Zac E. Imel

Untangling the Alliance-Outcome Correlation : Exploring the Relative Importance of Therapist and Patient Variability in the Alliance

Although the therapeutic alliance is a consistent predictor of psychotherapy outcomes, research has not distinguished between the roles of patient and therapist variability in the alliance. Multilevel models were used to explore the relative importance of patient and therapist variability in the alliance as they relate to outcome among 331 patients seen by 80 therapists (therapist average caseload was 4.1). Patients rated both the alliance and outcome and all models adjusted for baseline psychological functioning. The results indicated that therapist variability in the alliance predicted outcome, whereas patient variability in the alliance was unrelated to outcome. Reasons why therapist variability as opposed to patient variability predicted outcome are discussed. Clinical implications include therapists monitoring their contribution to the alliance, clinics providing feedback to therapists about their alliances, and therapists receiving training to develop and maintain strong alliances.

Posttraumatic Stress Disorder as a Risk Factor for Suicidal Ideation in Iraq and Afghanistan War Veterans

Posttraumatic stress disorder (PTSD) was examined as a risk factor for suicidal ideation in Iraq and Afghanistan War veterans (N = 407) referred to Veterans Affairs mental health care. The authors also examined if risk for suicidal ideation was increased by the presence of comorbid mental disorders in veterans with PTSD. Veterans who screened positive for PTSD were more than 4 times as likely to endorse suicidal ideation relative to non-PTSD veterans. Among veterans who screened positive for PTSD (n = 202), the risk for suicidal ideation was 5.7 times greater in veterans who screened positive for two or more comorbid disorders relative to veterans with PTSD only. Findings are relevant to identifying risk for suicide behaviors in Iraq and Afghanistan War veterans.

A meta-analysis of psychotherapy and medication in unipolar depression and dysthymia

BACKGROUND There remains considerable disagreement regarding the relative efficacy of psychotherapy and medication across types of depression. METHOD We used random effects meta-analysis to examine the relative efficacy of psychotherapy vis-à-vis medication at post-treatment and follow-up. We also estimated the relative efficacy of continued medication versus discontinued psychotherapy. As twenty-eight studies (39 effects, n=3,381) met inclusion criteria, we were able to conduct an adequately powered test of between-study heterogeneity and examine if the type of depression influenced relative efficacy. RESULTS Psychotherapy and medication were not significantly different at post-treatment, however effect sizes were not consistent. Although there was no association between severity and relative efficacy, a small but significant advantage for medications in the treatment of dysthymia did emerge. However, psychotherapy showed a significant advantage over medication at follow-up and this advantage was positively associated with length of follow-up. Moreover, discontinued acute phase psychotherapy did not differ from continued medication at follow-up. LIMITATIONS Limitations included relatively fewer studies of severe and chronic depression, as well as dysthymia. In addition, only a minority of studies reported follow-up data. CONCLUSIONS Our results indicated that both psychotherapy and medication are viable treatments for unipolar depression and that psychotherapy may offer a prophylactic effect not provided by medication. However, our analyses diverged from previous findings in that effects were not consistent and medication was significantly more efficacious than psychotherapy in the treatment of dysthymia.

Beyond the individual: Group effects in mindfulness-based stress reduction

Abstract The authors explored the group as a source of change in mindfulness-based stress reduction (MBSR). Participants consisted of 606 adults in 59 groups who completed an 8-week MBSR program. The authors examined change in the General Symptom Index (GSI) of the Symptom Checklist-90-Revised and the Medical Symptom Checklist (MSC) from pre- to postintervention. Multilevel models were used to examine the extent to which groups differed in the amount of change reported by the participants. After controlling for pretreatment severity, group accounted for 7% of the variability in the GSI and 0% in the MSC. The authors discuss the implications of these findings for the practice of MBSR as well as for research investigating the effects of MBSR and other programs or psychotherapies.

Racial/Ethnic Disparities in Therapist Effectiveness: A Conceptualization and Initial Study of Cultural Competence.

As a result of mental health disparities between White and racial/ethnic minority clients, researchers have argued that some therapists may be generally competent to provide effective services but lack cultural competence. This distinction assumes that client racial/ethnic background is a source of variability in therapist effectiveness. However, there have been no direct tests of the therapist as a source of health disparities. We provided an initial test of the distinction between general and cultural competence by examining client racial/ethnic background as a source of variability in therapist effectiveness. We analyzed cannabis use outcomes from a psychotherapy trial (N = 582) for adolescent cannabis abuse and dependence using Bayesian multilevel models for count outcomes. We first tested whether therapists differed in their effectiveness and then tested whether disparities in treatment outcomes varied across therapist caseloads. Results suggested that therapists differed in their effectiveness in general and that effectiveness varied according to client racial/ethnic background. Therapist effectiveness may depend partially on client racial/ethnic minority background, providing evidence that it is valid to distinguish between general and cultural competence.

Rating Scales in Psychotherapy Practice

Therapists can gain invaluable information by administering rating scales to clients throughout the therapy process. Indeed, research has demonstrated therapists who utilize client feedback can improve their clients’ outcomes. We provide an overview of the research of using rating scales in therapy. Next, we describe some practical considerations in the selection of rating scales; specifically, we highlight the benefits and feasibility of using global outcome and working alliance scales. Finally, we provide examples of brief, psychometrically sound, rating scales that can be integrated into practice.

Valuing Diversity Implementing Our Best Intentions

Articles in this issue describe the genesis, development, and implementation of the Counseling Psychology Model Training Values Statement Addressing Diversity. This commentary extends the dialog on issues inherent to the Values Statement and the accompanying articles contained in this issue, with particular attention to the resolution of conflicting values and to empirical findings related to attitude change of bias and prejudice.

What characterizes effective therapists

This chapter begins with the assumption that there are therapist effects, and then goes on to address the next obvious question of who the best therapists are and what they are doing in therapy. After describing conceptual and methodological difficulties related to understanding what sets these therapists apart, Wampold et al. review the characteristics and competencies that have currently been shown to contribute or not contribute to therapist effect