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Torous, J., Lipschitz, J., Ng, M., & Firth, J. (2020). Dropout rates in clinical trials of smartphone apps for depressive symptoms: A systematic review and meta-analysis. Journal of Affective Disorders, 263, 413-419.

Depression is a leading cause of disability worldwide, and yet more than 50% of people do not have access to adequate therapy. One solution might be to provide individuals with smartphone apps to help screen, monitor, or provide treatment. Smart phones are ubiquitous, and depression apps are one of the most downloaded categories of apps by the public. Research seems to suggest that smartphone apps provide some positive results for members of the public, but these findings are compromised by the high drop-out rates reported in the primary studies. Further, one study found that although many people download the apps, only about 4% actually use them. Whereas smartphone apps appear attractive to the consumer, very few actually make use of and therefore benefit from them. In this systematic review, Torous and colleagues conduct a meta-analysis of drop-out rates from studies that test the use of smart phone apps. They found 18 independent studies representing data from 3,336 participants who received a psychological intervention for depression via a cell phone app, or who were in a placebo control condition. A total of 22 different apps were tested in the studies. Initially, the pooled drop-out rate from the depression app treatment arms appeared to be about 26.2% (95% C.I.=11.34% to 46.75%), which would be in line with average drop-out rates from randomized controlled trials of face to face psychotherapy. But, the authors noted two things. First, the drop-out rate from the placebo control conditions (14.2%; 95% C.I. = 8.236 to 23.406) was almost half as high as that found for the apps. Second, through some sophisticated statistical analyses, they found evidence of “publication bias” in this research area. This means that a number of studies testing these apps likely were completed but never published (i.e., these might be studies funded by an app manufacturer that demonstrated negative findings or high drop-out rates). When the authors statistically adjusted for publication bias, they found that the actual drop-out rate from the apps was about 47.8%. That is, almost half of users did not complete or dropped out of the studies. There were no differences in drop-out between types of interventions (CBT, mindfulness, or others), and studies with larger sample sizes (i.e., better quality studies) had higher drop-out rates.

Practice Implications

Although smartphone apps appear really attractive and may be potentially useful as an adjunct to face to face psychotherapy for depression, their utility is plagued by extremely low usage rates (4%) and high drop-out rates from studies (almost 50%). Leading writers and researchers define psychotherapy as primarily a healing relationship that also includes specific interventions. The key ingredient is the human relationship. Depressed or otherwise troubled individuals cannot (because of feeling demoralized) or will not interact with a machine for healing. One way or another, when it comes to smartphone apps, depressed individuals are voting with their feet. Given these findings, health care providers should consider the ethics of giving a depressed individual only e-therapy as the primary mode of treatment.

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.

Friedlander, M. L., Escudero, V., Welmers-van de Poll, M. J., & Heatherington, L. (2018). Meta-analysis of the alliance–outcome relation in couple and family therapy. Psychotherapy, 55(4), 356-371.

In individual psychotherapy the therapist’s tasks include to develop an alliance with one patient. Goals and tasks of therapy need to be collaboratively negotiated, and therapists need to develop an emotional bond with the patient. The alliance also has to be nurtured continuously throughout treatment. This process is more complicated in couple and family therapy. Only in couple and family therapy (and in group therapy) does a therapist have to develop an alliance with multiple people simultaneously. The challenge is greater when family members are in conflict, or when the therapist’s alliance is stronger with one member than another. Such “split” alliances can be problematic especially when family members view their experiences of the therapist differently. To complicate things more, therapists have to be aware of the alliance within the family or couple system. That is, are the family members allied with each other – do they agree on therapy goals and tasks, and are they able to maintain an emotional connection to each other? In addition, just as therapeutic alliance ruptures can occur in individual therapy, so can they occur in couple and family therapy. An alliance rupture may occur when a there is a “split” alliance or when a patient responds to the therapist or other family members with confrontation or withdrawal behaviors. In this meta-analysis of therapeutic alliance in couple and family therapy, Friedlander and colleagues included 48 studies with a total of 2,568 families and 1,545 couples. The correlation between quality of the alliance and outcome was significant (r = .297, 95% CI [0.223, 0.351], p < .001), indicating that a stronger alliance was related to better outcomes. There was some evidence of publication bias suggesting that this estimate may be over-inflated, but even after adjusting for publication bias the correlation was still significant. The correlation between split alliances and outcome was also significant (r = .316, 95% CI [0.157, 0.458], p < .001), indicating that more split alliances contributed to poorer outcomes. The correlations were similar in strength both in couple and in family therapy, and the alliance was important in all therapeutic orientations. However, correlations were larger when the targeted child in the family was younger, and when families were seeking help and not mandated.

Practice Implications

Like in individual therapy, the therapeutic alliance in couple and family therapy is important to improve the outcomes of patients. Regardless of therapeutic orientation, therapists must spend time and effort developing therapeutic alliances with each member of the system, and must try to maintain relatively equal alliances with each family member to avoid splits in the alliance. Therapists should be particularly aware of any confrontation and withdrawal behaviors towards the therapist or within the family or couple as these may indicate an alliance rupture. In such instances, therapists should emphasize shared goals and feelings, validate the common struggle among family members, and focus on the emotional bond with the disaffected patient. Each person’s alliance matters, and family member alliances are not interchangeable. Assessing the alliance with each member throughout therapy will identify potential problems and facilitate better outcomes.

Karver, M. S., De Nadai, A. S., Monahan, M., & Shirk, S. R. (2018). Meta-analysis of the prospective relation between alliance and outcome in child and adolescent psychotherapy. Psychotherapy, 55(4), 341-355.

Over the past decades there has been increasing research on the efficacy of psychotherapy for children and adolescents, but outcomes have not always been positive. Treatment of children and adolescents comes with challenges that are unique from those experienced in therapy of adults. For example, unlike most adults, children and adolescents may not be the ones to choose to attend therapy - that decision is often made by adults in their lives. Furthermore, psychotherapists must also develop and maintain a collaborative relationship with parents, on whom the therapist and child/adolescent rely in order to be able to engage in treatment. Because of the unique characteristics of working with children and adolescents, negotiating, developing, maintaining, and repairing the therapeutic alliance is potentially complex. The therapeutic alliance is defined as an agreement on tasks of therapy, an agreement on goals of therapy, and the relational bond between therapist and client. In this meta-analysis, Karver and colleagues reviewed 28 studies of psychotherapy with children and adolescents. The mean age was about 12 years, most children/adolescents had internalizing problems, but others had problems with externalizing behaviors, and substance abuse. Almost two thirds of the studies involved a version of behavior or cognitive behavioral therapy. The therapeutic alliance was measured from the perspective of the client, therapist, and/or the parent. The overall mean effect size of the alliance-outcome relationship was small to moderate: r = .19 (p < .01, 95% confidence interval [CI] [0.13, 0.25]). Larger effect sizes were seen in those therapies of children and adolescents with internalizing disorders (r = .19), and when the therapist – parent alliance was measured and correlated with outcomes (r = .30). In other words, a positive alliance was most important for internalizing disorders, and for the relationship between therapist and parent.

Practice Implications

The findings of this meta-analysis indicate that the therapeutic alliance, especially with the parent, is important to the outcomes of children and adolescents in psychotherapy. Clinicians should not only develop an alliance with the youth, but also with the parent/caregiver. Therapists should also consider measuring the alliance regularly during therapy as a means of heading off any ruptures (with the youth or the parent) that might endanger the therapy. The authors recommended using the Therapeutic Alliance Scale for Children – Revised with children/adolescents, and the Working Alliance Inventory with parents.

Soto, A., Smith, T.B., Griner, D., Rodriguez, M.D., & Bernal, G. (2018). Cultural adaptations and therapist multicultural competence: Two meta‐analytic reviews. Journal of Clinical Psychology, 74, 1907-1923.

There is emerging evidence that a client’s cultural experiences and background have an impact on the therapeutic alliance and on client outcomes. One means of adjusting psychotherapy is by cultural adaptations, which involve modification of treatment to consider language and culture in such a way that the treatment is more compatible with the client’s values. Cultural adaptation might incorporate holistic/spiritual concepts of wellness, and may include cultural rituals. Therapists could also align treatment goals and methods with the client’s culture. Domains of psychotherapy that psychotherapists can adapt to a client’s culture include: language of treatment, metaphors used in therapy, the person of the therapist (assigning a therapist with a similar cultural background), content discussed, concepts explored, goals of therapy, methods of interventions consistent with cultural values, and the context of treatment. Cultural competence refers to the therapist’s ability to engage and work effectively with diverse clients. These competencies include: awareness (ability to recognize cultural backgrounds, assumptions, and biases), knowledge (understanding of specific cultural groups and their history and experiences), and skills (ability to engage cultural groups and modify treatment to match cultural needs). In the first of two meta analyses, Soto and colleagues identified 99 studies of cultural adaptation that included data from almost 14,000 clients who were mainly Asian American, Hispanic/Latin American, or African American. The most frequent adaptations were for language of therapy, cultural values, and matching therapists with similar racial/ethnic backgrounds. Cultural adaptation had a significant, moderate, and positive effect to improve psychotherapy outcomes, d = 0.50 (se = 0.04; 95% CI, 0.42–0.58; p < 0.001). Even after adjusting for publication bias, the findings were significant but smaller d = 0.35 (95% CI, 0.27–0.43). All types of adaptation had a positive impact, but the biggest effect came with providing treatment in the native language of the client. Also, older clients benefitted most for cultural adaptation. In the second meta-analysis, the authors identified 15 studies of 2,640 clients on the effect of therapists’ level of multicultural competence. They found a significant and moderate association between therapist cultural competence and positive client outcomes, r = 0.24 (95% CI, 0.10–0.37; p < 0.001). However, only the client’s (and not the therapist’s) rating of therapist cultural competence was associated with better outcomes.

Practice Implications

The results of these meta-analyses clearly indicate that both cultural adaptations of psychotherapy and therapist cultural competence improve client outcomes. During the assessment phase, therapists should evaluate clients’ racial and ethnic backgrounds and the salient culturally-specific values and worldviews held by the client. Therapists could, whenever feasible, adapt their treatment to the client’s culturally-held values. Therapists might, if possible, arrange to provide therapy in the native language of the client – particularly for older clients. Cultural issues should be handled by therapists in a humble way. And therapists should keep in mind that it is the client’s experience, and not the therapist’s self-assessment, of cultural competence that is most relevant.

Author email: Alberto_Soto@brown.edu

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