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Constantino, M.J., Boswell, J.F., & Coyne, A.E. (2021). Patient, therapist, and relational factors. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 7.

Many times, clinicians are interested in knowing what the likelihood is of a patient improving, how long that improvement might take, and what to expect in terms of degree of improvement. Some of the patient factors that predict these outcomes are indicators of the patient’s mental health at the start of treatment. In this part of the chapter, Constantino and colleagues review the research on several mental health indicators and their association with treatment and outcomes. First, functional impairment refers to the degree of impaired daily living, disrupted work performance, and social maladjustment. Generally, the research indicates that greater functional impairment is associated with poorer outcomes, and when coupled with a dual diagnosis (substance use disorder or another mental health diagnosis) greater functional impairment is associated with longer and more costly treatments. Second, chronicity (longer symptom duration) is also related to poorer treatment outcomes and slower rate of improvement. Third, symptom severity had a mixed association with patient outcomes. Generally, very high or very low severity of symptoms was related to poorer outcomes. It is possible that very high symptom severity may interfere with a patient’s capacity to use therapy, but that very low symptom severity may lead to the patient being less motivated to change. The fourth area was diagnostic comorbidity. Patients with major depressive disorder and personality disorder are twice as likely to have a poor outcome from psychotherapy. Similarly, patients with primary substance use disorder and a comorbid diagnosis typically dropped out at a higher rate and had poorer outcomes.

Practice Implications

It is sometimes helpful for clinicians and patients to know what to expect from psychotherapy and how long therapy might take. The more a patient’s work and social functioning is impaired and the longer they have had symptoms, the more sessions of therapy they might need. This means that both patients and therapists need to be realistic about what to expect in terms of progress. The same might be true for comorbid symptoms when the primary diagnosis is major depression or substance use. The picture for symptom severity is a little more complicated. Patients with very high symptoms may require an initial focus on reducing symptoms by increasing social supports, containment, and other practical interventions for them to make good use of therapy. On the other hand, patients with very low symptom severity may need help initially to increase their motivation for treatment to prevent a relapse.

Constantino, M.J., Boswell, J.F., & Coyne, A.E. (2021). Patient, therapist, and relational factors. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 7.

There are certain patient characteristics that interact with therapist behaviors and interventions, and these interactions have an impact on patient outcomes. Two of these that are reviewed by Constantino and colleagues are patient coping style and resistance. In a broad sense, coping style can be characterized as internalizing or externalizing. Internalizing coping refers to being self-critical and directing blame inward when under stress. Externalizing coping refers to acting out when stressed or placing blame on others or the environment when under stress. A meta-analysis of 1,947 patients from 18 studies, examined the interaction between coping style (externalizing vs. internalizing) and psychotherapy type, categorized as insight oriented vs. symptom-focused. Insight-oriented approaches (e.g., psychodynamic, humanistic) prioritize increasing self-understanding and emotional experiencing, whereas symptom-focused approaches (e.g., cognitive, behavioral) focus on changing symptoms directly through altering behaviors, cognitions, and reinforcement contingencies. The authors found a medium interactive effect on outcome (d = .60), such that those who typically engaged in internalizing coping had better outcomes in insight-oriented treatments and those who typically used externalizing coping had better outcomes in symptom-focused treatments. The second patient factor that interacts with interventions is patient resistance (also known as reactance). Resistance involves emotional arousal when one perceives that another is controlling or limiting one’s freedom, and the behaviors one engages in to resist this control. A meta-analysis of 13 controlled studies with a total of 1,208 patients found that patients higher in resistance had better outcomes when their therapist took a less directive approach and patients lower in resistance had better outcomes when their therapist adopted a more directive approach (d = 0.79).

Practice Implications

Therapists should pay attention to and assess their patients’ coping style and level of resistance. This information will inform how therapists should approach these patients or what their interpersonal stance should look like. Patients with a more internalizing coping style may do better with a more insight-oriented approach to therapy. Patients with a more externalizing coping style may do better in a therapy that requires them to engage in problems solving and is symptom focused. Also, patients who appear to be highly resistant (wary of or not willing to follow suggestions) may respond better when a therapist takes a less directive or less authoritative interpersonal stance. Conversely, patients who are lower in resistance (more agreeable or compliant) may respond better to therapists who are more directive in their in their interpersonal style.

Castonguay, L.G., Barkham, M., Youn, S.J., & Page, A. (2021). Practice-based evidence: Findings from routine clinical settings. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 6.

Practice-based evidence refers to research that is conducted as part of routine clinical practice. Often these studies do not impose strict research conditions like randomization of patients, and so they produce findings that are more relevant to psychotherapy as practiced real-world. In studies from practice-research networks, clinicians are often involved in the design and implementation of the study. Our Psychotherapy Practice-Research Network (PPRNet) is an example of a collaboration between researchers and clinicians to produce practice-based evidence. In a large survey, we found that most clinicians regardless of theoretical orientation wanted more research on the therapeutic relationship and on professional development. And so PPRNet developed a research program on training psychotherapists to identify and repair therapeutic alliance ruptures and microaggressions. In this chapter, Castonguay and colleagues review some of the key findings from practice research networks. First, White patients report better outcomes than Black patients in routine care, and these differences were linked back to the clinicians. That is, therapists varied in their effectiveness with racial and ethnic minority patients. Second, patients benefit when clinicians monitor the therapeutic alliance and outcomes on a session-to-session basis using reliable and valid measures. Noticing when a patient’s ratings of the alliance decline from one session to the next, might indicate a problem in the therapeutic relationship. Third, when monitoring the alliance, therapists should also rate the alliance. If a therapist’s ratings of the alliance are higher than their patients, then this may be a sign that the therapist is not paying attention to problems in the alliance. Fourth, developing and maintaining a strong therapeutic alliance likely will improve patient outcomes. Fifth, a reliable and valid assessment of client’s past and current interpersonal difficulties is likely to improve a therapist’s treatment plan for that patient.

Practice Implications

Doing research in clinical practices is not as well controlled as clinical trials research. But practice-based evidence is more relevant to how psychotherapy is done in the real world with real patients. The research is not so clear about why some therapists are more effective with racial and ethnic minority (REM) patients. However, complementary research suggests that some therapists who have a previously high level of multicultural orientation (cultural humility, open to conversations about culture, and cultural comfort) are more effective with REM patients. Also monitoring the therapeutic alliance with a valid scale on a session-to-session basis leads to better outcomes. Such monitoring will alert the therapist to resolve an alliance rupture if a patient’s ratings decrease from one session to the next. If therapists also rate the alliance and find that their scores are higher than their patient’s, then this may alert the therapist to a potential problem. Finally, knowing if a patient has current and past interpersonal problems can inform a therapist to focus on how those problems affect current symptoms and to talk about how those problems manifest themselves in the therapeutic relationship.

Constantino, M.J., Boswell, J.F., & Coyne, A.E. (2021). Patient, therapist, and relational factors. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 7.

Race refers to socially constructed perceptions of physical attributes shared by a group of people, whereas ethnicity refers to a group of people's shared cultural values,

attitudes, and behaviors. By extension, racial identity represents a sense of belonging that stems from a perception that one shares a heritage with a particular racial group. In this part of the chapter, Constantino and colleagues review the psychotherapy research on these important patient factors. The research suggests that racial and ethnic minority (REM) patients have more difficulty accessing therapy, and that the quality of mental health treatment that they receive is lower than for White patients. REM patients may be at greater risk for premature termination from therapy than White patients. One solution might be to match REM patients to therapists with similar identities. A meta-analysis of 52 studies found that patients significantly preferred a therapist of the same race or ethnicity (d = .32), and patients perceived therapists of the same race or ethnicity more positively. However, the same study found little benefit for patient outcomes of matching therapists and patients on their racial or ethnic identities. The exception was for African American patients who experienced significantly better outcomes when treated by a same race/ethnicity therapist, but the effect was small (d = 0.19).

Practice Implications

The mental health disparities and higher dropout rates experienced by racial and ethnic minority (REM) patients should be a cause of concern for all psychotherapists. As reported in the next blog entry, some therapists are significantly less effective when working with REM vs White patients, and some therapists are more effective when working with REM patients. Overall, the findings suggest that specific therapist behaviors and practices affect REM patients’ mental health outcomes. One way to improve these outcomes is to assess a patient’s cultural identity and to culturally adapt treatment to aspects of patients’ cultural backgrounds. Another approach is for therapists to develop multicultural competence and a multicultural orientation that includes cultural humility, openness to conversations about culture, and cultural comfort.

Barkham, M. & Lambert, M.J. (2021). The efficacy and effectiveness of psychological therapies. In In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 5.

In this part of the chapter, Barkham and Lambert review the debate about which psychotherapy is most effect for a particular disorder. This is a debate that has been ongoing since the middle of the last century. The current status of this debate centers around questions like how big are the differences between treatments, are these differences clinically meaningful, and if the specific interventions of a particular therapy are not the cause of change, then what are? It turns out that the early estimations of differences in therapies favoring CBT were over-blown. This was caused by combining effects across different studies that did not directly compare the treatments in question (the technical explanation is that comparing the effects of CBT vs a wait list control group in one study to the effects of psychodynamic therapy to a control group in another study introduces a whole host of confounds that make interpreting the differences in effects across studies unreliable). When subsequent researchers conducted meta-analyses of the effects of psychological therapies and only included studies in which bona-fide therapeutic approaches were directly compared to each other in the same study, then the differences between therapeutic approaches were small and clinically irrelevant (and even those small effects were be wiped out by controlling for the researchers’ allegiance [i.e., the effect caused by the researchers’ preference of one therapy over another]). Another way to consider the question is to assess the effects of the specific interventions of a therapy. That is, if CBT is effective because of its cognitive or behavioral components, then removing a component of CBT should reduce its effectiveness. These are often referred to dismantling studies. However, reviews of these types of studies indicate that removing components of treatment seem to have little or no impact on patient outcomes. That is, the effect of a therapy seems to have little to do with the specific intervention associated with the therapy (e.g., cognitive restructuring, exposure and response prevention). In fact, by far the largest predictors of patient outcomes are the factors common across most therapies: the therapeutic alliance, therapist empathy, goal consensus, therapist interpersonal skills, cultural adaptation of therapies, and others.

Practice Implications

This research domain is far from perfect, and the debate over which therapy is better unfortunately will likely continue for some time. However, clinically and from a public health perspective, this is not a useful debate and hopefully with time it will fade. Much more useful questions likely center around how we can improve therapist skills in those factors that lead to better patient outcomes. That is, regardless of theoretical orientation, can we train therapists to verbally express emotions and empathy, improve their capacity to develop and maintain the therapeutic alliance, and adapt their interventions to the patient’s culture, characteristics, and preferences?

Barkham, M. & Lambert, M.J. (2021). The efficacy and effectiveness of psychological therapies. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 5.

For decades now, researchers have been trying to address the question of how many sessions of therapy is optimal for the average patient. In this part of the chapter, Barkham and Lambert review some of the research related to the question: how much therapy is necessary? Early research noted that it took about 13 sessions for 50% of patients to achieve clinically significant change, and 50 sessions was necessary for 75% of patients to achieve significant change. In other words, the number of sessions need to be doubled for another 25% of patients to improve. (Of note, half of patients did not improve after 13 sessions). Such research suggests a dose-response relationship, such that more therapy sessions result in more patients getting better – but the rate of return slows considerably with more sessions. The problem with this approach to estimating how many sessions are necessary is that it assumes that all patients improve at a consistent rate across sessions, but that may not be the case. Other researchers suggest that patient rate of change is individual, and that when a patient achieves a good enough level of change, they will terminate therapy. The research area is complicated by several factors. First, much of the research was conducted in university counselling centers with therapists in training, student patients, and bounded by the semester system. So, by definition, the therapy is time-limited and patients may be homogenous with regard to symptom severity. Second, some of the data in meta-analyses come from randomized controlled trials that by necessity represent brief treatments. Third, different modes of delivery in different countries appear to have an impact on how many sessions are delivered and what kind of therapy is offered. Fourth, patient severity at baseline may be related to longer treatments and slower rates of change.

Practice Implications

Although the dose-response research has been used in some settings to arbitrarily select treatment length offered to all patients, the results of this research may not be reliable. Predetermined fixed treatment lengths are likely not appropriate for patients. For example, greater patient severity at the start of treatment, and comorbidity and complexity of problems will likely result in such patients requiring a higher number of treatment sessions. A one-size-fits-all approach to determining how many sessions are offered to patients will likely negatively affect the most vulnerable of patients.