-analysis. Journal of Clinical Psychology, 74, 1964-1979.

Next to the therapeutic alliance, client stage of change is one of the most researched concepts in psychotherapy. The theory posits that clients come for treatment with varying levels of motivation, preparation, and capacity for behavior change. And their overall readiness for change influences the process and outcome of the psychotherapy they receive. Researchers have identified five stages that clients may go through during the change process, and they identified most effective therapist stances to help clients move from one stage to the next. Precontemplation is the stage in which the client has no intention of changing, and they may have been coerced into coming to therapy. During this stage therapists may help the client increase their awareness of the advantages of changing and the costs of not changing. Contemplation is the stage in which the client is aware that there is a problem, but has not yet made a commitment to take action. During this stage the client may face the sadness or anxiety related to letting go of behaviors that no longer work. Therapists may help a client to re-evaluate themselves should they change their behaviors. Preparation is a stage in which the individual is fully intending to take action, and they may make small behavioral changes. Therapists may help clients in this stage to act on their belief that they have the ability to change their behavior. Action is the stage in which clients modify their behaviors or environment to overcome their problems. Therapists may help clients at this stage by ensuring clients perceive adequate reinforcements for their efforts and resist the tendency to avoid problematic situations or feelings. Finally, the maintenance stage is the point at which clients have made desirable changes and now work to prevent relapse and consolidate gains. Therapists may help individuals during the maintenance phase to be prepared for or to avoid situations that may induce relapse. A key aspect of therapist stances related to client stages of change is exemplified by the process of motivational interviewing, in which the therapist works with the client’s resistance rather than taking a confrontational stance. In this meta-analysis, Krebs and colleagues systematically reviewed the literature on stages of change and summarize 76 studies with over 21,000 clients. The association between stage of change and client outcome was significant and moderate in effect size (d = 0.41; 95% CI: 0.34, 0.48). That is the stage of change at which the client starts has a measurable impact on their outcomes, with pre-contemplation being related to poorest outcomes, and action being related to best outcomes. These results were consistent across theoretical orientations. In a second meta-analysis, the authors found that tailored interventions to move clients to more advanced stages of change were significantly related to better outcomes, though the effects were small (d = 0.18; 95% CI: 0.16, 0.20).

Practice Implications

The stage of change theory is transtheoretical – that is, it operates across most therapeutic situations and clients. The findings of this meta-analysis indicate that therapists who know the client’s stage of change and who act accordingly will improve their client’s outcomes. Many therapists tend to believe that their clients are at the action stage, but this may not be the case. Treating someone who is contemplating change as if they are ready to make changes may be counter-therapeutic as it represents a mismatch of goals. Hence, therapists should work with clients to set realistic goals for therapy, and therapists should keep in mind that a patient who is not ready to change will not likely change if confronted. The best strategy may be to discuss with the client the risks and benefits of their behaviors, and help them make a decision of how or if to move forward with therapy.

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.