Practice-Based Psychotherapy Research
To Improve The Wellbeing Of Our Community

PPRNet Blog: November 2017

Giorgio A. TascaAt the PPRNet conference in November 2012 over 100 psychotherapy clinicians, researchers, and educators were very keen to receive ongoing information about psychotherapy research that is practice-oriented and presented in an easily readable format. And so the PPRNet Blog was born.

About once a month I will review and summarize two or three published psychotherapy research articles. As part of the summary, I will highlight the practice implications of the research.

Because of copyright issues, we cannot post the full text of the articles, but we will provide a link to the abstract on the publisher's web site. I will also post the author's email address. Most authors are very happy to share their work. So if you want a copy of the article send the author an email with a request for a pdf or reprint.

At the bottom of each review you can post a comment, and comment on your colleagues' comments. I will update these as frequently as possible.

If you have ideas for an article to review or a topic you would like to see covered, please send me an email at

Giorgio A. Tasca

blogTherapist Multicultural Orientation and Client Outcomes

Hayes, J.A., Owen, J., Nissen-Lie, H.A. (2017). The contribution of client culture to differential therapist effectiveness. In L. G. Castonguay and C. E. Hill (Eds.) How and why are some therapists better than others? Understanding therapist effects (Ch. 9). Washington: American Psychological Association.

Some therapists may have better client outcomes because they are more adept at working with clients of different cultures. In this chapter, Hayes and colleagues define culture as referring to a group of people who share common history, values, beliefs, symbols, and rituals. The cultural groups to which one may belong include those based on: gender, religion, ethnicity, disability status, sexual orientation, race, and age, among others. Research suggests that culturally adapted therapy is more effective than unadapted therapy for racial minority clients. This may be due to more effective therapists being able to explain clients’ mental health problems and provide a rationale for specific therapy interventions that is congruent with the client’s beliefs. The most common model of multicultural therapy is multicultural competence, which is defined by having knowledge of various cultural groups, skills to navigate cultural processes, and self-awareness of personal bias. However, Hayes and colleagues argue for a multicultural orientation model in which a therapist is humble, respectful, and open to addressing culture in therapy. Whereas multicultural therapy is about acquiring knowledge, multicultural orientation refers to a way of being with clients. Hayes and colleagues review the research literature that indicates that therapists with cultural expertise are those who acknowledge when they do not have specific knowledge about a culture, have a high tolerance for not knowing, and at the same time recognize that cultural socialization affect clients’ mental health. A multicultural orientation is intended to bolster and support current therapeutic practices. For example, therapists may recognize that they need to better understand clients’ heritage when deciding whether or not to challenging a deeply held core belief related to the clients’ culture. In support of this, Hayes and colleagues review the research that indicates that: (1) client perception of therapist humility is related to client outcomes, especially for clients with a strong cultural identity; (2) clients who perceived that their therapist missed opportunities to discuss cultural issues in session had worse therapy outcomes; (3) clients who perceived therapists as culturally oriented experienced the therapy as more credible; and (4) therapist cultural comfort was related to better client outcomes.

Practice Implications
The authors suggest that therapists ask open-ended questions to clients regarding their cultural identity, such as asking the role that religion and spirituality play in their lives. This would allow therapists to learn about client cultural identity in the client’s own words. It is particularly important for therapists to maintain a stance of humility and cultural comfort, and to attend to opportunities to work productively with cultural issues in therapy in order to improve their clients’ outcomes.

Click here for chapter abstract.

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blogDo Psychotherapy Trainees Get Better with More Training?

Owen, J., Wampold, B. E., Kopta, M., Rousmaniere, T., & Miller, S. D. (2016). As good as it gets? Therapy outcomes of trainees over time. Journal of Counseling Psychology, 63, 12-19.

Does psychotherapy training improve trainees’ knowledge and skills? Do trainees improve in their ability to produce positive client outcomes over time? The research on training psychotherapists is mostly inconclusive. Some studies show little or no difference between trainees and experienced therapists, and others found no association between level of experience and client outcomes. On the other hand, some researchers have found a relationship between training and competence in delivering a particular type of treatment. Overall, the research seems to show that there is a lot of variability between therapists in their outcomes and on how training affects their practice and their clients’ outcomes. However, rarely do these studies assess outcomes within the same trainee over time as they accumulate more training. In this study, Owen and colleagues evaluate if psychotherapy trainees’ client outcomes improved with training over time. They assessed 114 psychology trainees at different levels of training in 47 clinics across the U.S. These training therapists saw over 1100 clients over at least a 12-month period, and many therapists were followed for three years. The average client improved, but with small effects (d = .31, CIs not reported). Therapists were more effective with clients who were more distressed (d = .66) than clients who were less distressed (d = .10), probably because more distressed clients had more room to improve. Trainees’ outcomes improved significantly over time, although their average improvement over time was small. Most importantly, trainees’ improvements over time varied so that the researchers were able to identify four patterns of change over a three year period of training: (1) one group of trainees started out with moderately good outcomes and their outcomes remained moderately good over time; (2) a second group started out with small positive effects in their client outcomes and they improved to achieve moderately good outcomes by their third year; (3) a third group of trainees started out with small positive client outcomes but their outcomes got worse by their third year; and (4) a fourth group started out with poor outcomes and improved to achieve small positive outcomes by year 3 of their training.

Practice Implications
Trainees appear to have various trajectories in their ability to foster positive client outcomes over time, and, at times, that trajectory is negative. Trainees whose outcomes get worse over time (group 3) or who do not achieve at least moderately good outcomes (group 4) may need specific training to foster better interpersonal effectiveness, empathy, management of countertransference, and humility. In general, therapists should assess their clients’ outcomes with progress monitoring tools in order to use the feedback to improve their outcomes over time. If outcomes are not positive on average, then therapists should consider remediation, further training, or consultation.

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blogPsychotherapy for Depression Also Reduces Interpersonal Problems

McFarquhar, T., Luyten, P., & Fonagy, P. (2018). Changes in interpersonal problems in the psychotherapeutic treatment of depression as measured by the Inventory of Interpersonal Problems: A systematic review and meta-analysis. Journal of Affective Disorders, 226, 108-123.

Interpersonal problems are commonly reported by depressed people. Interpersonal problems are seen by many as both a cause of depressive symptoms and as a result of depression. Depression may be the result of lacking basic human needs like social supports, stable relationships, and intimacy. One of the most important ways of assessing interpersonal problems is with the Inventory of Interpersonal Problems (IIP). The IIP is based on a circumplex model of two independent dimensions: affiliation (friendliness vs hostility) and status (dominance vs submissiveness). Greater problems in any of these domains or any combination of these domains may lead to interpersonal distress that result in or are the result of depression. Many psychotherapies target interpersonal problems in their treatment of depression: Interpersonal Psychotherapy (IPT), Short Term Dynamic Psychotherapy (STDP), and Emotion Focused Therapy (EFT). In this meta-analysis, McFarquhar and colleagues evaluated whether psychotherapy for depression is related to changes in interpersonal distress and whether specific types of interpersonal problems at baseline are related to treatment outcomes for depression at post-treatment. The authors looked at both randomized and non-randomized trials of psychotherapy for adults with depression. They found 10 studies that met inclusion criteria, six of which were randomized controlled trials. Psychotherapy for depression resulted large positive changes in interpersonal problems (overall pre- to post-treatment ES g=0.74, 95% CI=0.56–0.93). Unfortunately, there were too few studies (k = 3) that met meta-analytic criteria to do an analysis of pre-treatment interpersonal distress as a predictor of depression outcomes. However, of 8 studies that looked at this question, six showed that higher interpersonal distress was associated with poorer outcomes for depression at post-treatment.

Practice Implications
Given that interpersonal problems both cause and are caused by depressive symptoms, targeting relationship difficulties (lack of social support, conflict in relationships, low intimacy, relationship avoidance) in psychotherapy should be a priority. This meta-analysis showed that interpersonal distress improves after psychotherapy for depression, and there was some evidence that higher interpersonal problems at the outset may reduce the effects of the therapy for depressive symptoms.

Click here for article abstract.

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