Patient preference as a predictor of outcomes in a pilot trial of person-centred counselling versus low-intensity cognitive behavioural therapy for persistent sub-threshold and mild depression

The aim of this analysis was to explore whether pre-treatment intervention preferences were related to outcomes for patients with persistent sub-threshold and mild depression who received one of two treatment types. Thirty-six patients took part in a two-arm, parallel group, pilot randomized controlled trial that compared short term (3 month and 6 month) outcomes of person-centred counselling (PCC) compared with low-intensity, CBT-based guided self-help (LICBT). Patient preferences for the two interventions were assessed at baseline assessment, and analysed as two independent linear variables (pro-PCC, pro-LICBT). Eight out of 30 interactions between baseline treatment preferences and treatment type were found to be significant at the p < .05 level. All were in the predicted direction, with patients who showed a stronger preference for a treatment achieving better outcomes in that treatment compared with the alternative. However, pro-LICBT was a stronger predictor of outcomes than pro-PCC. The findings provide preliminary support that treatment preferences should be taken into account when providing interventions for patients with persistent sub-threshold and mild depression. It is recommended that further research analyses preferences for different treatment types as independent variables, and examines preferences for format of treatment (e.g. guided self-help vs. face-to-face).     

Racial/ethnic matching of clients and therapists in mental health services: a meta-analytic review of preferences, perceptions, and outcomes

Across several decades the effects of matching clients with therapists of the same race/ethnicity have been explored using a variety of approaches. We conducted a meta-analysis of 3 variables frequently used in research on racial/ethnic matching: individuals' preferences for a therapist of their own race/ethnicity, clients' perceptions of therapists across racial/ethnic match, and therapeutic outcomes across racial/ethnic match. Across 52 studies of preferences, the average effect size (Cohen's d) was 0.63, indicating a moderately strong preference for a therapist of one's own race/ethnicity. Across 81 studies of individuals' perceptions of therapists, the average effect size was 0.32, indicating a tendency to perceive therapists of one's own race/ethnicity somewhat more positively than other therapists. Across 53 studies of client outcomes in mental health treatment, the average effect size was 0.09, indicating almost no benefit to treatment outcomes from racial/ethnic matching of clients with therapists. These 3 averaged effect sizes were characterized by substantial heterogeneity: The effects of racial/ethnic matching are highly variable. Studies involving African American participants demonstrated the highest effect sizes across all 3 types of evaluations: preferences, perceptions, and outcomes.     

Bridging the divide in work and organizational psychology: evidence from practice

This study explores the extent to which work and organizational (W&O) psychology practitioners use evidence, how they apply it to the everyday contexts in which they work, and the types of barriers they encounter in so doing. It adopts a mixed methods approach involving the administration of a survey to a UK sample (N = 163) of W&O psychologists and a series of semi-structured interviews (N = 25) exploring in greater depth how evidence is applied in practice. Findings reveal that practitioners consult a wide range of different types of evidence which they employ at various stages of engagement with client organizations and that this evidence is pressed into service in the pursuit of solutions which are both acceptable from the client perspective and consistent with the scientific standards underpinning professional knowledge and expertise in W&O psychology. Barriers to evidence-use were mainly practical in nature, concerning issues around managing the client–consultant relationship and the particularities of implementation context, both of which were shown to influence evidence utilization. The study contributes to current debate on the extent to which W&O psychologists adopt an evidence-based approach and provides a valuable and much called-for empirical insight into the enactment of the scientist–practitioner model in W&O psychology.     

CLIENT PREFERENCE FOR COUNSELOR GENDER

This article presents the results of an investigation of male and female clients' expressed preferences for gender of their counselor. The study addressed two major comparisons: clients with a preference for therapist gender versus those without a preference, and clients with a preference for a male therapist versus those with a preference for a female therapist. LOGIT analyses indicate significant relationships among sex of the client, sex of the intake counselor, whether or not clients express a preference, and whether they express a preference for a male or female counselor. Results also suggest an influence of the sex of the intake counselor. Results are discussed in terms of their implications for counseling and research activities.     

Cognitive Behavioural Therapy and Applied Relaxation for Generalized Anxiety Disorder: A Time Series Analysis of Change in Worry and Somatic Anxiety

The present study examined symptom change profiles in patients with generalized anxiety disorder (GAD) receiving either cognitive behavioural therapy (CBT) or applied relaxation (AR). It was hypothesized that (a) changes in worry would uniquely predict changes in somatic anxiety for most participants receiving CBT and (b) changes in somatic anxiety would uniquely predict changes in worry for most participants in the AR condition. Twenty participants (CBT n = 10; AR n = 10) completed daily ratings of worry and somatic anxiety during therapy, and multivariate time series analysis was used to assess the causal impact of each variable on the other. The hypotheses were not supported because we found no evidence of a match between individual symptom change profiles and treatment condition. Rather, a bidirectional relationship between worry and somatic anxiety was observed in 80% of participants receiving CBT and 70% of participants receiving AR. When only treatment responders were considered, 83% of participants receiving CBT and 86% of those receiving AR had such a bidirectional effect. The findings are discussed in terms of models of psychopathology that posit dynamic interactions between symptom clusters and in terms of the value of examining treatment mechanisms at the individual level.     

Women’s preference of therapist based on sex of therapist and presenting problem: An analog study

An analog study was conducted to examine differences in women’s preference for and anticipated comfort self-disclosing to hypothetical therapists of different sexes based on the type of hypothetical presenting problem. The impact of general level of self-disclosure was also examined. Participants included female college students (n?=?187). Anticipated comfort self-disclosing to male or female therapist was rated by subjects when presented with therapists of each sex with the same qualifications. Women preferred and reported higher levels of anticipated comfort self-disclosing to a female therapist. The type of hypothetical presenting problem and general level of self-disclosure also impacted anticipated comfort self-disclosing. There was an interaction between general level self-disclosure and the sex of therapist on anticipated comfort self-disclosing. General level of self-disclosure only impacted anticipated comfort self-disclosing when the therapist was male. This information is relevant for therapists or organizations that provide psychosocial services to women. Organizations may want to inquire about a client’s preferences about sex of therapist beforehand and, if possible, cater to the client’s preference.     

To switch or not to switch: Inviting bilingual clients to switch languages in psychotherapy

In the present study, we used an audio-analog design to test whether exposing bilingual participants to a therapist who invited a bilingual client to switch languages in a psychotherapy session would have a positive effect on participants’ perceptions of the therapist. We also explored whether participants’ sense of belonging to their ethnic group and to the larger US culture would enhance or attenuate this effect. Sixty-three bilingual Latino/a university students listened to one of two recordings of a simulated psychotherapy session with a bilingual Latina therapist and client. In one recording, the therapist invited the client to switch from English to Spanish when the client had trouble expressing complicated feelings; in the other, the therapist did not invite the client to switch. When listening, participants were asked to imagine themselves in the role of client and to rate the credibility and multicultural competence of the therapist, and the emotional bond they would anticipate with her. Contrary to expectation, only participants who expressed a greater sense of belonging to US culture rated the therapist who invited the client to switch as being more multiculturally competent. We discuss how these findings contribute to the literature on language switching and bilingualism in psychotherapy.     

Standardized Web-Based Cognitive Behavioural Therapy of Mild to Moderate Depression: A Randomized Controlled Trial with a Long-Term Follow-Up

Depression is common but undertreated. Web-based self-help provides a widely accessible treatment alternative for mild to moderate depression. However, the lack of therapist guidance may limit its efficacy. The authors assess the efficacy of therapist-guided web-based cognitive behavioural treatment (web-CBT) of mild to moderate depression. Fifty-four individuals with chronic, moderate depression participated in a randomized wait-list controlled trial, with an 18-month follow-up (immediate treatment: n = 36, wait-list control: n = 18). Primary outcome measures were the Beck Depression Inventory (BDI-IA) and the Depression scale of the Symptom Checklist-90-Revised (SCL-90-R. DEP). Secondary outcome measures were the Depression Anxiety Stress Scales and the Well-Being Questionnaire. Five participants (9%) dropped out. Intention-to-treat analyses of covariance revealed that participants in the treatment condition improved significantly more than those in the wait-list control condition (.011 < p < .015). With regard to the primary measures, between-group effects (d) were 0.7 for the BDI-IA and 1.1 for the SCL-90-R DEP. Posttest SCL-90- R DEP scores indicated recovery of 49% of the participants in the treatment group compared with 6% in the control group (odds ratio = 14.5; p < .004). On average, the effects were stable up to 18 months (n = 39), although medication was a strong predictor of relapse. The results demonstrate the efficacy of web-CBT for mild to moderate depression and the importance of therapist guidance in psychological interventions.     

Predictors of Therapist Adherence and Emotional Bond in Multisystemic Therapy: Testing Ethnicity as a Moderator

This study examined the interaction between problem severity and race\ethnicity as a predictor of therapist adherence and family-therapist emotional bond. Data for this study came from a longitudinal evaluation of Multisystemic Therapy (MST) provided by licensed MST provider organizations in community settings. Outcome variables included mid-treatment levels of caregiver report of therapist adherence, changes in caregiver report of therapist adherence over the course of treatment, and overall levels of caregiver-therapist and youth-therapist emotional bond. Hypothesized predictors included race\ethnicity and levels of poly-substance use, externalizing behavior, and youth self-report of delinquency early in treatment as well as pre-treatment number of arrests. Participants were 185 adolescents (M age = 15.35, SD = 1.29) and their caregivers. Of the participating youth, 48 % self-identified as Caucasian, 20 % as African-American, 28 % as Hispanic\Latino, and 4 % as “other.” Two-level Hierarchical Linear Modeling analyses revealed that for Caucasian youth, lower rates of self-reported delinquency were associated with greater increases in caregiver report of therapist adherence over the course of MST. For Hispanic\Latino caregivers, higher externalizing behavior and poly-substance use were associated with reports of lower therapist adherence at mid-treatment and poorer overall levels of emotional bonding with therapists. In contrast, for African-American participants, higher levels of youth externalizing behavior and poly-substance use were associated with higher overall levels of caregiver and youth report of emotional bonding with therapists, respectively. Results provide evidence that race\ethnicity interacts with problem severity in predicting therapist adherence and family-therapist emotional bond within real-world practice settings and suggest possible therapeutic process differences across race.     

Treatment Planning as Collaborative Care Map Construction: Reframing Clinical Practice to Promote Client Involvement

Collaborative care map construction is proposed as an alternative reference to the clinical practice of treatment planning. This reframe is intended to highlight the importance of client–therapist collaboration in “mapping out” care. Six therapist postures or practices are presented and discussed that promote client involvement: (a) speaking tentatively, (b) revisiting role induction, (c) inviting client preferences, (d) determining direction, (e) wondering aloud, and (f) checking for clarity and soliciting feedback. Suggestions are provided for employing these postures within the time constraints and external controls of managed care entities.     

A Meta-Analysis on the Efficacy of Technology Mediated CBT for Anxious Children and Adolescents

Several meta-analyses indicate that cognitive-behavioral therapy (CBT) via electronic/technological devices or applications (i.e., eCBT) is an effective alternative to standard therapist-delivered CBT for anxious adults. However, we know little about the efficacy of eCBT interventions for anxious children and adolescents. The present meta-analysis set out to investigate the efficacy of eCBT in comparison to standard CBT or waitlist control for anxious children and adolescents. Eight randomized controlled studies (N = 404 participants) that targeted anxiety at post-intervention and follow-up were included in the analysis. The results indicated that eCBT was as effective as standard CBT (g = .295) and more effective than waitlist (g = 1.410) in reducing anxiety symptoms. Moderation analyses revealed that anxious children and adolescents benefited the most from eCBT in the minimal therapist involvement condition (g = 2.682) in contrast to the significant therapist involvement group (g = .326). Furthermore, older participants seemed to extract greater clinical benefits from eCBT in contrast to younger participants (slope = .514). Current eCBT interventions for anxious children and adolescents appear to be promising, but require further investigation.     

Self-help interventions for adjustment disorder problems: a randomized waiting-list controlled study in a sample of burglary victims

Adjustment disorders (AjD) are among the most frequent mental disorders yet often remain untreated. The high prevalence, comparatively mild symptom impairment, and transient nature make AjD a promising target for low-threshold self-help interventions. Bibliotherapy represents a potential treatment for AjD problems. This study investigates the effectiveness of a cognitive behavioral self-help manual specifically directed at alleviating AjD symptoms in a homogenous sample of burglary victims. Participants with clinical or subclinical AjD symptoms following experience of burglary were randomized to an intervention group (n = 30) or waiting-list control group (n = 24). The new explicit stress response syndrome model for diagnosing AjD was applied. Participants received no therapist support and assessments took place at baseline, after the one-month intervention, and at three-month follow-up. Based on completer analyses, group by time interactions indicated that the intervention group showed more improvement in AjD symptoms of preoccupation and in post-traumatic stress symptoms. Post-intervention between-group effect sizes ranged from Cohen’s d = .17 to .67 and the proportion of participants showing reliable change was consistently higher in the intervention group than in the control group. Engagement with the self-help manual was high: 87% of participants had worked through at least half the manual. This is the first published RCT of a bibliotherapeutic self-help intervention for AjD problems. The findings provide evidence that a low-threshold self-help intervention without therapist contact is a feasible and effective treatment for symptoms of AjD.     

Internet-Based Treatment of Pathological Gambling with a Three-Year Follow-Up

Effective therapies for pathological gambling exist, but their use is limited to about 10% of the target population. In an attempt to lower the barriers for help, Internet-based cognitive behavioural therapy (ICBT) has been shown to be effective when delivered to a non-depressed sample with pathological gambling. This study sought to extend this finding to a larger, more representative population, and also test a model to predict responder status. Following advertisement, a total of 284 participants started an 8-week ICBT programme with minimal therapist contact via e-mail and weekly telephone calls of less than 15 min. The average time spent on each participant, including telephone conversations, e-mail, and administration, was 4 h. In addition to a mixed effects model to evaluate the effectiveness of the treatment, two logistic regression analyses were performed with the following eight pre-defined response predictor variables: work-life satisfaction, primary gambling activity, debts due to gambling, social support, personal yearly salary, alcohol consumption, stage of change, and dissociative gambling. ICBT resulted in statistically significant reductions in the scores of pathological gambling, anxiety, and depression as well as an increase in quality of life compared to pre-treatment levels. Follow-ups carried out in the treatment group at 6, 18, and 36 months indicated that treatment effects were sustained. Using the eight predictor variable model rendered an acceptable predictive ability to identify responders both at post-test (AUC = .72, p < .01) and at 36-month follow-up (AUC = .70, p < .01). We conclude that ICBT for pathological gamblers, even if depressed, can be effective and that outcome can partly be predicted by pre-treatment characteristics.     

Therapist empathy,homework compliance,and outcome in cognitive behavioral therapy for generalized anxiety disorder: partitioning within- and between-therapist effects

Although client-perceived therapist empathy relates to positive therapy outcomes, including in cognitive behavioral therapy (CBT), little is known about how empathy exerts its ameliorative effect. One possible way is by promoting clients’ subsequent homework compliance, a variable that also predicts positive outcomes in CBT. The present study sought to investigate simultaneously, in the context of 43 therapist–client dyads receiving 15 sessions of CBT for generalized anxiety disorder, (1) the association of early client-perceived therapist empathy (averaged over sessions 1, 3, 5) with mid-treatment client homework compliance (averaged over sessions 6, 8, 10); (2) the association of mid-treatment homework compliance on client posttreatment worry severity; and (3) the indirect effect of early perceived therapist empathy on posttreatment worry through mid-treatment homework compliance. Given that clients were nested within therapists, we examined both within- and between-therapist differences in clients’ ratings of therapist empathy and homework compliance, and tested both of these indices as predictors of the relevant dependent variables in a multilevel model. At the within-therapist level (i.e., differences between clients within a given therapist’s caseload), greater early empathy was associated with greater mid-treatment homework compliance. At the between-therapist level (i.e., differences between therapists across all of their cases), greater between-therapist homework compliance was related to lower posttreatment worry. Finally, homework compliance was not found to mediate the relationship between empathy and posttreatment outcome. The results underscore the importance of parsing client and therapist effects, and are discussed with regard to their training and research implications.     

Self-fulfilling prophecies in the clinical context: Review and implications for clinical practice

The expectancies a therapist and client bring into the clinical relationship can act as self-fulfilling prophecies. This article reviews the literature bearing on three types of self-fulfilling prophecies in a clinical context. First, I look at how the initial expectancies held by a therapist may bias the diagnosis and treatment of the client. Second, I look at the client's own self-expectancies for improvement and how they can enhance or impede progress. Last, I look at how receiving mental health treatment may be regarded as a stigma by others, resulting in negative social interactions for the client. For each of these domains, practical examples and implications are discussed, and suggestions are offered to therapists for how they can avoid or minimize damaging effects of negative self-fulfilling prophecies.     

Focusing on Patient Needs and Preferences May Improve Genetic Counseling for Colorectal Cancer

During cancer genetic counseling, different items which counselors consider important are discussed. However, relatively little empirical evidence exists regarding the needs and preferences of counselees. In this study needs and preferences were assessed from counselees with a personal and/or family history of colorectal cancer (CRC), who were referred for genetic counseling regarding CRC. They received a slightly modified version of the QUOTE-GENE^ca questionnaire prior to their first visit to the Hereditary Cancer Clinic. Response rate was 60 % (48/80 participants). Counselees rated the importance of 45 items assessing their needs and preferences regarding the content and process of genetic counseling. Participants rated the items regarding discussion of information about their familial CRC risk (100 %) and preventive options (98 %) as important or very important. Fewer participants rated items concerning general information on genetics as important. Sensitive communication during counseling was considered very important by a large percentage of counselees. Generally, no major differences were seen between participants in relation to individual characteristics. Our data suggest that focusing on familial CRC risk and surveillance options, in combination with sensitive communication may lead to better satisfaction with genetic counseling.     

Client self-image,therapist acting,and the establishment of the therapeutic alliance in a training context

This study examined how clients’ self-image and perception of therapist’s behavior are related to the therapeutic alliance, as well as how these variables change in the psychotherapy process in trainee-led psychotherapy. A total of 164 participants (M = 28.9 years) who attended two semesters of treatment at the Psychology Clinic of Umeå University completed the Working Alliance Inventory (WAI) to evaluate their perception of their alliance with the therapist. They also completed two questionnaires based on the Structural Analysis of Social Behavior (SASB) model to give insight into their self-image patterns and to analyze their perceptions of the therapist’s behavior. The results show that a positive self-image and positive perceptions of the therapist’s actions increased significantly over the course of the therapy, with a corresponding decrease in negative patterns. The alliance scores show that the therapeutic alliance gains significance over time and that it is influenced more by the perception of the therapist’s behavior than by the self-image. The self-image becomes relevant after the mid part of therapy, underlining the role of the therapist in co-creating the treatment relationship. The implications of these results are discussed, and so are directions for future research in other trainee-led settings and samples.     

Evidence-Based Therapist Responsivity to Disruptive Clinical Process

Although a historically prominent model of evidence-based practice (EBP) privileges the faithful delivery of single empirically supported treatment (EST) packages, psychotherapy research demonstrates that therapist adherence to an EST is often unrelated to patient outcome. Additionally, perseverative adherence when facing disruptive clinical process can relate to worse outcomes. In contrast, unmanipulated within-case variability in adherence, or the natural incorporation of theoretically “off-brand” interventions into an EST, can associate with more improvement. Further supporting the value of therapist flexibility, treatments that intentionally integrate theory-informed departures (away from the foundational EST) vis-à-vis specific disruptive clinical processes can outperform the standard EST without such departures. Thus, responsively adjusting treatments, such as cognitive-behavioral therapy (CBT), to patients’ contextualized pathology, characteristics, and momentary interactions with the provider may represent a more empirically well-supported form of EBP. Consistent with these ideas, we present an overview of context-responsive psychotherapy integration (CRPI), an approach to EBP in an if-then key. CRPI frames common factors as typical and potentially disruptive clinical “if” situations that therapists will encounter and to which they “then” need to be responsive beyond strict adherence to any EST. Notably, such departures can be temporary, thereby supporting vs. replacing the primary EST interventions. To illustrate CRPI’s application to practice, we focus on one example of patient resistance to CBT as a contextual process marker and motivational interviewing as a theory- and evidence-informed departure response. We also discuss clinical, cultural, empirical, and training considerations from the CRPI perspective.     

The Effect of Demographic Variables on Client Attachment Patterns to Clinical Social Workers

Abstract

Client attachment to therapist is a new topic in the field of clinical social work. Using attachment theory, this study examined the relationship between three types of client attachment to therapist (secure, avoidant-fearful, and preoccupied) and the following variables: marital status, age of participant, and gender of the social worker, among a sample of 174 mental health clients. The results showed that there is a significant relationship between a secure pattern and gender of the social worker. In addition, they showed a significant relationship between avoidant-fearful and preoccupied patterns and the marital status of the participants. Furthermore, the results indicated a significant relationship between a preoccupied pattern and the age of the participants. The findings of the current study have implications for the field of clinical social work in Kuwait.