Sexual Orientation

The clinical need for lesbian, gay, bisexual, and queer (LGBQ+) affirmative psychotherapies has been widely recognized; however, empirical research on the outcomes of such psychotherapies is limited. This chapter begins by offering definitions and delineating four key themes of LGBQ+ affirmative psychotherapies. The authors conceptualize LGBQ+ affirmative psychotherapies not as sexual orientation group specific but rather as considerations and practices that can be applied with all clients. The chapter then summarizes a search for studies to attempt a meta-analysis and discusses limitations and directions for research based on this search. The chapter ends by delineating diversity considerations and recommending therapeutic practices for advancing affirmative psychotherapy with clients of all sexual orientations.

Personalizing Psychotherapy: Results, Conclusions, and Practices

The chapter concludes the third edition of the book by summarizing what works and what does not in psychotherapy responsiveness and treatment adaptations. The authors present the Task Force conclusions and 28 recommendations for training, practice, research, and policy. The authors conclude that adapting psychotherapy in ways reviewed in this book demonstrably improves treatment outcomes and prevents premature deterioration.

Stages of Change

The transtheoretical model and the stages of change are often used to adapt treatment to the individual client. This chapter aims to review the stages of change and popular measures of change readiness in psychotherapy and to conduct a meta-analysis of the relation between readiness measures and psychotherapy outcomes. This chapter reports data from 76 studies, encompassing 25,917 patients. Moderate-sized effects (d =.41) were found for the association between stages and psychotherapy success. Outcomes were a function of pretreatment stage of change; that is, the farther a patient is along the stages, the better the treatment outcomes. The chapter concludes with limitations of the research, diversity considerations, and therapeutic practices for stage matching in psychotherapy specifically and behavioral health more generally.

Religion and Spirituality

Some religious or spiritual (R/S) clients seek psychotherapy that integrates R/S values, while others may be reticent to disclose R/S-related aspects of struggles in a presumably secular setting. The authors meta-analyzed 97 outcome studies (N = 7,181) examining the efficacy of tailoring treatment to patients’ R/S beliefs and values. They compared the effectiveness of R/S-tailored psychotherapy with no-treatment controls, alternate secular treatments, and additive secular treatments. R/S-adapted psychotherapy resulted in greater improvement in clients’ psychological (g = .74) and spiritual (g = .74) functioning compared with no treatment and non-R/S psychotherapies (psychological g = .33; spiritual g = .43). In more rigorous additive studies, R/S-accommodated psychotherapies were equally effective to standard approaches in reducing psychological distress (g = .13) but resulted in greater spiritual well-being (g = .34). The chapter features several clinical examples and concludes with evidence-based therapeutic practices.

Preferences

Client preferences in psychotherapy reflect specific conditions and activities that clients desire in their treatment, with increasing evidence pointing to preference accommodation as facilitating psychotherapy outcomes. This updated meta-analysis establishes the magnitude of the effect of client preference accommodation in psychotherapy. Based on data from 53 studies and over 16,000 clients, preference accommodation was associated with fewer treatment dropouts (odds ratio = 1.79) and more positive treatment outcomes (d = .28). The chapter provides case examples of preference accommodation, limitations of the research, diversity considerations, and practice recommendations for working with client preferences.

Reactance Level

Resistance and its extreme variation, reactance, are uniformly observed across varieties of psychotherapy. This chapter provides definitions of reactance, reviews its frequent measures, and offers 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. 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.

Coping Style

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, commonly distinguished between those who deal with change by looking inwardly (internalization) and those who deal with it outwardly (externalization). This chapter provides definitions of coping styles, clinical examples, and frequent measures. It updates a 2011 meta-analytic review that revealed a consistent interaction between coping styles and treatment focus—symptom focus versus insight focus. The current meta-analysis of 18 studies revealed a medium to large effect (d = .60) and suggested that a symptom focus proves more effective for internalizing patient whereas an insight focus is generally more effective for internalizers. The chapter concludes with limitations of the research, diversity considerations, and therapeutic practices based on the meta-analytic results.

Attachment Style

Attachment style describes characteristic patterns of relating to close others and has important implications for psychotherapy. This chapter provides an original meta-analysis of 36 studies (3,158 patients) to determine the association of patient attachment with psychotherapy outcome. Patients with secure attachment pretreatment show better psychotherapy outcome than insecurely attached patients. Further, improvements in attachment security during therapy coincides with better treatment outcome. Moderator analyses suggest that those who experience low attachment security may find better treatment outcome in therapy that focuses on interpersonal interactions. The chapter closes with research limitations, training implications, diversity considerations, and therapeutic practices.

Evidence-Based Psychotherapy Responsiveness: The Third Task Force

This chapter introduces the second volume of Psychotherapy Relationships That Work and frames its work within the Interdivisional APA Task Force on Evidence-Based Relationships and Responsiveness. The book presents clinical examples, original meta-analyses, diversity considerations, training implications, and research-infused practice recommendations for nine methods of adapting or tailoring psychotherapy to clients’ transdiagnostic characteristics (attachment style, coping style, racial/ethnic culture, gender identity, therapy preferences, reactance level, religion/spiritual identity, sexual orientation, and stages of change). The chapter outlines the purpose and history of the interdivisional task force and its relation to previous efforts to identify evidence-based practices in psychotherapy. The chapter also presents the key limitations of the work.

Gender Identity

This chapter reviews the research evidence on the effectiveness of attending to clients’ gender identity in psychotherapy. It begins with definitions and measures of gender identity and provides clinical examples. A literature search did not yield studies that fit the authors’ search criteria; thus meta-analyses were not conducted. Instead, the authors conducted a content analysis of the 10 qualitative and quantitative studies on psychotherapy with transgender individuals. The chapter concludes by highlighting the limitations of the research base, describing diversity considerations, and recommending therapeutic practices that attend to gender, gendered systems of power, oppression, and privilege.