Showing papers in "Psychotherapy in 2018"
TL;DR: A meta-analysis of 295 independent studies that covered more than 30,000 patients (published between 1978 and 2017) for face-to-face and Internet-based psychotherapy confirmed the robustness of the positive relation between the alliance and outcome.
Abstract: The alliance continues to be one of the most investigated variables related to success in psychotherapy irrespective of theoretical orientation. We define and illustrate the alliance (also conceptualized as therapeutic alliance, helping alliance, or working alliance) and then present a meta-analysis of 295 independent studies that covered more than 30,000 patients (published between 1978 and 2017) for face-to-face and Internet-based psychotherapy. The relation of the alliance and treatment outcome was investigated using a three-level meta-analysis with random-effects restricted maximum-likelihood estimators. The overall alliance-outcome association for face-to-face psychotherapy was r = .278 (95% confidence intervals [.256, .299], p < .0001; equivalent of d = .579). There was heterogeneity among the effect sizes, and 2% of the 295 effect sizes indicated negative correlations. The correlation for Internet-based psychotherapy was approximately the same (viz., r = .275, k = 23). These results confirm the robustness of the positive relation between the alliance and outcome. This relation remains consistent across assessor perspectives, alliance and outcome measures, treatment approaches, patient characteristics, and countries. The article concludes with causality considerations, research limitations, diversity considerations, and therapeutic practices. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
765 citations
TL;DR: Two-thirds of the studies found that ROM-assisted psychotherapy was superior to treatment-as-usual offered by the same practitioners, and Feedback practices reduced deterioration rates and nearly doubled clinically significant/reliable change rates in clients who were predicted to have a poor outcome.
Abstract: This systematic review and meta-analysis examines the impact of measuring, monitoring, and feeding back information on client progress to clinicians while they deliver psychotherapy. It considers the effects of the 2 most frequently studied routine outcome monitoring (ROM) practices: The Partners for Change Outcome Management System and the Outcome Questionnaire System. Like other ROM practices, they typify attempts to enhance routine care by assisting psychotherapists in recognizing problematic treatment response and increasing collaboration between therapist and client to overcome poor treatment response. A total of 24 studies were identified and considered suitable for analysis. Two-thirds of the studies found that ROM-assisted psychotherapy was superior to treatment-as-usual offered by the same practitioners. Mean standardized effect sizes indicated that the effects ranged from small to moderate. Feedback practices reduced deterioration rates and nearly doubled clinically significant/reliable change rates in clients who were predicted to have a poor outcome. Clinical examples, diversity considerations, and therapeutic advances are provided. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
225 citations
TL;DR: A meta-analysis of research on the relation between therapist empathy and client outcome indicated that empathy is a moderately strong predictor of therapy outcome, however, there was considerable heterogeneity in the effects.
Abstract: Put simply, empathy refers to understanding what another person is experiencing or trying to express. Therapist empathy has a long history as a hypothesized key change process in psychotherapy. We begin by discussing definitional issues and presenting an integrative definition. We then review measures of therapist empathy, including the conceptual problem of separating empathy from other relationship variables. We follow this with clinical examples illustrating different forms of therapist empathy and empathic response modes. The core of our review is a meta-analysis of research on the relation between therapist empathy and client outcome. Results indicated that empathy is a moderately strong predictor of therapy outcome: mean weighted r = .28 (p < .001; 95% confidence interval [.23, .33]; equivalent of d = .58) for 82 independent samples and 6,138 clients. In general, the empathy-outcome relation held for different theoretical orientations and client presenting problems; however, there was considerable heterogeneity in the effects. Client, observer, and therapist perception measures predicted client outcome better than empathic accuracy measures. We then consider the limitations of the current data. We conclude with diversity considerations and practice recommendations, including endorsing the different forms that empathy may take in therapy. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
185 citations
TL;DR: The most frequently used measures of alliance ruptures and clinical examples to illustrate their repair are presented and limitations of the research, diversity considerations, and research-informed therapeutic practices for repairing ruptures are concluded.
Abstract: A rupture is a deterioration in the therapeutic alliance, manifested by a disagreement between the patient and therapist on treatment goals, a lack of collaboration on therapeutic tasks, or a strain in their emotional bond. We present the most frequently used measures of alliance ruptures and clinical examples to illustrate their repair. To examine the relation of rupture repairs to outcome, and the impact of rupture resolution training on outcome, we conducted two meta-analyses. In the first meta-analysis, we examined 11 studies (1,314 patients) that examined the relation between rupture repair episodes and patient treatment outcomes. Results yielded an effect size of r = .29, d = .62, 95% confidence interval [.10, .47], p = .003, indicating a moderate relation between rupture resolution and positive patient outcome. Our second meta-analysis examined the impact of rupture resolution training or supervision on patient outcome. We examined 6 studies (276 trainees/supervisees) that compared the outcomes of trainees who received rupture resolution training with a comparison group. Results did not find a significant relation, r = .11, d = .22, 95% confidence interval [-.09, .30], p = .28. Moderator analyses indicated that the relation between training and outcome was stronger when the sample included fewer patients with personality disorders, when the training was more closely aligned with cognitive behavioral therapy than psychodynamic therapy, and when the treatment was brief. The article concludes with limitations of the research, diversity considerations, and research-informed therapeutic practices for repairing ruptures in ways that contribute to good treatment outcome. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
143 citations
TL;DR: A meta-analysis examining the relation between group cohesion and treatment outcome in 55 studies indicates that the weighted aggregate correlation between cohesion and Treatment outcome was statistically significant, reflecting a moderate effect size and supporting moderator analyses.
Abstract: Cohesion is the most popular of the relationship constructs in the group therapy literature. This article reviews common definitions of cohesion, the most frequently studied measures, and a measure that may clarify group relations using two latent factors (quality and structure) to explain common variance among frequently used group relationship instruments. We present the results of a meta-analysis examining the relation between group cohesion and treatment outcome in 55 studies. Results indicate that the weighted aggregate correlation between cohesion and treatment outcome was statistically significant, r = .26, z = 6.54 (p < .01), reflecting a moderate effect size (d = .56). Heterogeneity of effect sizes was significant (Q = 260.84, df = 54, p < .001) and high (I2 = 79.3%), supporting moderator analyses. Six moderator variables were found to significantly predict the magnitude of the cohesion-outcome association (type of outcome measure, leader interventions to increase cohesion, theoretical orientation, type of group, emphasis on group interaction, and dose or number of group sessions). Patient contributions, diversity considerations, and evidence-based therapeutic practices are highlighted. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
118 citations
TL;DR: A previous meta-analysis of 46 independent samples receiving the treatment of at least 3 sessions revealed a significant association between more optimistic baseline, or early treatment, OE and more adaptive posttreatment outcomes.
Abstract: Patients' outcome expectation (OE) represents their belief about the mental health consequences of participating in psychotherapy. A previous meta-analysis of 46 independent samples receiving the treatment of at least 3 sessions revealed a significant association between more optimistic baseline, or early treatment, OE and more adaptive posttreatment outcomes (weighted r = .12 or d = .24; Constantino, Glass, Arnkoff, Ametrano, & Smith, 2011). The present study represents an update to that meta-analysis. To be included, articles published through June 2017 had to (a) include a clinical sample, (b) include a therapist-delivered treatment of at least 3 sessions, (c) include a measure of patients' own OE, (d) include at least 1 posttreatment mental health outcome not explicitly referenced as a follow-up occasion, and (e) report a statistical test of the OE-outcome association. The updated meta-analysis was conducted on 81 independent samples (extracted from 72 references) with 12,722 patients. The overall weighted effect size was r = .18, p < .001, or d = .36, with high heterogeneity (I2 = 76%) and no evidence of publication bias. Several variables (patient age, measure type, and treatment manual used) moderated the OE-outcome association. These robust, replicated meta-analytic findings are discussed in light of methodological limitations and with regard to their practice implications. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
115 citations
TL;DR: Results indicate initial evidence linking multicultural orientation constructs to therapy outcomes (e.g., perceived improvement, racial/ethnic disparities in termination, and therapy alliance).
Abstract: After several decades of slow progress, researchers are beginning to make advances in linking constructs based on the multicultural competencies tradition-especially those focused on qualities of the therapist-to therapy outcomes. The multicultural orientation framework was developed in response to several trends within the multicultural competencies tradition, with a particular emphasis on integrating the multicultural competencies tradition into research on psychotherapy process. We provide a narrative review of studies that include one of the three constructs (i.e., cultural humility, cultural opportunities, and cultural comfort) articulated by the multicultural orientation framework. Results indicate initial evidence linking multicultural orientation constructs to therapy outcomes (e.g., perceived improvement, racial/ethnic disparities in termination, and therapy alliance). Results also supported the social bond and social oil hypotheses from theorizing on humility. Implications for future research and therapy practice are discussed. (PsycINFO Database Record
112 citations
TL;DR: A meta-analytic review of prospective studies of youth therapy that used an explicit measure of alliance found a weighted random effect size of r = .19 consistent with the adult alliance literature and with prior youth meta-analyses.
Abstract: In the youth treatment literature, the alliance has been defined and measured as a consensual or collaborative bond. In this article, we review varied definitions of the alliance, enumerate its frequent measures, and present clinical examples. We provide a meta-analytic review on the relation between the therapeutic alliance and treatment outcome in child and adolescent psychotherapy. In particular, this review only includes prospective studies of youth therapy that used an explicit measure of alliance. The meta-analysis of 28 studies revealed a weighted random effect size of r = .19 (k = 28, N = 2419, p < .01, 95% confidence interval [.13, .25]), which is a small to medium effect (equivalent to d = 0.39) consistent with the adult alliance literature and with prior youth meta-analyses. Given that a medium-large amount of heterogeneity was observed in effect sizes (I2 = 64.19%), theory- and method-based moderators were examined. Multiple moderators of the alliance-outcome association were found, including diagnosis class, type of therapy, study design (randomized controlled trials [RCT] vs. nonrandomized trials [non-RCT]), and treatment setting (inpatient vs. outpatient). Research limitations, patient contributions, and diversity considerations follow. The article concludes with research-informed practices for building and maintaining the therapeutic alliance with youth. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
107 citations
TL;DR: It is revealed that successful countertransference management is related to better therapy outcomes and the limitations of the research base are summarized, highlighting the therapeutic practices predicated on research.
Abstract: In this article, we review the history and definition of countertransference, as well as empirical research on countertransference, its management, and the relation of both with psychotherapy outcome. Three meta-analyses are presented, as well as studies that illustrate findings from the meta-analyses. The first meta-analysis indicated that countertransference reactions are related inversely and modestly to psychotherapy outcomes (r = -.16, p = .02, 95% CI [-.30, -.03], d = -0.33, k = 14 studies, N = 973). A second meta-analysis supported the notion that countertransference management factors attenuate countertransference reactions (r = -.27, p = .001, 95% CI [-.43, -.10], d = -0.55, k = 13 studies, N = 1,065). The final meta-analysis revealed that 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). In all meta-analyses, there was significant heterogeneity across studies. We conclude by summarizing the limitations of the research base and highlighting the therapeutic practices predicated on research. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
86 citations
TL;DR: Meta-analytic evidence showed that alliance–outcome associations did not differ for couple versus family therapy, but correlations were significantly stronger in samples with younger problem children, older adults, proportionally more male youth and adults, and when the families voluntarily sought help (as compared with involuntary or mandated families).
Abstract: This article reviews meta-analytic evidence for the alliance-outcome relation in couple and family therapy (CFT), with implications for clinical practice. We begin by describing the unique features of CFT alliances and their measurement, followed by two case descriptions. We explain that due to the systemic context of CFT, each patient's personal alliance with the therapist affects and is affected by other family members' levels of collaboration. Because family members often seek help when they are in conflict with one another, "split" alliances are common, as are problematic within-system alliances, defined as the degree to which family members agree on the nature of their problems and value participating in therapy together to achieve shared goals. In our meta-analysis of 48 studies with 40 independent samples, we used a three-level random effects model (Ns = 2,568 families, 1,545 couples, and 491 effect sizes) and found r = .297. In another analysis with seven independent samples and 31 effect sizes, the split alliance-outcome association was also significant, r = .316, indicating that the more split or unbalanced the alliance, the poorer the outcome. Moderator analyses showed that alliance-outcome associations did not differ for couple versus family therapy, but correlations were significantly stronger in samples with younger problem children, older adults, proportionally more male youth and adults, and when the families voluntarily sought help (as compared with involuntary or mandated families). The article concludes with research-informed strategies for building and sustaining strong systemic alliances in CFT. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
63 citations
TL;DR: The case of an AfroLatinx queer immigrant is presented to illustrate some of the challenges and opportunities while simultaneously considering (a) the client's multiple marginalized identities, (b) the way clients are impacted by systemic oppression, and (c) integrating the clients' personal experiences and narratives in psychotherapy.
Abstract: Culturally responsive and racially conscious psychotherapeutic work requires that therapists recognize the ways clients are impacted by their multiple marginalized identities and by systems of oppression (e.g., racism, ethnocentrism, sexism, heterosexism, and nativism). Attending exclusively to clients' marginalized identities (i.e., weak intersectionality) may drive therapists to only focus on internal, subjective, and emotional experiences, hence, missing the opportunity to consider and address how multiple sociostructural dimensions (i.e., strong intersectionality) may be impacting the client's presenting problems. Alternatively, focusing solely on the impact of sociostructural dimensions on the lives of clients may miss the more nuanced and variable individual personal experiences. In this article, we highlight the challenge of maintaining a culturally responsive and racially conscious stance when considering multiple marginalized identities, overlapping systemic inequities, and how both affect clients' lives and experiences. The case of an AfroLatinx queer immigrant is presented to illustrate some of the challenges and opportunities while simultaneously considering (a) the client's multiple marginalized identities, (b) the way clients are impacted by systemic oppression, and (c) integrating the client's personal experiences and narratives in psychotherapy. (PsycINFO Database Record
TL;DR: A meta-analysis of the association between patients’ credibility perception and their posttreatment outcomes found no significant moderating effects on the credibility–outcome association for any of the potential moderators that were evaluated.
Abstract: Patients' perception of treatment credibility represents their belief about a treatment's personal logicality, suitability, and efficaciousness. Although long considered an important common factor bearing on clinical outcome, there have been no systematic reviews of the credibility-outcome association. The present study represents a meta-analysis of the association between patients' credibility perception and their posttreatment outcomes. To be included, articles published through August, 2017 had to (a) include a clinical sample, (b) include a therapist-delivered treatment of at least 3 sessions, (c) include a measure of patients' own early treatment credibility perception, (d) include at least 1 posttreatment mental health outcome not explicitly referenced as a follow-up occasion, and (e) report a statistical test of the credibility-outcome association. The meta-analysis was conducted on 24 independent samples (extracted from 19 references) with 1,504 patients. The overall weighted effect size was r = .12, p < .001, or d = .24, with high heterogeneity (I2 = 57%) and no evidence of publication bias. There were no significant moderating effects on the credibility-outcome association for any of the potential moderators that we evaluated. The meta-analytic findings are discussed in light of methodological limitations and with regard to their practice implications. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
TL;DR: Two meta-analyses were applied to explore the association between therapist expression of emotion and psychotherapy outcome, and client expression of emotions and psychotherapeutic outcome and third-party rating of emotional expression emerged as a significant moderator of outcomes.
Abstract: Although emotion has long been considered important to psychotherapeutic process, empirical assessment of its impact has emerged only recently. The present study applied two meta-analyses to explore the association between therapist expression of emotion and psychotherapy outcome, and client expression of emotion and psychotherapy outcome. Overall, 66 studies (13 for the therapist meta-analysis and 43 for the client meta-analysis) were included. A significant medium effect size was found between the therapist's emotional expression and outcomes (d = 0.56) and a significant medium-to-large effect size between the client's emotional expression and outcomes (d = 0.85). Third-party rating of emotional expression emerged as a significant moderator of outcomes. Limitations of the research, diversity considerations, and therapeutic practices that conclude the article are then presented. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
TL;DR: Results suggest patient–therapist goal consensus and collaboration enhance psychotherapy outcome, and research suggests that therapists seek input from patients to form and effect treatment goals and plans, provide patients with regular feedback, and seek their involvement throughout therapy.
Abstract: This article provides meta-analyses of the relation between goal consensus and collaboration and individual psychotherapy outcome using studies published in English between 1978 and June 2017. Inclusion criteria involved (a) a measure of psychotherapy outcome, (b) a measure of goal consensus and/or collaboration, (c) a group design, (d) adult patients (aged 18 years or older), and (e) a reported effect or statistic that could be converted to an effect size. For the 54 studies (N = 7,278) of goal consensus and outcome, the result was r = .24 (95% confidence interval [CI] [.19, .28]) or d = .49, representing a medium effect. For the 53 studies (N = 5,286) of patient-therapist collaboration and outcome, the result was r = .29 (95% CI [.24, .34]) or d = .61, another medium effect. In all, 21 studies (N = 2,081) of therapist collaboration and outcome yielded an omnibus effect of .26 (95% CI [.18, .35]) or d = .54. Results suggest patient-therapist goal consensus and collaboration enhance psychotherapy outcome. The article concludes with research limitations, diversity considerations, and therapeutic practices. Limitations of the studies included a dearth of diverse samples, assessment of goal consensus and/or collaboration at a single time during treatment, failure to relate measures to outcome, and analyses that do not permit causal conclusions. Research suggests that therapists seek input from patients to form and effect treatment goals and plans, provide patients with regular feedback, and seek their involvement throughout therapy. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
TL;DR: The results of this study clearly suggest that providing training in LGBT-affirmative psychotherapy can enhance therapists’ attitudes, knowledge, and skills, and that the benefits associated with such training appear to hold regardless of therapists' characteristics.
Abstract: Lesbian, gay, bisexual, and transgender (LGBT) people seek psychotherapy at high rates, and the importance of providing culturally appropriate and LGBT-affirmative psychotherapy has been widely acknowledged. Despite this, remarkably little research has investigated the effects of therapist training in LGBT-affirmative psychotherapy. Here we examined the effectiveness of a training protocol for LGBT-affirmative psychotherapy with 96 mental health professionals, ranging in therapeutic experience from <1 year to 37 years (M = 6.54 years). Across all outcomes, therapists reported increased knowledge and skills related to working with LGBT clients following the training. Therapists also displayed reductions in homo-negativity and trans-negativity. Therapists' characteristics did not influence the extent to which they benefited from training. Specifically, years of clinical experience, therapist religiosity, and therapist psychological flexibility were unrelated to changes in attitudes, knowledge, and skills. The results of this study clearly suggest that providing training in LGBT-affirmative psychotherapy can enhance therapists' attitudes, knowledge, and skills. Of particular importance is that the benefits associated with such training appear to hold regardless of therapists' characteristics. (PsycINFO Database Record
TL;DR: These analyses support PR’s standing as a significant component of the therapy relationship that leads to improved clinical outcomes and support recommendations for using PR in practice.
Abstract: This article meta-analytically reviews the research on the association between therapist positive regard (PR) and treatment outcome. The history of the construct of unconditional PR in client-centered theory and the efforts to clearly operationalize and measure this construct are reviewed. Several clinical examples are presented. The updated meta-analysis, which features expanded inclusion criteria and a larger number of studies (k = 64) than previous analyses, yielded a small positive association between PR and treatment outcome, g = .28. To control for the repeated use of data sets and study samples within the database, a multilevel meta-analysis was adopted that indicated a stronger relation between PR and clinical outcome (g = 0.36). These analyses support PR's standing as a significant component of the therapy relationship that leads to improved clinical outcomes. The article concludes with limitations of the research, patient contributions, diversity considerations, and recommendations for using PR in practice. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
TL;DR: If cultural dynamics of perinatal grief are recognized within the therapy relationship, then psychotherapy has the immense opportunity to break the taboo by validating the parent’s loss as real and helping the parent to mourn within an empathic and affect-regulating relationship.
Abstract: This paper argues that there is a cultural taboo against the public recognition and expression of perinatal grief that hinders parents' ability to mourn and their psychological adjustment following a loss. It is proposed that this cultural taboo is recreated within the therapy relationship, as feelings of grief over a perinatal loss are minimized or avoided by the therapist and parent or patient. Importantly, it is suggested that if these cultural dynamics are recognized within the therapy relationship, then psychotherapy has the immense opportunity to break the taboo by validating the parent's loss as real and helping the parent to mourn within an empathic and affect-regulating relationship. Specifically, it is suggested that therapists break the cultural taboo against perinatal grief and help parents to mourn through: acknowledging and not pathologizing perinatal grief reactions, considering intrapsychic and cultural factors that impact a parent's response to loss, exploring cultural reenactments within the therapy relationship, empathizing with the parent's experience of loss and of having to grieve within a society that does not recognize perinatal loss, coregulating the parent's feelings of grief and loss, and helping patients to create personally meaningful mourning rituals. Lastly, the impact of within and between cultural differences and therapist attitudes on the therapy process is discussed. (PsycINFO Database Record
TL;DR: A meta-analysis is presented on the association between the strength of the real relationship and the outcome of psychotherapy and revealed a moderate association with outcome.
Abstract: Although writing about the real relationship has existed from the beginnings of the "talking cure," it is only in recent years that empirical research has focused on this phenomenon. The real relationship is the personal relationship between patient and therapist marked by the extent to which each is genuine with the other and perceives/experiences the other in ways that are realistic. The strength of the real relationship is determined by both the extent to which it exists and the degree to which it is positive or favorable. In this article, a meta-analysis is presented on the association between the strength of the real relationship and the outcome of psychotherapy. Summed across 16 studies, this meta-analysis revealed a moderate association with outcome (r = .38, 95% confidence interval [.30, .44], p < .001, d = 0.80, N = 1.502). This real relationship-outcome association was independent of the type of outcome studied (treatment outcome, treatment progress, and session outcome) and of the source of the measure (whether the client or the therapist rated the real relationship and/or treatment outcome). We also present commonly used measures of the real relationship, limitations of the research, and patient contributions. The article concludes with diversity considerations and practice recommendations for developing and strengthening the real relationship. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
TL;DR: Across the 21 studies examined, the most frequent subsequent processes were enhanced therapy relationship, improved client mental health functioning, gains in insight, and overall helpfulness, suggesting that most often TSD and Im were followed by positive and beneficial therapeutic processes.
Abstract: We review definitions and provide case examples of therapist self-disclosure (TSD) and immediacy (Im). We then present a qualitative meta-analysis of 21 studies that examined the subsequent process following TSD and Im in psychotherapy (excluding analogue and correlational studies). Across the 21 studies, the most frequent subsequent processes were enhanced therapy relationship, improved client mental health functioning, gains in insight, and overall helpfulness, suggesting that most often TSD and Im were followed by positive and beneficial therapeutic processes. In additional analyses, TSD was associated more often with improved mental health functioning, overall helpfulness, and enhanced therapy relationships, whereas Im was associated more often with clients opening up and being immediate. We also consider possible moderating variables, including client contributions and diversity issues. The article concludes with research-informed recommendations for judiciously using TSD and Im in practice. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
TL;DR: This article defines and provides clinical examples of congruence and presents an original meta-analysis of its relation with psychotherapy improvement, and addresses patient contributions, limitations of the extant research, diversity considerations, and therapeutic practices that might promote congruity and improve psychotherapy outcomes.
Abstract: Congruence or genuineness is a relationship element with an extensive and important history within psychotherapy. Congruence is an aspect of the therapy relationship with two facets, one intrapersonal and one interpersonal. Mindful genuineness, personal awareness, and authenticity characterize the intrapersonal element. The capacity to respectfully and transparently give voice to ones' experience to another person characterizes the interpersonal component. Although most fully developed in the person-centered tradition, congruence is highly valued in many theoretical orientations. In this article, we define and provide clinical examples of congruence. We also present an original meta-analysis of its relation with psychotherapy improvement. An analysis of 21 studies (k), representing 1,192 patients (N), resulted in a weighted aggregate effect size (r) of .23 (95% confidence interval = [.13, .32]) or an estimated d of .46. Moderators of the association between congruence and outcome are also investigated. In closing, we address patient contributions, limitations of the extant research, diversity considerations, and therapeutic practices that might promote congruence and improve psychotherapy outcomes. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
TL;DR: Results showed that therapeutic relationship predicted improvement in outcome and that feedback reversed the course of relationship deterioration and reduced rates of relationship failure when progress feedback was held constant.
Abstract: Routine outcome monitoring (ROM) systems that identify clients at-risk for treatment failure using outcome and therapeutic process measures are a recognized evidence-based practice. However, only 3 empirical studies have tested ROMs in group therapy, producing mixed results. This randomized clinical trial tested the Outcome Questionnaire System, the ROM system with the most empirical support for individual therapy patients, with 430 group therapy patients who were randomly assigned to 2 experimental arms (Group Questionnaire [GQ] + Outcome Questionnaire-45 [OQ-45] vs. OQ-45). Given the strong evidence for progress feedback, the primary purpose of this study was to ascertain if therapeutic relationship feedback using the GQ reduced rates of relationship deterioration and failure when progress feedback was held constant. Group leaders simultaneously ran pairs of groups that were randomly assigned to the 2 conditions. Of the 430 patients enrolled in 58 groups, 374 attended more than 4 sessions. Results showed that therapeutic relationship predicted improvement in outcome and that feedback reversed the course of relationship deterioration and reduced rates of relationship failure. Although there were no effects on attendance and dropout for feedback, the 2 experimental arms produced mixed results for the OQ-45 not-on-track cases. The combined relationship and progress feedback (GQ/OQ-45) was associated with fewer outcome deterioration cases, while the progress feedback condition (OQ-45) showed higher outcome improvement cases. Findings are discussed with respect to previous group ROM studies, clinical implications, and future research. (PsycINFO Database Record
TL;DR: It is described how the CCRT formulation may be used to rise above relational enactments in a supportive way and how it can provide a corrective emotional experience to enhance the emotional bond between the patient and the therapist.
Abstract: Supportive-expressive psychodynamic psychotherapy builds on the core conflictual relationship theme (CCRT) as a framework for case formulation and interpretations Much has been written on how interpretive techniques should be implemented in the treatment sessions to bring about therapeutic change, but less is known about implementing supportive techniques for strengthening the alliance using this framework The present article uses CCRT formulations to articulate clear and concrete supportive techniques that clinicians can use in clinical practice To this end, we offered 4 main steps and used clinical case examples to illustrate them We described how the CCRT formulation may be used to rise above relational enactments in a supportive way and how it can provide a corrective emotional experience to enhance the emotional bond between the patient and the therapist Clinical cases from the pilot phase of a randomized clinical trial, together with theoretical conceptualizations and empirical findings, are intertwined to demonstrate the potential of the techniques presented (PsycINFO Database Record
TL;DR: Compared with 2 matched nonclinical reference samples from representative surveys, therapist trainees reported lower scores on attachment-related avoidance and higher scores on harmonious interpersonal motives.
Abstract: Interpersonal characteristics contribute to therapists' ability to form helpful working alliances with their patients. But how are attachment styles and interpersonal motives distributed among therapist trainees? This study examines attachment styles and interpersonal motives of therapist trainees by comparing them with matched reference samples from representative surveys. A total sample of 285 trainees, who were enrolled in either cognitive-behavioral or psychodynamic therapy training programs, was recruited via their training institutes. Participants answered questionnaires on attachment (Experiences in Close Relationships-Revised, 36-item version, and Experiences in Close Relationships-Revised, 8-item version) and interpersonal motives (Circumplex Scales of Interpersonal Values). Compared with 2 matched nonclinical reference samples from representative surveys, therapist trainees reported lower scores on attachment-related avoidance and higher scores on harmonious interpersonal motives. Therapist trainees are characterized by a wish for warm proximity with others and feel comfortable in close relationships. (PsycINFO Database Record
TL;DR: It is suggested that feedback in outpatient group psychotherapy does not improve outcomes but that fewer sessions may be sufficient to obtain outcomes similar to treatment as usual.
Abstract: There is evidence that progress feedback combined with a clinical support tool (CST) improves treatment outcome in individual psychotherapy. This study examined the effect of feedback in combination with a CST in outpatient group psychotherapy. A prospective cohort study was performed with patients meeting diagnostic criteria for a major depressive disorder or an anxiety disorder. Patients received cognitive-behavioral group therapy or interpersonal group therapy and completed the Outcome Questionnaire-45 on a session by session basis. In the control cohort (N = 132), no feedback was provided. In the feedback cohort (N = 137), patients and clinicians received feedback on the treatment progress based on the Outcome Questionnaire-45. If a patient was deteriorating as compared with the start of treatment or the previous session, the CST was offered. Both cohorts showed a significant decrease in symptoms during therapy, but no significant differences existed on treatment outcome. The number of sessions was significantly lower in the feedback cohort. The results suggest that feedback in outpatient group psychotherapy does not improve outcomes but that fewer sessions may be sufficient to obtain outcomes similar to treatment as usual. More research with the use of progress feedback in outpatient group therapy is needed, especially with CSTs. (PsycINFO Database Record
TL;DR: It is argued that clinical practice would benefit from monitoring difference instead of change, as these are not equivalent, and future research and development efforts should focus on the development of a working approach to monitoring induced difference.
Abstract: A fundamental part of professional practice is to monitor case progress to inform basic clinical decisions about when to discontinue interventions, when to adjust interventions, and when to proceed as planned. When interpreting observed change, there are at least five distinct types of clinical difference that can occur independently, and mistaking one for another can lead to misinformed clinical decisions. We introduce a distinction between observed difference, detected difference, predicted difference, attainment difference, and induced difference, and use these to analyze current systems for routine outcome monitoring (ROM) in clinical practice. Contrary to what supporting evidence of current ROM systems suggests, we find that-by design-these systems fail to detect and predict potentially harmful treatment and fail to detect and predict likely treatment responders. We discuss implications of the presented classification for professional practice and further development of ROM systems. We argue that clinical practice would benefit from monitoring difference instead of change, as these are not equivalent. We further argue that future research and development efforts should focus on the development of a working approach to monitoring induced difference, improving how to monitor predicted difference, exploring statistical models that better discriminate between various types of clinical cases, and better communicate what can and cannot be interpreted from the clinical differences that are actually monitored, as guided by the presented classification of clinical differences to monitor in practice. (PsycINFO Database Record
TL;DR: Investigation of the relation between trainees’ attachment to their supervisors and trainee perceptions of their own counseling self-efficacy found that individuals who reported greater levels of experience were more likely to report greater Levels of CSE.
Abstract: Clinical supervision is often considered to be one of the important tasks in training psychotherapists The present study investigated the relation between trainees' attachment to their supervisors and trainees' perceptions of their own counseling self-efficacy (CSE), as potentially moderated by trainee level of experience Results indicated that trainees with greater avoidant attachment to their supervisors demonstrated lower levels of CSE Although the results of the moderator analyses were not statistically significant, levels of avoidance significantly predicted levels of CSE even when controlling for level of experience, whereas levels of anxiety were not found to significantly predict levels of CSE The study also found that individuals who reported greater levels of experience were more likely to report greater levels of CSE The implications of the study are discussed, and recommendations for clinical supervision process are offered (PsycINFO Database Record
TL;DR: This article describes how individualized feedback, in the form of a clinical formulation, is used in the dynamic-relational group treatment of perfectionism (Hewitt et al., 2015), a core vulnerability or transdiagnostic personality factor.
Abstract: In this article, we describe how individualized feedback, in the form of a clinical formulation, is used in our dynamic-relational group treatment of perfectionism (Hewitt et al., 2015), a core vulnerability or transdiagnostic personality factor. The authors discuss briefly their conceptualization and assessment of perfectionism as well as other aspects of patients' functioning, and the use of both psychodynamic and interpersonal models to derive, for individual patients, their unique formulation or idiosyncratic model of their perfectionistic and related behavior. Moreover, we describe the process of providing the formulation feedback to each patient in preparation for group psychotherapy and, finally, provide an illustrative case. (PsycINFO Database Record
TL;DR: This article argues that the theory of mentalization helps to explain why some parents successfully resolve this central challenge during pregnancies after loss and go on to develop a secure attachment to the next infant, whereas others continue to experience long-term attachment problems.
Abstract: Pregnancies after loss are often characterized by feelings of depression, anxiety, trauma-like symptoms, and problems bonding to the fetus. Difficulties bonding to the unborn baby during pregnancy are of clinical importance because they are predictive of problems in the mother-infant attachment relationship, perhaps explaining why some studies show a higher risk of insecure attachment for babies born after loss. O'Leary (2004) has proposed that problems in prenatal bonding during pregnancies after loss are the result of the challenge these mothers face of having to grieve the loss of one baby while bonding to another. This article argues that the theory of mentalization helps to explain why some parents successfully resolve this central challenge during pregnancies after loss and go on to develop a secure attachment to the next infant, whereas others continue to experience long-term attachment problems. Specifically, pregnancies after loss are conceptualized as a potentially traumatic experience in which mentalization may decrease and, at the same time, serve as a protective factor against attachment problems with infants born after loss due to unresolved trauma and grief. Several aspects of mentalization, including the capacity to mentalize: (a) affect associated with trauma and loss, (b) attachment relationships as distinct, (c) multiple and conflicting mental states, and (d) early inadequate attachment experiences related to trauma and loss, are proposed to help mothers pregnant after loss to mourn the loss of one baby while attaching to another, ameliorating potential attachment problems postpartum. Clinical interventions for facilitating these mentalizing capacities are suggested. (PsycINFO Database Record
TL;DR: This study reports on the development of a therapeutic relationship monitoring system for group treatment using results from 6 Group Questionnaire studies conducted in 4 unique clinical populations: nonclinical process, counseling center, European inpatient, and seriously mentally ill inpatients.
Abstract: The use of outcome monitoring systems to identify clients that are at-risk for treatment failure has now become part of daily clinical practice, shown in >25 empirical studies to improve client outcomes. These promising findings have led to outcome monitoring systems being recognized as evidence-based. Feedback systems based on client perception of therapeutic processes are recent additions to the monitoring literature, and the research suggests that these too lead to improved outcomes. Unfortunately, feedback systems and research have been primarily limited to individual therapy, creating a knowledge gap for multiperson treatment. This study reports on the development of a therapeutic relationship monitoring system for group treatment using results from 6 Group Questionnaire (GQ) studies conducted in 4 unique clinical populations: nonclinical process, counseling center, European inpatient, and seriously mentally ill inpatients. The GQ is a factor-analytically derived scale, which assesses a client's perception of 3 relationship quality constructs (positive bond, positive work, and negative relationship) across 3 structural domains (member-member, member-leader, and member-group). The first goal of the present study was to replicate the previously established factor structure across each clinical population. The second goal was to establish normative values and relevant feedback alerts for the GQ subscales in each population. Findings support the GQ factor structure across clinical populations, indicating that the constructs measured by the GQ bear similar relationships in each population. Further, findings support the implementation of unique norms and feedback alerts in each clinical population, reflecting the reality of meaningful differences between clinical populations. (PsycINFO Database Record
TL;DR: A rationale for the application of the MCO framework to the practice of group therapy is provided, and how group therapists’ cultural humility, comfort, and opportunities can assist in establishing a multicultural group orientation throughout the development of the group are illustrated.
Abstract: Multicultural group work has received growing attention over the past two decades; however, there is a lack of conceptual frameworks to guide therapists' cultural processes within group therapy at present. As such, we extend the multicultural orientation (MCO) to group therapy in an effort to provide a conceptual framework for group therapists to effectively engage multicultural group work. The MCO framework was developed in an effort to operationalize therapists' cultural processes of cultural humility, cultural comfort, and cultural opportunity. Although the MCO framework has been empirically tested within an individual psychotherapy context, application to alternative therapeutic modalities is needed. Given the inherent multicultural nature of group therapy and calls for group therapist to be culturally competent in the delivery of group-based services, we extend the MCO framework to the practice of group therapy. In this article, we provide a rationale for the application of the MCO framework to the practice of group therapy, and illustrate how group therapists' cultural humility, comfort, and opportunities can assist in establishing a multicultural group orientation throughout the development of the group. (PsycINFO Database Record