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Hall, G.C.N., Ibarak, A.Y., Huang, E.R., Marti, C.N., & Stice, E. (2016). A meta-analysis of cultural adaptations of psychological interventions. Behavior Therapy.

Cultural adaptation of psychological interventions involves identifying cultural contexts of behaviors and developing constructs of mental health functioning relevant to the cultural context. Most cultural adaptation of psychotherapies involves taking existing treatments originally developed for those of European ancestry and adapting them for another specific cultural group or context. However, a few efforts exist in which new treatments were developed within a particular culture to address culture-specific concerns. Eight dimensions along which interventions could be culturally adapted include: language, people, metaphors, content, concepts, goals, methods, and context. Some researchers have expressed concern that cultural adaptation could distance an intervention from its evidence-base, and reduce its effectiveness. In this meta analysis by Hall and colleagues, the researchers look closely at the effects all culturally adapted treatments and prevention methods. They reviewed 78 studies that included nearly 14,000 participants. All studies included culturally adapted interventions for individuals of non-European ancestry. For example, these included studies that adapted CBT interventions for various disorders (mainly depression and anxiety disorders), or studies that match therapist to client in terms of ethnicity. Only 5% of studies created a new intervention developed within a particular culture, whereas the vast majority of studies adapted an existing treatment initially developed for clients of European ancestry. The average effect size was g = .67 (confidence intervals not reported), indicating that culturally adapted interventions produced better outcomes than comparison conditions.  Culturally adapted interventions were also more likely to result in better outcomes than the same interventions that were not adapted (g = .52). Effect sizes for cultural adaptation in treatment studies (g = .72) were larger than for prevention studies (g = .25), likely because participants in treatment studies had higher levels of initial psychopathology. There was little evidence that matching therapist and client on ethnicity was helpful.

Practice Implications

This meta analysis provides compelling evidence that cultural adaptation of existing treatments can result in more positive outcomes compared to not adapting the same treatment. The effect sizes may even underestimate the true effects of cultural adaptation because the outcome variables like measures of depression were rarely adapted to a specific culture (e.g., depression among Chinese participants may be expressed differently than depression among European participants, and most depression measures were created by and for Europeans).

Levitt, H.M., Pomerville, A., & Surace, F.I. (2016). A qualitative meta-analysis examining clients’ experiences in psychotherapy: A new agenda. Psychological Bulletin. Online First Publication, April 28, 2016.

Much of psychotherapy research over the past several decades has focused on therapy outcomes, with the general conclusion that outcomes are equivalent across major psychotherapy orientations. Some of the effects of psychotherapy can be explained by relational factors (e.g., therapeutic alliance). There is also a growing and interesting line of research about therapist variables and therapist effects (see this month’s PPRNet blog on differences between therapists’ outcomes in a large UK sample). Many experts argue that client effects and characteristics account for the largest amount of variance in therapy outcomes. That is, who clients are and what experiences they have are the largest determinants of whether psychotherapy will be helpful. However the client’s experience is often neglected in psychotherapy research reviews. Levitt and colleagues conducted a qualitative meta analysis of qualitative studies of clients’ experiences in psychotherapy. Qualitative research typically involves interviewing clients about their experiences in therapy and coding the transcripts of these interviews. Methods of synthesizing and categorizing themes from client narratives, such as the grounded theory method and thematic analysis, create a rich source of understanding about how clients experience change in psychotherapy. Levitt and colleagues applied qualitative methods to synthesize 109 qualitative studies of over 1400 clients as a way of analysing this research. Six clusters or themes emerged from their qualitative meta analysis: (1) clients experienced therapy as a process of identifying and understanding personal patterns; (2) clients who felt understood and had their experiences validated were able to internalize the therapist’s voice; (3) clients experienced the structure of therapy (spacing of sessions and time allotted to sessions) and therapist expertise as generating credibility for the therapy, but also at times the structure reduced clients’ experience of therapeutic relationship’s authenticity; (4) clients experienced an inherent power differential with therapists that was sometimes compounded by differences in race, gender, and class; (5) clients played a major role in the therapeutic process, and clients felt pleased when they were invited to take the lead; (6) clients’ experiences of being cared-for supported their ability to recognize maladaptive patterns and address unmet vulnerable needs.

Practice Implications

This qualitative meta analysis highlights the important role played by the client’s experience and by the therapy context in promoting good outcomes. The results suggested that better outcomes may be achieved when: (1) therapists encourage clients’ curiosity about their cognitive, emotional and relational patterns; (2) therapists engage in an accepting and caring relationship in order to help clients decrease their defensiveness about vulnerable topics; (3) therapists maintain the therapeutic structure in order to increase clients’ sense of confidence in the process; (4) therapists explicitly acknowledge power differences and repair alliance ruptures; (5) therapists encourage clients to take an active role in therapy as a means of self-healing; and (6) therapists regularly check with clients about the fit of interventions, in-session needs, and treatment goals.

Xu, H. & Tracey, T.J.G. (2016). Cultural congruence with psychotherapy efficacy: A network meta-analytic examination in China. Journal of Counseling Psychology, 63, 359-365.

Cultural congruence refers to providing psychotherapy that is consistent with the client’s cultural context in its description of the etiology of symptoms and in its therapeutic procedures. In general, congruence of treatments with clients’ expectation, preferences, and beliefs is related to greater psychotherapy efficacy. And specifically identifying culturally appropriate or adapted treatments is important because this is often related to better therapy outcomes for ethnic and racial minorities. Psychotherapy as a professional practice developed recently in China. Cognitive-behavioral, existential-humanistic, and psychodynamic therapies have taken their place along side indigenous therapies including Naikan therapy, Taoism cognitive therapy, and Morita therapy. Historically in China mental health problems were seen as a disturbance in ying-yang or a sin committed in a previous life. Healing practices included engaging in altruism or religious practices to achieve redemption. Xu and Tracey argue that Chinese culture strongly endorses an experiential and subjective orientation and is less aligned with analytic and objective orientations. Using this understanding, the authors expected that experiential-humanistic and indigenous therapies would be more congruent and therefore more effective than cognitive-behavioral education or psychodynamic therapy in alleviating mental health issues. In this meta analysis, Xu and Tracey reported on 235 studies conducted in China that compared the various treatments to a control condition or to each other. There were too few studies of psychodynamic therapy, so it was not included in the analyses. All treatments were effective compared to a control condition with large effect sizes (g = .85 to 1.18). However, whereas experiential-humanistic and indigenous therapies were equally effective, each was significantly more effective (g = .34) than cognitive-behavioral psychoeducation.

Practice Implications

The three modalities, experiential-humanistic, indigenous, and cognitive-behavioral psychoeducation were effective. However the two therapies that were more experiential and subjective in nature were more effective to reduce Chinese clients’ symptoms. When working with Chinese clients, therapists may achieve better outcomes if they work on more experiential components (e.g., feelings and therapeutic relationship) and focus on subjective experiences (e.g., introspection and reflection). The results of the meta analysis suggest that when working with Chinese clients interpersonal processes and emotions should be the clinical focus and take priority over dysfunctional cognitions and psychoeducation.

Del Re, A.C., Fluckiger, C., Horvath, A.O., Symonds, D., & Wampold, B.E. (2012). Therapist effects in the therapeutic alliance-outcome relationship: A restricted-maximum likelihood meta-analysis. Clinical Psychology Review, 32, 642-649.

The therapeutic alliance, defined as the agreement on tasks and goals and the bond between therapist and patient, is one of the most researched concepts in psychotherapy. A meta-analysis of over 200 studies showed that the association between the therapeutic alliance and patient outcomes is moderate but robust (i.e., consistent across studies, patient types, and therapy types). Some have stated that the importance of the therapeutic alliance as reported in studies is an under-estimate of its real impact on patient outcomes. Del Re and colleagues argue that the main reason for this underestimation is that while the therapist’s effect on the alliance-outcome relationship might be large, the client’s effect might be quite small, and so the average of these two effects (which is what most studies report) will be diminished. Del Re and colleagues conducted the first meta analysis to assess the relative size of therapist versus client effects across many studies. Their strategy was clever. They looked at the ratio of the number of patients to therapists (PTR) within a study as a “predictor” of the alliance-outcome relationship across studies. This allowed them to examine the relative contribution of therapists and clients to the alliance-outcome relationship. Two extreme examples illustrate this ratio. (1) In one study, many patients might have been seen by only one therapist, in which case the alliance-outcome correlation could only be attributed to differences between clients since there was only one therapist. (2) In another study, each client might have been seen by a different therapist (i.e., there were as many therapists as clients), in which case the alliance-outcome correlation could only be attributed to differences between the therapists; that is, there are no differences between clients seen by the same therapist as this did not occur. The patient to therapist ratio (PTR) captures the variability between these two extreme examples across studies. Del Re and colleagues included 69 studies that provided enough information about the number of patients and therapists. The overall correlation between alliance and outcome was moderate, r = .27, which was very similar to what was found in a previous large meta-analysis. PTR was significantly associated with the alliance-outcome relationship even after controlling for a number of possible confounding variables. Patients accounted for almost 0% of the alliance-outcome relationship, whereas the effect of therapists was substantially larger, r = .40, accounting for 16% of the alliance-outcome association.

Practice Implications

Therapists’ capacity to develop an alliance with their patients is associated with outcomes. We also know that some therapists demonstrate better patient outcomes than others. So, therapists who consistently are better at forming alliances with patients likely have patients with better treatment outcomes. The quality of the alliance between patients and therapists appears to be the result of what therapists do or bring to the therapy. And so, on average, the therapist’s role in the alliance is most important for achieving good patient outcomes. Del Re and colleagues note that they were not able to look at the interaction between therapist and patient factors. For example, it may be possible that some therapists might form better alliances some types of patients, but not others. Integrating feedback systems so therapists can monitor the therapeutic alliance and patient outcomes may help therapists identify areas in which they need more training or supervision.

Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month from the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content and sections of the book can be read on Google Books.

Baldwin, S. & Imel, Z.E. (2013). Therapist effects. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6^th Edition (pp. 258-297). New York: Wiley.

Does it matter that some therapists are more effective than others? Can less effective therapists be trained to improve their outcomes and relationship quality with patients?  These are important questions not only for our patients’ well-being but also for the long term survival of psychotherapy as a health enterprise. If we do not measure outcomes and help therapists who are less effective, stakeholders (i.e., clients, families, agencies, insurance companies) may stop paying for the services. In the September 2013 blog I discussed a large study that showed that a few therapists were reliably harmful and some therapists were reliably helpful to their patients. That study also reported that most therapists were effective in 5 of 12 problem domains for which their patients sought help. What these findings and the Handbook chapter by Baldwin and Imel (2013) show is that there are significant between-therapist effects (i.e., therapists differed from each other on patient outcomes) and within-therapist effects (i.e., therapist outcomes within their own caseload differed based on the patients’ problems). Baldwin and Imel (2013) reported on their meta analysis in which between-therapist differences accounted for 5% of the outcome variance. That seems small, but it’s not. One study, for example, estimated that for each 100 patients that would be treated, the worst therapist compared to the best therapist would have 6 more patients who deteriorated. I would prefer my loved ones to be seen by the best therapist, even if the difference between best and worst is only 5%. Nevertheless, 95% of the variance in outcomes is within the therapist’s caseload. That is, the patient, other contextual variables, and the therapist-patient relationship are by far the biggest contributors to outcome. As Baldwin and Imel point out, not only are some therapists are more effective for some patients and not others, but also some therapists are better at developing a therapeutic relationship with some patients than with others. Baldwin and Imel reported that, on average, 9% of the variance in the quality of the therapeutic alliance is associated with the therapist – that’s a clinically meaningful effect.

Practice Implications

As Baldwin and Imel (2013) state, ignoring therapist accountability is detrimental to patients and to the mental health field in general. If stakeholders do not see evidence of positive outcomes, then they will withdraw funding, and patients will have even less access to services. Therapists differ in their outcomes, and outcomes also differ within each therapist’s caseload. If a primary goal is to improve therapist performance and patient outcomes, then therapists need to measure outcomes and therapeutic relationship quality. This knowledge about performance with specific patients can help therapists seek continuing education and training to improve outcomes and therapeutic alliances with specific patients for whom the therapist is less effective. This may require continuous outcome monitoring and real-time feedback to therapists regarding their patients’ outcomes (see my September 2013 blog in identifying clients who might deteriorate).

Horvath, A.O., Fluckiger, C., Del Re, A.C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48, 9-16.

The psychotherapy alliance is probably the most researched concept in psychotherapy. A PsychInfo search of terms including the word “alliance” will turn up over 7000 hits. Although the concept of alliance has been around at least since the 1950s, the commonly acceptable pan-theoretical definition that is currently used was proposed by Bordin in the 1970s. This definition emphasizes the conscious aspects of the collaboration between therapist and client, and involves three elements: agreement on goals, agreement on tasks, and the bond between client and therapist. What is important in terms of developing the alliance is the therapist’s ability to step back from his or her own agenda and emphasize, prioritize, and negotiate the collaborative relationship. This allows for the selection of an intervention that is congruent with client expectations, which then will foster a high level of mutuality. Horvath and colleagues conducted a large meta analysis of alliance - outcome research from the years 1991 to 2009 that included 190 independent studies and over 14,000 participants. The overall relationship between alliance and outcome was statistically significant and moderate in size. This was a highly reliable effect. The results were consistent regardless of which measure was used, who rated the alliance (client, therapist, independent rater), or what type of treatment was studied (i.e., CBT, IPT, Psychodynamic, etc). Similar results were found in separate published meta analyses of child and adolescent psychotherapy and of family and couple therapy, though the effect is larger in couple therapy.

Practice Implications

The quality of the alliance is an index of the level of mutual and collaborative commitment to therapy by the therapist and client. Its distinguishing feature is the focus on therapy as a collaborative enterprise. Establishing a good alliance prevents clients from dropping out, and the sense of collaboration creates a context to introduce new ways of addressing the client’s concerns. In the early phases of therapy, tailoring the methods of therapy (tasks) to suit the specific client’s needs, expectations, and capacities is important in building the alliance. Misjudging the client’s experience of the alliance (i.e., believing that it is in good shape when the client does not share this perception) could render therapeutic interventions less effective. Horvath and colleagues suggest active monitoring the clients’ alliance throughout treatment. Therapists’ nondefensive responses to client negativity or hostility are critical for maintaining a good alliance. Research indicates that therapists who are good at building a strong alliance tend to have better alliances with most of their clients. However, the reverse is also true – some therapists consistently struggle to establish and maintain a good alliance with their clients. The strength of the alliance often fluctuates when therapists’ challenge clients to deal with difficult issues, when misunderstandings arise, and when transference occurs and/or is highlighted. Resolution of these normal variations is associated with good treatment outcomes. The next blog entry discusses research on alliance ruptures and repairs.

Author email: horvath@sfu.ca