Adapting psychotherapy to patient reactance level: A meta-analytic review.

Resistance and its extreme variation, reactance, are uniformly observed across varieties of psychotherapy. Social psychologists note that reactant individuals prove to be less so when offered a receptive and nondirective environment. We provide definitions of reactance, review its frequent measures, and offer a clinical example. A meta-analysis of 13 controlled studies (1,208 patients) examined the degree to which treatment outcomes are enhanced when therapists offer less directive treatments to high-reactance patients. The results revealed a large effect size (d = .79), confirming that highly reactant individuals did better in psychotherapy when the therapist assumed a reflective and nondirective stance than a directive and authoritative one. To a lesser degree, the opposite was also true. Limitations of the research and diversity considerations are noted. Practice recommendations are provided to minimize a patient's reactant behavior.

Fitting psychotherapy to patient coping style: A meta-analysis.

Over the course of 60 years of research, several personality traits have emerged as potential predictors of differential change in psychotherapy. Among them is the patient's coping style (CS), commonly distinguished between those who deal with change by looking inwardly (internalization) and those who deal with it outwardly (externalization). This study provides definitions of CSs, clinical examples, and frequent measures. We update a 2011 meta-analytic review that revealed a consistent interaction between CSs and treatment focus-symptom focus versus insight focus. The current meta-analysis of 18 studies revealed a medium to large effect (d = 0.60) and suggested that a symptom focus proves more effective for externalizing patient whereas an insight focus is generally more effective for internalizers. The article concludes with limitations of the research, diversity considerations, and therapeutic practices based on the meta-analytic results.

Selecting the most appropriate treatment for each patient / Selección del tratamiento más adecuado para cada paciente

Reviews the emergence of research on fitting treatment procedures to the unique needs and proclivities of patients. Traditional research on efficacy of psychotherapy focuses on the role of interventions and theoretical brands, minimizing factors that cannot be randomly assigned. This line of research has not realized its initial and desired promise, perhaps because it fails to incorporate into the study of psychotherapy important and effective treatment variations that are associated with therapist and non-diagnostic patient factors. Contemporary efforts to ‘‘fit’’ treatments to patients emphasize the roles of interventions, participant factors, and contextual/relationship factors. For these complex interactions, any of which reflect factors that cannot be randomly assigned, randomized clinical trials (RCT) protocols are inappropriate as a ‘‘gold standard’’. Several studies are presented which illustrate not only the predictive power of incorporating both treatment mediators and moderators into the realm of psychotherapy study, but the value of a multi-method approach to research. Converging studies moreover, provide a way to incorporate matching algorithms into decisions about assigning optimal treatments (AU)

Se revisa el surgimiento de la investigación sobre procedimientos de ajuste de tratamientos a las necesidades de los pacientes. La investigación tradicional sobre la eficacia de la psicoterapia se centra en el papel de las intervenciones y los modelos teóricos, minimizando los factores que no pueden ser asignados al azar. Esta línea de investigación no ha dado cuenta de su deseada promesa inicial, tal vez porque no incorporó en el estudio de la psicoterapia importantes y eficaces variaciones de tratamiento asociadas al terapeuta y a factores no diagnósticos de los pacientes. Los esfuerzos contemporáneos para ‘‘encajar’’ tratamientos a pacientes destacan el papel de las intervenciones, de factores participantes y de factores contextuales/relacionales. Estas complejas interacciones reflejan factores que no pueden ser asignados al azar, ensayos clínicos aleatorizados (ECA) que son inapropiadas como ‘‘estándar de oro’’. Se presentan varios estudios que ilustran no sólo el poder predictivo de la incorporación de ambos mediadores y moderadores de tratamiento en el ámbito de estudio de la psicoterapia, sino también el valor de un enfoque multi-método de investigación. Estudios convergentes proporcionan una manera de incorporar algoritmos en las decisiones sobre la asignación de tratamientos óptimos (AU)

Selecting the most appropriate treatment for each patient.

Reviews the emergence of research on fitting treatment procedures to the unique needs and proclivities of patients. Traditional research on efficacy of psychotherapy focuses on the role of interventions and theoretical brands, minimizing factors that cannot be randomly assigned. This line of research has not realized its initial and desired promise, perhaps because it fails to incorporate into the study of psychotherapy important and effective treatment variations that are associated with therapist and non-diagnostic patient factors. Contemporary efforts to "fit" treatments to patients emphasize the roles of interventions, participant factors, and contextual/relationship factors. For these complex interactions, any of which reflect factors that cannot be randomly assigned, randomized clinical trials (RCT) protocols are inappropriate as a "gold standard". Several studies are presented which illustrate not only the predictive power of incorporating both treatment mediators and moderators into the realm of psychotherapy study, but the value of a multi-method approach to research. Converging studies moreover, provide a way to incorporate matching algorithms into decisions about assigning optimal treatments.

Se revisa el surgimiento de la investigación sobre procedimientos de ajuste de tratamientos a las necesidades de los pacientes. La investigación tradicional sobre la eficacia de la psicoterapia se centra en el papel de las intervenciones y los modelos teóricos, minimizando los factores que no pueden ser asignados al azar. Esta línea de investigación no ha dado cuenta de su deseada promesa inicial, tal vez porque no incorporó en el estudio de la psicoterapia importantes y eficaces variaciones de tratamiento asociadas al terapeuta y a factores no diagnósticos de los pacientes. Los esfuerzos contemporáneos para "encajar" tratamientos a pacientes destacan el papel de las intervenciones, de factores participantes y de factores contextuales/relacionales. Estas complejas interacciones reflejan factores que no pueden ser asignados al azar, ensayos clínicos aleatorizados (ECA) que son inapropiadas como "estándar de oro". Se presentan varios estudios que ilustran no sólo el poder predictivo de la incorporación de ambos mediadores y moderadores de tratamiento en el ámbito de estudio de la psicoterapia, sino también el valor de un enfoque multi-método de investigación. Estudios convergentes proporcionan una manera de incorporar algoritmos en las decisiones sobre la asignación de tratamientos óptimos.

Evidence-based supervision: Tracking outcome and teaching principles of change in clinical supervision to bring science to integrative practice.

Supervision is the primary way in which psychotherapy trainees develop the skills of applying interventions, conceptualizing cases, and practicing self-reflection. Although critical to professional development, the nature and objectives of supervision can vary widely among supervisors, depending on idiosyncratic differences and the orientation used. As clinical psychology moves toward integrating science and practice, the need to teach students evidence-based principles of therapeutic change and how to use outcome measures to enhance progress is paramount. Furthermore, with hundreds of "evidence-based" interventions and widely diverse supervisors, the fact that cross-cutting interventions and common factors carry the burden of most therapeutic change is frequently lost. In this article, we outline an experimental training system that is being tested as a means to teach student-therapists to use empirically established moderators (treatment factors) and mediators of change to tailor their interventions to client differences. This experimental approach is derived from Systematic Treatment Selection (Beutler, Clarkin, & Bongar, 2000), a cross-cutting system that can be used to aid individualized treatment planning as well as to track and use client outcomes in clinical supervision within a graduate-level training clinic.

Cultural adaptation in measuring common client characteristics with an urban Mainland Chinese sample.

OBJECTIVES: This study aimed to develop a culturally adapted version of the Systematic Treatment Selection-Innerlife (STS) in China. METHODS: A total of 300 nonclinical participants collected from Mainland China and 240 nonclinical US participants were drawn from archival data. A Chinese version of the STS was developed, using translation and back-translation procedures. After confirmatory factor analysis (CFA) of the original STS sub scales failed on both samples, exploratory factor analysis (EFA) was then used to access whether a simple structure would emerge on these STS treatment items. Parallel analysis and minimum average partial were used to determine the number of factor to retain. RESULTS: Three cross-cultural factors were found in this study, Internalized Distress, Externalized Distress and interpersonal relations. CONCLUSIONS: This supported that regardless of whether one is in presumably different cultural contexts of the USA or China, psychological distress is expressed in a few basic channels of internalized distress, externalized distress, and interpersonal relations, from which different manifestations in different culture were also discussed.

Welcome to the party, but...

Laska, Gurman, and Wampold (2014, pp. 467-481) argue for the inclusion of common factors (CF) approaches to psychotherapy to be an alternative to empirically supported therapies when developing an evidence-based practice. Although we applaud their scholarship and the cogency of their arguments, we believe that they fall short of what is needed to define an optimal and effective therapy. Integration rather than amalgamation better captures the complexity of psychotherapy and adds to the explained variance. While CF dimensions certainly should be considered within the research definition of "psychotherapy," there are also important characteristics of the participants that are not captured in either the patient's diagnosis or the interventions that the therapist uses that affect outcome. We believe that the authors have inadvertently equated CFs with nonspecific ones and thus excluded a host of moderating variables in psychotherapy that produce specific and differential effects but which are not "nonspecific".

Concerns about the dissemination and implementation of evidence-based psychotherapies in the Veterans Affairs health care system.

Comments on the article by B. E. Karlin and G. Cross (see record 2013-31043-001). The present authors have concerns stemming primarily from how the Department of Veterans Affairs (VA) defines evidence-based psychotherapies (EBPs). The article by Karlin and Cross alluded to some of the controversies surrounding EBPs and why they have not been broadly implemented in many settings. For example, EBP guidelines often are perceived as mechanistic and only appropriate for certain patient populations; and, indeed, for many troubled individuals, EBPs do not work or require adjustment. A group of 19 current and recent past presidents of three APA divisions (12, 29, and 50) and the North American and International Societies for Psychotherapy Research has identified several questions, the answers to which may be important to increase the optimization of such guidelines.

Common, specific, and cross-cutting psychotherapy interventions.

There are certain strategies and techniques clinicians use in session that produce significant change, at least when they are guided by an effective strategy. The following illustrates several broadly based classes of interventions along with their supporting empirically derived principles of effecting strategic change. The interventions include procedures to (a) enhance the relationship, (b) develop and maintain a therapeutic contract, and (c) adjust treatment to match to certain unique patient qualities. Classes of interventions and the strategic principles which drive them, rather than specific techniques, were the point of focus of this article out of the observation that the effects of specific techniques are therapist dependent, whereas classes of interventions produce more cross-cutting effects (see Beutler et al., Guidelines for the systematic treatment of the depressed patient. New York: Oxford University Press, 2000; Beutler and Harwood, Prescriptive psychotherapy: A practical guide to systematic treatment selection. New York: Oxford University Press, 2000). Additionally, classes of interventions can more effectively be fit to classes of moderating therapist and patient variables to allow for specialized treatment planning. In conclusion, the readers are directed to an online self-report assessment tool (www.Innerlife.com), which provides additional assistance in identifying and using interventions at this level of strategy and the research which supports them.

Psychotherapy integration in the treatment of personality disorders: a commentary.

Whereas research on the treatment of personality disorders over the past several decades has focused primarily on comparing the efficacy of various treatment packages associated with different theoretical models, there is increasing evidence that the field would benefit from focusing more attention on developing integrative treatments that are both informed by research and capable of scientific verification. The articles assembled for this special section each propose a different approach to integrative treatment for personality disorders. In this commentary, we outline a number of reasons for making such a shift to more integrative treatments, consider some of the potential challenges to integration, and discuss the different approaches to integration illustrated in these articles. We highlight some of the difficult tradeoffs that must be made in developing an integrative approach and discuss similarities and differences in the response to such challenges by the contributors to this special section. Finally, we point to several areas for future research that we believe will contribute to the development of increasingly effective treatments for individuals with personality disorders.

Resistance/reactance level.

Psychotherapists from all professions and perspectives periodically struggle to effectively manage a patient's resistance to change. This article provides definitions and examples of patient-treatment matching applied to patient resistance or reactance. We report the results from an original meta-analysis of 12 select studies (N = 1,102) on matching therapist directiveness to patient reactance. Our findings support the hypothesis that patients exhibiting low levels of trait-like resistance respond better to directive types of treatment, while patients with high levels of resistance respond best to nondirective treatments (d = .82). Limitations of the research reviewed are noted, and practice recommendations are advanced.

Coping style.

The fit of patient coping style and psychotherapy focus has been suggested as improving treatment outcome. This article reviews the definitions, measures, and previous research surrounding this hypothesis. An original meta-analysis of 12 carefully selected studies (N = 1,291 patients) resulted in a weighted, mean effect size (d) of .55 in favor of a fit between externalizing patients and symptom-focused treatment or, alternatively, internalizing patients and insight-focused treatment. This medium-size effect indicates that nondiagnostic patient factors, like coping style, are important considerations in the selection of effective therapies. Clinical examples and clinical recommendations are provided.

Cross-cultural differences in risk perceptions of disasters.

Public risk perceptions of mass disasters carry considerable influences, both psychologically and economically, despite their oft-times imprecise nature. Prior research has identified the presence of an optimistic bias that affects risk perception, but there is a dearth of literature examining how these perceptions differ among cultures-particularly with regard to mass disasters. The present study explores differences among Japanese, Argentinean, and North American mental health workers in their rates of the optimistic bias in risk perceptions as contrasted between natural disasters and terrorist events. The results indicate a significant difference among cultures in levels of perceived risk that do not correspond to actual exposure rates. Japanese groups had the highest risk perceptions for both types of hazards and North Americans and Argentineans had the lowest risk perceptions for terrorism. Additionally, participants across all cultures rated risk to self as lower than risk to others (optimistic bias) across all disaster types. These findings suggest that cultural factors may have a greater influence on risk perception than social exposure, and that the belief that one is more immune to disasters compared to others may be a cross-cultural phenomenon.

Clinically significant change in psychotherapy for depressive disorders.

BACKGROUND: The assessment of change has been a problematic issue in psychotherapy research and has become increasingly important in the up rise of evidence-based practices. METHODS: In the present paper, the clinical significance of the change of 243 patients who received one of nine treatments for depression was analysed using the Reliable Change Index [Jacobson, N.S., Follette, W.C., Revenstorf, D., 1984. Psychotherapy outcome research: Methods for reporting variability and evaluating clinical significance. Behav. Ther. 15, 336-352.] and normative comparisons (Equivalency Testing; [Kendall, P.C., Marrs-Garcia, A., Nath, S.R., Sheldrick, R.C., 1999. Normative comparisons for the evaluation of clinical significance. J. Consult. Clin. Psychol. 67, 285-299.]). While the first method addresses the question of whether or not the change that occurred was large enough to be attributable to treatment rather than to measurement error, the second method addresses the issue of comparing the level of functioning of treated individuals with non-clinical population. Hence, the nine treatments of depression were compared in terms of their reliability and clinical significance. Traditional statistical tests in treatment outcome studies were also conducted. RESULTS: Findings support the importance of analysing the clinical significance of change during psychotherapy. While all but one treatment led to statistical significant changes in depressive symptoms, differences among treatments were found in terms of their reliability and clinical significance. LIMITATIONS: Small sample sizes and representativeness of each treatment warrant further replication of these results. CONCLUSIONS: Implications of the use of clinical significance testing in the exploration of empirical support for psychotherapy treatments in conjunction with traditional statistical analyses are discussed, which will be more readily useful and meaningful to clinicians who wish to embark in evidence-based practices.

Narrative change in psychotherapy: differences between good and bad outcome cases in cognitive, narrative, and prescriptive therapies.

This study aimed to clarify the relationship between changes in the patients' narratives and therapeutic outcomes. Two patients were selected from three psychotherapeutic models (cognitive, narrative, and prescriptive therapies), one with good therapeutic outcome and the other with bad therapeutic outcome. Sessions from the initial, middle, and final phases for each patient were evaluated in terms of narrative structural coherence, process complexity, and content diversity. Differences between patients' total narrative production were found at the end of the therapeutic process. Good outcome cases presented a higher statistically significant total narrative change than poor outcome cases.

Using mediators and moderators to test assumptions underlying culturally sensitive therapies: an exploratory example.

Factors hypothesized to impact Asian American responses to counseling were tested as mediators and moderators of perceived counselor credibility and working alliance. Asian and European American college students (N = 182) were assigned randomly to view simulated directive or nondirective therapy approaches. Mediation analyses examined whether ethnic group differences in initial perceptions were accounted for by therapist understandability and previous therapy experiences. Moderation analyses examined whether expectations for directive therapy, ambiguity tolerance, and resistance influenced initial perceptions across directive and nondirective counseling. Asian Americans rated the counseling approaches significantly less favorably than Europeans Americans. A significant mediation effect was found for therapist understandability, whereas a significant moderation effect was found for expectation for directive therapy on initial perceptions of counselor credibility.

The dirty dozen: twelve failures of the hurricane katrina response and how psychology can help.

This comprehensive analysis addresses the United States' alarming lack of preparedness to respond effectively to a massive disaster as evidenced by Hurricane Katrina. First, a timeline of problematic response events during and after Hurricane Katrina orients readers to some of the specific problems encountered at different levels of government. Second, a list of the "Dirty Dozen"--12 major failures that have occurred in prior disasters, which also contributed to inadequate response during and after Hurricane Katrina--is presented. Third, this article encourages expanding psychology's role beyond the treatment of trauma to encompass disaster planning and mitigation efforts from a broader public health perspective. Finally, areas for important interdisciplinary research in human behavior that will influence our nation's overall preparedness for future catastrophes are identified, and ways psychologists can become personally involved beyond treating casualties are discussed.

Common and specific effects of couples treatment for alcoholism: a test of the generic model of psychotherapy.

The generic model of psychotherapy (Orlinsky & Howard, 1987) eschews the view that inputs, processes or outputs associated with treatment exert linear and independent effects on outcomes. Variables within these three clusters must be viewed both within the context of time and through their interactions with other variables within a class. This study illustrates the use of this model by identifying common (comprising both traditional relationship factors and shared therapy ingredients) and specific factors in cognitive-behavioural (CB) and family systems (FS) treatments for alcoholic couples and tracking their contributions over two treatment phases - the acute phase, and the follow-up phase. While four process variables (therapy type, intensity of treatment, common elements and FS-specific procedures) contributed to outcomes during the active treatment phase, these variables became more interactive during follow-up. Indeed, high levels of both specific interventions of both treatments were negatively associated with benefit, if common factors were also frequently used during the acute phase. The best effects were obtained when common and specific interventions were counterbalanced, one being frequently used and the other being infrequently used. Implications for future alcohol treatment and recommendations for research on common and specific factors are discussed.

Therapeutic factors in dysphoric disorders.

The working group on the treatment of dysphoric disorders focused on ways to integrate variables and qualities that optimize treatment effects for this clinical population. The variables examined represent three aspects or domains of the treatment context that effect positive change. These included aspects of the patient and therapist (participant factors), those relating to the development and role of the therapeutic relationship (relationship factors), and those that defined the application of formal interventions that are implemented by the therapist (techniques factors). The treatment literature on dysphoric populations was reviewed and a variety of relationships was identified, which then were translated into principles that are thought to enhance treatment effects. The principles representing the three domains of this review are then collected, in this article, into a set of cohesive suggestions for treating patients whose problems are characterized by major or minor depression, alone or as a comorbid condition.