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Reich, C.M. & Berman, J.S. (2018). Are psychotherapies with more dropouts less effective? Psychotherapy Research. Online first publication.

The client dropout rate in clinical studies is about 20%, and almost double that in regular clinical practice. A dropout is a unilateral decision on the part of the patient to discontinue treatment after the first session. This is often viewed as a treatment failure, but it is possible that some patients feel better enough to not continue with therapy, and others may have practical constraints like transportation or childcare difficulties. In three meta analyses, Reich and Berman ask: (1) do those who drop out experience more distress than completers to begin with?, (2) do completers have better outcomes than drop outs?, and (3) do less effective treatments also have more drop outs? In general, the studies included different types of psychotherapy but most were CBT (~75%), most therapists had a masters or doctoral degree (~33%) but many studies also included student therapists (~25%), client problems included depression (~17%), anxiety (25%), or other disorders, and most studies were randomized controlled trials (~61%). To answer the first question the authors conducted a meta analysis of 76 studies. Clients who dropped out of therapy were in more distress prior to beginning treatment than individuals who completed the treatment (d= − 0.14, 95% CI [− 0.08, − 0.20], p < .001). The effect was small but significant. Younger and male clients tended to be in more distress at pre-treatment. To answer the second question, the authors conducted a meta analysis of 43 studies. Clients who dropped out of therapy were significantly more distressed following therapy than individuals who completed treatment (d = .0.56, 95% CI [.0.37, 0.70] p < .001). This was a moderately large and significant effect. To answer the third question, the authors completed a meta regression of data in 34 studies. Overall, treatments with more drop outs also had completers with worse outcomes at post treatment, β = -.37, SE = 0.17, p < .05. Also, when treatments were shorter in length, greater overall dropout was associated with even worse outcomes for treatment completers, β = − 1.28, SE = 0.35, p < .001.

Practice Implications

These meta analyses support the notion that on average those who drop out do so because they do not find the treatment to be helpful. Patients who drop out tend to be more distressed to begin with, and are more likely to be young and male. An intriguing finding was that those treatments with more drop outs also tended to be less effective for those who completed the therapy. In other words, effective treatments also tended to maintain more patients. Previously, writers suggested clinically useful methods to reduce premature termination from psychotherapy. These include: providing patients with information about duration of therapy and how change occurs, educating patients about therapist and patient roles, taking into account patient preferences when deciding on treatment methods and therapist stances, strengthening early hope, fostering the therapeutic alliance, and assessing and discussing treatment progress on an ongoing basis.

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.

Hayes, J. A., Gelso, C. J., Goldberg, S., & Kivlighan, D. M. (2018). Countertransference management and effective psychotherapy: Meta-analytic findings. Psychotherapy, 55(4), 496-507.

This is another meta analysis from the Psychotherapy Relationship That Work series that will be published in a book by Norcross and Wampold in 2019. Psychotherapists’ unresolved personal conflicts and the cognitive, emotional, or behavioural manifestations of these conflicts in therapy are called countertransference. Countertransference can result in reactions within the therapist that negatively affect their relationship with patients and patient outcomes. Successfully managing these reactions may be an important aspect of positive outcomes in psychotherapy. The old view of countertransference, dating back to Freud, was that countertransference was detrimental to therapy, and therapists had to work to keep their personal reactions out of therapy. More contemporary views see therapist countertransference as inevitable and as providing potentially important information about the patient. In their model of countertransference management, Hayes and Gelso identified five aspects managing countertransference. 1) Origins of countertransference refer to therapists gaining an understanding of their unresolved issues from their past that can interact with patient characteristics in therapy (therapist unresolved family issues, low professional self esteem). 2) Triggers refer to specific issues within the patient that stimulate a specific unresolved issue in the therapist (the patient is competitive and the therapist has a fragile professional self esteem). 3) Manifestations refer to therapist cognitive, behavioural, or affective reactions to triggers and origins (the therapist puts the competitive client in his or her place). 4) Effects refer to the impact of countertransference manifestations on the therapy process or outcome (patient who is put in his or her place drops out or goes silent). 5) Management refers to therapists’ strategies to manage countertransference, including self awareness, self care, consultation and supervision, or personal therapy. In this series of meta analyses, Hayes and colleagues found that: (1) countertransference reactions are associated with poorer therapy outcomes (r = -.16, p = .02, 95% CI [-.30, -.03], d = -0.33, k = 14 studies, N = 973); (2) therapists’ management of countertransference reduces countertransference reactions (r = -.27, p = .001, 95% CI [-.43, -.10], d = -0.55, k = 13 studies, N = 1,065); and (3) successful countertransference management is related to better therapy outcomes (r = .39, p = .001, 95% CI [.17, .60], d = 0.84, k = 9 studies, N = 392 participants).

Practice Implications

The research on countertransference management is still in its early stages but results are promising. Therapists’ ability to identify unresolved issues within themselves, how these issues interact with specific patient behaviors and clinical presentations, and management of therapist reactions are important to their work. The work of psychotherapy is fraught with emotional challenges and potential pitfalls for the therapist. Every therapist will experience confusing or challenging emotional reactions to a client. Better understanding and management of these reactions and their manifestations will not only lead to better patient outcomes, but also to greater therapist personal well-being and work satisfaction.

Reese, R. J., Duncan, B. L., Bohanske, R. T., Owen, J. J., & Minami, T. (2014). Benchmarking outcomes in a public behavioral health setting: Feedback as a quality improvement strategy. Journal of Consulting and Clinical Psychology, 82(4), 731-742.

Psychotherapy has demonstrated its efficacy in randomized controlled trials. But do these findings in highly controlled studies translate to everyday practice in publicly funded agencies that treat low income clients? Previous research in the US showed that outcomes of treatment-as-usual in public behavioural health agencies are generally not positive, so that only 20 to 35% of clients reliably improved. One approach to improving outcomes is to transport specific evidence-based treatments into practice settings. For example, research on applying CBT for panic and depression in a publicly funded agency resulted in similar outcomes to those achieved in randomized controlled trials. However, an alternative strategy of improving outcomes is to use continuous outcome monitoring, which involves repeated (weekly) measurement of client outcomes with reliable scales, and feedback to therapists on the client’s status relative to previous sessions and relative to other similar clients. Research has demonstrated that this strategy improves client outcomes and reduces the number of clients who deteriorate. In this study, Reese and colleagues examined the outcomes of a large public behavioural health service in the U.S. that treats low-income individuals. The service implemented repeated outcome monitoring of clients with feedback to therapists. Over 5,000 clients mainly with depression, mood, and anxiety disorders were treated by 84 therapists who were licensed at the masters degree or higher. The clients completed the Outcome Rating Scale (a measure of symptom outcome) prior to each session, and the Session Rating Scale (a measure of the therapeutic alliance) after each session. Therapists received two days of training on how to use these measures and on the continuous feedback they were provided in order to improve their treatment of clients and their outcomes. Outcomes from this public behavioural health service were compared to previous large studies in publicly funded settings that implemented specific evidence-based treatments. The findings were similar, with about 42% showing reliable pre- to post-treatment improvement. The results of implementing continuous outcome monitoring with feedback for depressive symptoms were also large and positive (d = 1.34). These effects were similar to benchmarks established in randomized controlled trials of specific psychotherapies.

Practice Implications

Continuous outcome feedback enables therapists to identify clients who are not benefiting
from a given treatment, so that clinicians may collaboratively design different interventions or change their interpersonal stances. The inclusion of outcome monitoring and feedback in this publicly funded psychotherapy system, resulted in outcomes that were: better than what is often seen in such public service settings, equivalent to those public systems that implemented specific evidence based treatments, and similar to those reported in highly controlled randomized trials. The authors concluded that adding routine outcome monitoring and feedback is a viable alternative to transporting specific evidence based treatments to publicly funded psychotherapy programs. The measures used in this study are available free for individuals to use at: betteroutcomesnow.com.

Author email: jeff.reese@uky.edu

Munder, T., Fluckiger, C., Leichsenring, F, Abbass, A.A., Hilsenroth, M.J., … Wampold, B.E. (2018). Is psychotherapy effective? A re-analysis of treatments for depression. Epidemiology and Psychiatric Sciences, 1-7.

Based on a deeply flawed review in 1952, Hans Eysenck declared that psychotherapy was no more effective than custodial care for treating mental disorders. Later, he qualified this by stating that behaviour therapy was effective and other forms of psychotherapy were not. These statements touched off decades of angst and debate in the psychotherapy community, and also resulted in a great deal of research about psychotherapy’s effectiveness. By the 1970s the new research technique of meta-analysis was developed and was applied to psychotherapy research. In their seminal meta analysis of controlled studies, Smith and Glass found that psychotherapy was useful and with large effects compared to no treatment. And yet the debate continues. In 2018, Cuijpers argued that waitlist control groups (i.e., a common control condition in psychotherapy studies in which patients receive no treatment) are an inappropriate comparison leading to exaggerated estimates of the effects of psychotherapy. Recently, Munder and colleagues argued that waitlist controls are a way of estimating the natural course of the disorder (what would happen with no treatment) plus the effect of expecting to receive treatment (client expectations of receiving treatment tend to have a positive impact on symptoms). In fact, research shows that pre- to post-study effect sizes for the waiting period is approximately g = .40, or a medium effect. In other words, waiting for therapy in a study results in a moderate proportion of individuals getting better on their own without treatment. Therefore, Munder and colleagues argued that comparing psychotherapy to a waitlist control is appropriate and may be a conservative estimate of psychotherapy’s effects (i.e., psychotherapy has to outperform the effects of clients expecting treatment to help them). In their meta analysis, Munder and colleagues re-analysed 71 studies of psychotherapy for depression compared to a waitlist control condition. They found that the effect size in favour of psychotherapy was g = 0.75 (SE = 0.09) indicating a moderate to large effect. Psychotherapy was also more effective than care as usual (i.e., compared to another intervention that was not psychotherapy), g = 0.31 (SE = 0.11). There were no differences between types of psychotherapy (CBT, IPT, PDT, etc.) for depression outcomes.

Practice Implications

Despite various attempts during the history of psychotherapy to downplay or disparage its efficacy, research continues to show that psychotherapy is in fact effective. The average effect size compared to the natural history of depression is moderate to large (and that is likely an under-estimate). Again, there is no evidence that one type of psychotherapy is superior to another for treating depression. It is time for the field to move beyond questions of efficacy of psychotherapy and of the relative efficacy of different treatments, and look to understanding therapist interpersonal stances, client characteristics, and relationship factors that may improve outcomes from psychotherapy.

Davis, D. E., DeBlaere, C., Owen, J., Hook, J. N., Rivera, D. P., Choe, E., . . . Placeres, V. (2018). The multicultural orientation framework: A narrative review. Psychotherapy, 55(1), 89-100.

Many therapists have better outcomes with White or European clients than clients from diverse racial or ethnic minorities, and this might be due to racial and ethnic microaggressions that sometimes occur in therapy. Microaggression refer to intentional or unintentional brief commonplace verbal, behavioural, or environmental indignities that are experienced as derogatory or negative by racial and ethnic minority clients. A multicultural orientation refers to how the cultural worldviews, values, and beliefs of clients and therapists interact to co-create a relational experience in therapy. Therapist multicultural orientation has three elements. First, cultural humility, in which a therapist is able to maintain an interpersonal stance that is open to the client’s experience of cultural identity. Second, cultural opportunity, in which the therapist uses events in therapy to explore a client’s cultural identity in depth. Third, cultural comfort in which a therapist feels at ease, open, and calm with diverse clients. These elements are important in order to negotiate a therapeutic alliance (i.e. agreement on tasks and goals of therapy, and the emotional bond between client and therapist). In this narrative review, Davis and colleagues look at the small existing research on multicultural orientation and how that research can inform therapists’ practices. The authors found that in the two studies on the topic, greater therapist cultural humility was associated with better client outcomes. Several studies found that cultural humility was associated with a positive therapeutic alliance, and that therapist cultural humility was associated with fewer microaggressions as experienced by racial and ethnic minority clients. Finally, missed opportunities by therapists to explore the meaning of culture and identity were associated with negative client outcomes. Presumably, such missed opportunities meant that therapists did not recognize and repair cultural ruptures.

Practice Implications

The research on multicultural orientation suggests several practice implications. (1) Cultural humility requires therapists to explore their automatic cultural assumptions because if they remain unexplored they may be harmful to clients. (2) Therapists should overtly discuss the importance of cultural identities with clients in order to help both therapist and client develop a more complex understanding of the issues that bring the client to therapy. (3) A strong therapeutic alliance may require the therapist to incorporate their client’s cultural worldview and perspective when conceptualizing the client’s problems. (4) Depending on the client’s cultural worldview, therapists may consult with the client’s family and/or spiritual leaders when negotiating a culturally acceptable way of addressing the client’s problems. (5) Therapists need to identify for themselves when their values conflict with those of the client, and seek consultation or supervision when they do.