Practice-Based Psychotherapy Research
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PPRNet Blog: September 2015


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 pprnet@toh.on.ca.

Giorgio A. Tasca


blogIs Therapeutic Alliance Important?

The Great Psychotherapy Debate: Starting in April, 2015 I will review parts of The Great Psychotherapy Debate (Wampold & Imel, 2015) in the PPRNet Blog. This is the second edition of a landmark and sometimes controversial book that surveys the evidence for what makes psychotherapy work. Since this is a book I will not provide the author email. However, you can view parts of the book in Google Books.

Wampold, B.E. & Imel, Z.E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work (2nd edition). New York: Routledge.

In this part of the book, Wampold and Imel reviewed the research literature on the therapeutic alliance. The therapeutic alliance is considered a pan-theoretical construct that is critical to the success of all psychotherapies. Alliance is defined as the: (a) agreement on the goals of therapy, (b) agreement on the tasks of therapy, and (c) the bond between therapist and client. Numerous meta analyses across several decades demonstrate a robust relationship between the alliance and therapy outcome. For example, Horvath and colleagues (2011) conducted a meta analysis with 190 studies that included over 14, 000 clients in which the average effect size was r = .28, indicating a moderate and significant association between alliance and outcomes. Some researchers argued that this is an under-estimation of the alliance outcome relationship. In Horvath and colleagues’ meta analysis, they found no difference between type of psychotherapy (CBT, interpersonal, dynamic) and the alliance – outcome relationship. However, the alliance may work differently in some therapies. For example, in this CBT study there is some evidence that the collaborative bond is not related to outcomes, but rather the agreement on tasks and goals is related to patient outcomes. This highlights that an alliance cannot happen without techniques; in other words, if techniques fail to engage the patient in the work of therapy, then the technique is not working properly. Wampold and Imel also reviewed the research on whether the therapist or the patient is most influential in developing an alliance. Using sophisticated statistical techniques, they were able to disentangle the effects of therapists and clients. More effective therapists were those who had stronger alliances with patients, and their patients had better outcomes. However, the patient’s contributions to developing an alliance were not significant. Finally, Wampold and Imel reviewed the research on whether early alliance causes good outcomes, or whether early outcomes causes a good alliance. If the latter were true, then the therapeutic alliance would simply be an artifact of early improvement – that is, the alliance would not be necessary for patients to improve. Most of the studies, which were conducted by researchers of different theoretical orientations, concluded that early alliance predicts outcomes and not the other way around. There is some evidence that change in the alliance and change in symptoms have a reciprocal impact – as the alliance grows the patient subsequently improves and as the patient improves the alliance subsequently grows.

Practice Implications

Clearly, developing and maintaining a therapeutic alliance is important to achieving good patient outcomes in psychotherapy. The alliance is not independent from techniques of psychotherapy. In other words, therapists and clients have to agree on the tasks and goals of treatment, and this agreement is fundamental to all treatment modalities offered to patients. If there is no agreement, then therapists have to consider changing course or discussing with the client ways of achieving an agreement. Over and above that, therapists and clients must have some interpersonal bond that is likely underpinned by the therapist’s empathy, positive regard, and concern for the client. The research is clear that it is the therapist who most strongly contributes to the development of an alliance, and so it is the therapist’s responsibility to nurture a positive working alliance.

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blogDoes a Therapist’s Multicultural Competence Affect Patient Outcomes?

Tao, K. W., Owen, J., Pace, B. T., & Imel, Z. E. (2015). A meta-analysis of multicultural competencies and psychotherapy process and outcome. Journal of Counseling Psychology, 62(3), 337-350.

Cultural factors shape health-related beliefs, behaviors and values. For decades, many have argued that therapist multicultural competence shapes the therapy process and affects patient outcomes. Some therapists have poorer outcomes with patients of racial/ethnic minorities compared to White patients. Multicultural competence refers to the ability to work effectively across many groups including minority groups. In 2008, an American Psychological Association Task Force detailed recommendations for multicultural competencies. Multiculturally competent providers are those who: expand their knowledge of their client’s background, use culturally relevant interventions, and gain awareness of their own assumptions and the impact of these on their therapeutic work. In this meta analysis, Tao and colleagues aimed to assess the relationship between multicultural competence in therapists with therapy processes and client outcomes. They reviewed 18 studies that included over 1600 clients, the vast majority of whom identified as a racial/ethnic minority. Therapist multicultural competence was assessed by client self report. Therapist multicultural competence was highly correlated with therapy processes like: therapeutic alliance (r = .61), client satisfaction (r = .72), and session depth (r = .58). The association between therapist multicultural competence and client symptom outcomes were moderate in size but significant (r = .29). A separate analysis showed that the relationship between multicultural competence and therapy process variables (alliance, satisfaction, depth) were significantly larger that associations with client outcomes.

Practice Implications

Therapists’ abilities to integrate aspects of their client’s cultural narrative into their interventions significantly accounted for difference in outcomes. In other words, clients who perceived their therapist as more culturally sensitive had better outcomes. This was likely related to more positive therapeutic processes (i.e., alliance, satisfaction, session depth) between clients and therapist dyads, within which clients perceived the therapist as multiculturally sensitive. A provider’s ability to recognize how their own personal backgrounds influence their own and clients’ behaviors will result in better therapy processes and improved client outcomes.

View the Does a Therapist’s Multicultural Competence Affect Patient Outcomes? abstract.

Author email: k.tao@utah.edu

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blogPsychotherapy Reduces Relapse from Depression

Clarke, K., Mayo-Wilson, E., Kenny, J., & Phillig, S. (2015). Can non-pharmacological interventions prevent relapse in adults who have recovered from depression? A systematic review and meta-analysis of randomised controlled trials. Clinical Psychology Review, 39, 58-70.

According to the American Psychiatric Association, the risk for relapse from depression can be as high as 60% for those who had one episode, 70% for those who had two episodes, and 90% for those who had three previous episodes. Intervening after recovery from an episode of depression might prevent relapse. A relapse is defined as any significant deterioration in depression following a period of clear improvement. We know that relapse after discontinuing antidepressant treatment is greater than relapse after discontinuing psychotherapy, likely because psychotherapy and not medications result in the patient acquiring new coping skills and strengths. Clarke and colleagues conducted a meta analysis of psychological interventions that were designed or adapted in order to reduce relapse after the acute phase depression. These include mindfulness based therapy (MBT) which helps individuals process experience without judgment by using mindfulness techniques; cognitive behavioral therapy (CBT) which helps to modify thoughts and behaviors key to depression; and interpersonal psychotherapy (IPT) which focuses on helping to deal with interpersonal and social role problems related to depression. Clarke and colleagues reviewed 29 studies that included 4216 participants who had at least one episode of depression, had recovered after treatment, and who received either MBT, CBT, or IPT to prevent relapse. These were compared to control conditions that included wait-lists, treatment as usual, or some other active intervention. Compared to all of the controls, MBT, CBT, and IPT reduced relapse rates from 21% to 25% among patients one year post acute treatment. The effects for CBT were maintained up to two years post treatment. There were no differences between psychotherapies and control conditions in drop out rates.

Practice Implications

Psychotherapies (e.g., MBT, CBT, and IPT) reduce relapse from depression by about 22%. up to one year post recovery. Practitioners should consider offering MBT, CBT, or IPT as a form of booster sessions to reduce the likelihood of relapse from a previous episode of depression. Such interventions are important given the increasing relapse rates for each subsequent episode of depression.

View the Psychotherapy Reduces Relapse from Depression abstract.

Author email: k.clarke@ucl.ac.uk

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