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Nehrig, N., Prout, T.A., & Aafjes-van Doorn, K. (2019). Whose anxiety are we treating, anyway? Journal of Clinical Psychology. Online first publication.

Evidence-based practice (EBP) in psychotherapy is defined by the American Psychological Association as the deliberate integration of: (1) the research evidence, (2) clinician expertise in making treatment decisions, and (3) client characteristics, preferences, and culture. The EBP statement was meant to supplant an older model of prescriptive psychotherapy practice that resulted in the creation of lists of empirically-supported treatments (EST). The ESTs were defined as: (1) manualized therapies, (2) shown to be efficacious in randomized controlled trials, (3) for patients with a specific diagnosed mental disorder. However, manualized therapies are not necessarily more effective than non-manualized treatments, and patients in randomized controlled trials may not represent those typically seen by therapists in everyday practice. Although EBPs are the current standard by which psychotherapists should practice, many therapists and organizations focus almost exclusively on the first of the EBP criteria (the research evidence of ESTs) to the exclusion of the second and third criteria (clinician expertise, and patient characteristics, preferences, and culture). In this review article, Nehrig and colleagues speculated about why this is the case by asking: “whose anxiety are we treating?” They argued that manualized therapies identified as ESTs reduce therapists’ anxiety caused by: uncertainty about treatment outcomes, the emotional toll of providing psychotherapy to people who are suffering, and the negative emotions (anxiety, despair, cynicism) that sometimes arises in therapists from the work. Nehrig and colleagues argued that ESTs provide therapists with a sense of control and certainty, while limiting therapists’ attention on relational challenges in the work of therapy. However, this emphasis on ESTs comes at a cost for therapists and patients. Therapists may not focus on developing skills to manage the relational challenges inherent in providing psychotherapy, greater certainty may reduce therapists’ engagement in sufficient self-reflection, and therapists may attend only to patients’ symptoms and not to the patient as a whole person. Nehrig and colleagues also discuss the preference for ESTs among institutions, insurance companies, and government funders of psychotherapy. ESTs reduce anxiety in these contexts because ESTs are seen by managers as methods to enhance accountability and standardization of treatment, to uphold standards of care, and to reduce potential liability. The short-term nature of most ESTs also assuages economic concerns for institutions and funders who wish to manage costs. However, this emphasis on short term manualized treatment also reduces psychotherapy from a complex interpersonal process with inherent uncertainty to one that resembles a clear-cut medical procedure that encourages top-down decision-making about clinical practice.

Practice Implications

Anxiety about the complexity of psychotherapy can cause therapists, institutional managers, and government funders to place greater value on ESTs rather than on clinical expertise of the therapist and patient characteristics. Patient characteristics, preferences, and culture are related to developing the therapeutic alliance and to patient outcomes. Astute therapists can learn to adjust their interventions to these patient characteristics, which may mean using clinical judgement to alter or deviate from a prescriptive manual. An EBP approach that integrates research, clinical expertise, and patient characteristics allows therapists to take into account transtheoretical factors known to affect outcomes like the therapeutic alliance, repairing alliance ruptures, empathy, and to use their clinical expertise to adjust their interpersonal stances to relevant patient characteristics, preferences, and culture.

Ravitz, P., Watson, P., Lawson, A., Constantino, M.J., Bernecker, S., Park, J., & Swartz, H.A. (2019). Interpersonal Psychotherapy: A scoping review and historical perspective (1974-2017). Harvard Review of Psychiatry, 27, 165-179.

Interpersonal Psychotherapy (IPT) focuses on relationships and emotions, and emphasizes stressful interpersonal loss, life changes, relationship disputes, and social isolation as the causes and maintenance factors related to depression and other disorders. The IPT is predicated on the importance of relationships for survival and the bidirectional links between depression and problems with relationships and social support. IPT was first manualized in 1974 and used as a comparison condition in studies of pharmacotherapy for depression. Contrary to expectations, IPT did just as well as antidepressant medication in early treatment trials, thus giving rise to an important new psychological treatment. This scoping review by Ravitz and colleagues summarizes the development of IPT over the past 40 years. The review identified over 1000 articles of IPT, 133 of which were randomized controlled trials. Following the initial trials in the 1970s, IPT was included in the Treatment of Depression Collaborative Research Program in the 1980s, funded by the National Institute of Mental Health in the United States. This was the largest trial of its kind whose results indicated that patients with high baseline depression did best with medications followed by IPT, whereas CBT did not show significant advantage over the placebo condition. The 1990s to the mid-2000s saw a precipitous increase in randomized controlled trials of IPT in which IPT was: compared to other therapies, compared to medications, and/or provided in combination with medications. In addition, treatment trials of group IPT were conducted in low- and middle-income countries. These studies led the World Health Organization to publish and disseminate a group IPT manual. More recent research in the past decade has seen IPT offered in different formats (individual, telephone, group, internet), for different populations (adolescents, perinatal women, late-life), and in a variety of low- and high-income countries. Currently, there is good research support for the efficacy of IPT for depression, eating disorders, bipolar disorder, PTSD, and anxiety.

Practice Implications

Relationships play an important role in determining health, disease, vulnerability, recovery, and resilience. Because of the universal importance of relationships, IPT is relevant to mental health care across cultures and populations. Therapists should consider the importance of relationship loss and grief, role transitions throughout the lifespan, persistent conflicts in relationships, and social isolation when treating patients with depression and other mental disorders.

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

Truijens, F., Zühlke‐van Hulzen, L., & Vanheule, S. (2018). To manualize, or not to manualize: Is that still the question? A systematic review of empirical evidence for manual superiority in psychological treatment. Journal of Clinical Psychology. Advance online publication. 

In 2010 Webb and colleagues published a meta-analysis in which they showed that the association between adherence to a psychotherapy manual and treatment outcome was close to zero. The same was true for therapist competence in delivering the manualized psychotherapy – almost no relationship to client outcome. Psychotherapy manuals typically specify the theoretical basis for an intervention, the number and sequencing of treatment sessions, the content and objective of sessions, and the procedures of each session. National institutes in the US and the UK have promoted manuals as a means to define what is evidence-based psychotherapy. By doing so these institutes assume that psychotherapy that is manualized is more effective that non-manualized treatment. However, detractors have argued that: (1) strict adherence to manuals may reduce therapists’ ability to individualize treatment to client needs and characteristics; (2) manuals are often designed for single disorders but clients tend to have many comorbid conditions; and (3) it is impossible for clinicians to gain competence in all different manuals for the various client conditions they may encounter. In this systematic review, Truijens and colleagues ask: does the use of manuals increase therapy effectiveness? To answer this question they conducted three different systematic reviews. First, they reviewed six studies that directly compared manualized versus non-manualized versions of a psychotherapy within the same study. One study showed manuals were superior, three showed no difference, and two studies showed that non-manualized therapies were more effective. Second, they reviewed eight meta-analyses that compared the pre- to post-treatment effect sizes of manualized therapies and of non-manualized therapies versus no-treatment control conditions. Three meta-analyses concluded that manualized therapies were superior, four meta-analyses did not find differences, and one observed non-manualized treatments to be superior. Third, the authors reviewed 15 additional studies to those reviewed by Webb and colleagues in their original meta-analysis. Overall, Truijens found similar results that support the conclusion that the level of adherence to psychotherapy manuals is not substantially related to better treatment outcomes.

Practice Implications

Although treatment manuals may be helpful for training purposes and to ensure validity in psychotherapy research, there is actually little consistent evidence that adhering to a manual results in better client outcomes. Some have argued that rigid adherence to a treatment manual can be harmful to clients. Therapists may need to take a flexible stance when applying research-supported therapeutic principles and interventions. Such a stance adjusts therapy to take into account client characteristics like level of resistance, coping style, attachment style, and others. Truly evidence-informed approaches incorporate what we know about client characteristics, therapeutic relationship factors, and therapist factors to promote positive outcomes in psychotherapy clients.

Solstad, S.M., Castonguay, L.G., & Moltu, C. (2018). Patients’ experiences with routine outcome monitoring and clinical feedback systems: A systematic review and synthesis of qualitative empirical literature. Psychotherapy Research. doi=10.1080/10503307.2017.1326645.

Routine outcome monitoring or progress monitoring involves assessing client outcomes or the therapeutic alliance on a weekly basis in psychotherapy, and then giving feedback to the therapist about how the client is doing relative to the previous week and relative to similar clients. Research on progress monitoring indicates that it improves outcomes and it reduces by half the number of clients who might get worse. Despite its benefits, many therapists are not aware of progress monitoring or are reluctant to use the procedure. Some have expressed concerns that progress monitoring could interfere with the therapeutic relationship. However, very few studies have asked clients about their experiences of progress monitoring. In this synthesis of qualitative studies, Solstad and colleagues reviewed 16 studies in which clients were interviewed about their experiences of progress monitoring. The authors used a procedure in which they identified common themes across the studies and categorized client statements within those themes (e.g., thematic analysis). The authors were interested in identifying what were the hindering and helpful processes in clients’ experiences of their therapists’ use of progress monitoring. Four main themes emerged from the research. First, some clients voiced suspicion of how the progress monitoring data was going to be used and why the procedure was implemented. That is, clients sometimes felt that filling out questionnaires weekly was mainly a bureaucratic exercise, or possibly a means to justify reducing services. Second, some clients felt the questionnaires were not flexible enough to capture the complexity of mental health and of client concerns. The questionnaires often focused on symptoms, but clients were also interested in the therapeutic relationship, family, and social functioning. Third, some clients wanted to be more fully informed about the rationale for progress monitoring so that they could feel more empowered to define their own outcomes and treatment plans. Fourth, some clients found progress monitoring to help them to see graphically their own progress, to become more engaged in treatment planning, and to participate in collaborative and reflective discussions with their therapist.

Practice Implications

If psychotherapists choose to use progress monitoring in their practices, they should make sure that clients know what the data will be used for and that the exercise is not just a bureaucratic process. The practice of outcome or progress monitoring can be used to stimulate reflection not only in the therapist but also in the client. Reviewing the client data together might enhance conversations about therapy, the therapeutic relationship, and help to establish realistic goals for therapy. Therapists might consider not only measuring symptom progress repeatedly, but also measuring the working alliance on a regular basis.

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