Joanna M. Drinane

Psychotherapist effects in meta-analyses: How accurate are treatment effects?

Psychotherapists are known to vary in their effectiveness with their clients, in randomized clinical trials as well as naturally occurring treatment settings. The fact that therapists matter has 2 effects in psychotherapy studies. First, if therapists are not randomly assigned to modalities (which is rare) this may bias the estimation of the treatment effects, as the modalities may have therapists of differing skill. In addition, if the data are analyzed at the client level (which is virtually always the case) then the standard errors for the effect sizes will be biased due to a violation of the assumption of independence. Thus, the conclusions of many meta-analyses may not reflect true estimates of treatment differences. We reexamined 20 treatment effects selected from 17 meta-analyses. We focused on meta-analyses that found statistically significant differences between treatments for a variety of disorders by correcting the treatment effects according to the variability in outcomes known to be associated with psychotherapists. The results demonstrated that after adjusting the results based on most small estimates of therapist effects, ∼80% of the reported treatment effects would still be statistically significant. However, at larger estimates, only 20% of the treatment effects would still be statistically significant after controlling for therapist effects. Although some meta-analyses were consistent in their estimates for treatment differences, the degree of certainty in the results was considerably reduced after considering therapist effects. Practice implications for understanding treatment effects, namely, therapist effects, in meta-analyses and original studies are provided.

An experimental test of microaggression detection in psychotherapy: Therapist multicultural orientation.

Previous studies have documented a relatively high rate of racial–ethnic microaggressions in therapy (e.g., 53% to 81% of clients have reported at least 1 microaggression). In addition, clients who perceive racial–ethnic microaggressions from their therapist have reported lower working alliances and worse therapy outcomes. In one study, over 75% of microaggressions went unaddressed in psychotherapy, and the reason for this is not fully understood. It could be that therapists do not recognize racial–ethnic microaggressions when they occur or feel anxiety about the process of addressing them. A 1st step is to determine whether therapists are able to recognize racial–ethnic microaggressions. The current study included 78 therapists who were randomly assigned to one of 2 conditions: (1) a video vignette of therapy session with 3 racial–ethnic microaggressions (i.e., microaggression condition) and (2) a video vignette of a therapy session with no microaggressions (i.e., neutral condition). The results demonstrated that when compared to those in the neutral condition, participants in the microaggression condition rated the therapist as less sensitive overall, less culturally comfortable, and less culturally humble and as having missed more cultural opportunities. Within the microaggression condition, 38% to 52% of therapists accurately identified one of the 3 microaggressions.

Feedback informed treatment: An empirically supported case study of psychodynamic treatment

The use of client feedback, via self-report measures of psychological functioning and working alliance, is an effective way to improve therapy outcomes. Despite this progress, there are many questions about the mechanisms of change for these systems. The current study employed a case study approach to examine the effectiveness of feedback informed treatment within a psychodynamic therapy. We examined the case based on therapy outcomes, alliance processes, and verbatim dialogue of in-session exchanges. We also conducted a semistructured interview with the therapist to understand how she used and interpreted the feedback within her psychodynamic approach. The results demonstrated positive therapy outcomes and that feedback assisted with alliance formation, specifically decision making about therapeutic tasks and managing negative countertransference. The therapist reported that the feedback enhanced her ability to work in the here and now and to identify relational patterns. Implications for theory and practice are discussed.

Cultural concealment and therapy outcomes.

Therapy is predicated on the need for clients to share intimate details about their lives, including their cultural values, attitudes, and beliefs. Previous studies have found that clients conceal certain aspects of their lives including, but not limited to their symptoms and their feelings about the therapy process. To date, there has not been an investigation focused on whether clients conceal aspects of their cultural identities, whether some therapists are more likely to have clients conceal aspects of their cultural identities, and if cultural concealment is associated with therapy outcomes. The present study attempted to do so utilizing the caseloads of 37 therapists who treated a total of 233 clients in a university counseling center setting. Client data were collected at the end of treatment utilizing the Patient’s Estimate of Improvement (PEI; Hatcher & Barends, 1996), a measure that assesses client change on domains including general functioning, symptom related distress, intimate and social relationships, work or school, feelings about oneself, behavior, control of life, and tolerance for and ability to share painful feelings. Cultural concealment was assessed via 5 items regarding the amount and circumstances under which clients withheld cultural identity based information in therapy. Results indicated that within therapists’ caseloads, client’s ratings of cultural concealment were negatively associated with therapy outcomes. Additionally, therapists whose clients rated more cultural concealment on average had clients with worse therapy outcomes. Lastly, there was a significant contextual effect indicating that within and between therapist cultural concealment were statistically different from one another.

Construction and validation of the Multicultural Orientation Inventory—Group Version.

Given the continued racial/ethnic diversification of the United States, it is not uncommon for therapy groups to consist of members with diverse racial/ethnic backgrounds and various cultural identities. Scholars have underscored how this cultural diversity can directly impact many processes and outcomes of group-based interventions (Chen, Kakkad, & Balzano, 2008). However, there is presently a paucity of empirical research testing the relationship between cultural processes of therapy groups and members’ outcomes. Moreover, no psychometrically sound measure of the cultural process that unfolds in group therapy currently exists. As such, this study sought to adapt the Multicultural Orientation Inventory to develop and validate the Multicultural Orientation Inventory—Group Version (MCO-G), a measure assessing the cultural humility, cultural comfort, and cultural missed opportunities in therapy groups. Data for this validation study consisted of 208 members of 49 therapy groups across 10 university counseling centers. Confirmatory factor analyses supported a 3-factor structure of the MCO-G Inventory, wherein the 3 factors corresponded with the underlying constructs of cultural humility, cultural comfort, and cultural missed opportunities. This study provides initial evidence for the estimated internal and convergent validity of the MCO-G, as measured by clients’ perceptions of a higher-order group therapeutic factor and improvement in therapy. Results provide initial support for the psychometric properties of the MCO-G. Moreover, groups’ cultural humility and cultural missed opportunities were related to members’ improvement in therapy. Clinical implications and future research are discussed.

The Psychotherapy Outcome Problem: The Development of the Outcome Stability Index

Abstract Objective: Psychotherapy research commonly utilizes clients’ last session score as an indicator of treatment outcome. We examined whether this last session score is consistent with what would be predicted based on clients’ general trajectory in psychological functioning across sessions. We focused on the unstandardized residual variance at the last session, as this represents the degree to which the session score is divergent (or not) from what is predicted from the previous sessions (i.e., Outcome Stability Index; OSI). Method: The sample included 27,958 clients who attended on average 9.41 sessions. Each session, clients completed the Behavioral Health Measure-20 as a measure of psychological functioning. We converted the unstandardized residual variance for clients’ last session score into a Cohen’s d coefficient to aid in interpretation. Results: The mean OSI was 0.07 (SD = 0.58), suggesting excellent stability in their last session therapy outcome scores. However, approximately 33% of clients demonstrated poor or extremely problematic stability in their last session therapy outcome scores. Clients who demonstrated poor stability were classified as demonstrating reliable deterioration. Conclusions: Researchers may want to consider reporting OSI to assist readers’ understanding of the stability of therapy outcomes. Clinical or methodological significance of this article: Therapy outcome scores can vary from session to session, which can influence how we understand therapy outcomes that rely on last session scores. Studies examining therapy outcomes could report the Outcome Stability Index to better contextualize the results.