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Robert Elliott University of Strathclyde

Person-Centered Science: What We Know and How We Can Learn More about Humanistic/Person-Centered/Experiential Psychotherapies. Robert Elliott University of Strathclyde. Outline. Historical Introduction

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Robert Elliott University of Strathclyde

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  1. Person-Centered Science: What We Know and How We Can Learn More about Humanistic/Person-Centered/Experiential Psychotherapies Robert Elliott University of Strathclyde

  2. Outline • Historical Introduction • Question 1: What have we learned from existing quantitative research on Humanistic/Person-Centred/Experiential therapies? • Question 2: What have we learned from existing qualitative research on Humanistic/Person-Centred/Experiential therapies? • Question 3: How can we learn more?

  3. Context: Carl Rogers as Psychotherapy Research Pioneer • Innovations: • Use of voice recording technology • Psychotherapy process research • Controlled outcome research • Modern process-outcome research

  4. Humanistic Therapy in Eclipse • Rogers gave up scientific research when he moved to La Jolla • Lack of research 1965 - 1990 hurt scientific & academic standing of humanistic therapy • Led to humanistic therapies being marginalized

  5. Humanistic Therapy Revival • Since 1990: • Rise of qualitative research • Re-engagement in quantitative research • Newer therapies (e.g., Focusing-oriented, Process-Experiential/Emotion-Focused Therapy, Pre-therapy) • Available outcome research has tripled

  6. Current situation • Danger of split between: • Practitioners and training schools: reject quantitative research in favor of qualitative research • Small cadre of academic researchers: doing quantitative outcome research in order to gain official recognition

  7. Question 1a: What Does Positivist Outcome Research Tell Us? • Humanistic/Person-Centred/Experiential (HPCE) meta-analysis project • Meta-analysis: analysis of results • Effect size = standardized difference statistic • Creates a common for comparing results

  8. The HPCE Meta-Analysis Project • 1st Generation: Greenberg, Elliott & Lietaer, 1994 (n= 36 studies) …. • 5th Generation: Elliott & Freire (2008): • Supported by a grant from the British Association for the Person-Centred Approach • 180+ studies • 200+ samples of clients • >13,000 clients • 60 controlled studies (vs. no therapy or waitlist) • 110 comparative studies (vs. HPCE therapies)

  9. Elliott & Freire (2008) Meta-analysis Preliminary Results • 1. HPCE therapies associated with large pre-post client change • Effect size: 1.03 sd [standard deviation units] • = a very large effect • 2. Clients’ large posttherapy gains are maintained over early & late follow-ups • Post: .95sd => early follow-up: 1.08sd => late follow-up (12+ months): 1.14

  10. Elliott & Freire (2008) Meta-analysis Preliminary Results • 3. Clients in HPCE therapies show large gains relative to untreated clients • Effect size: .81 sd = a large effect size • Proves therapy causes client change.

  11. Elliott & Freire (2008) Meta-analysis Preliminary Results • 4. HPCE therapies in general are clinically and statistically equivalent when compared to other treatments(combining CBT and other therapies) • Effect size: .01 sd • = no difference in amount of change • Held true even when we only considered randomized (“gold standard”) studies

  12. Elliott & Freire (2008) Meta-analysis Results • 5. Comparison to Cognitive-Behavior Therapy (CBT): • HPCE therapies as a group slightly but trivially less effective than CBT: • Effect size: -.18 sd • =trivially worse (a small effect) • But…

  13. Elliott & Freire (2008) Meta-analysis Results • 6. Researcher theoretical allegiance effects strongly predict comparative ES: • Correlation between comparative ES and theoretical allegiance of researcher: -.52 • CBT-oriented researchers => worse effects for HPCE • Small negative effect for HPCE therapies vs. CBT disappears after statistically controlling for researcher allegiance

  14. Where does researcher allegiance effect come from? • Big differences in how different HPCE therapies do in comparison to CBT

  15. What is “Nondirective/ Supportive” Therapy? • Nondirective/supportive: • 87% studies carried out by CBT Researchers (40/46 in total sample) • 65% explicitly labelled as “controls” (30/46) • 52% involve non bona fide therapies (24/46) • 76% of researchers are North American (35/46) • 61% involve depressed or anxious clients (28/46)

  16. The Moral of this Story: • We don’t have to be afraid of quantitative research or RCTs • But if we let others define our reality, we are going to be in trouble. • Therefore, we need to do our own outcome research… including RCTs

  17. Question 1b: What does Quantitative Process-Outcome Research Tell Us? • Process-outcome research predicts outcome from in-therapy process measures, e.g., therapist empathy • Best-known process variable is Therapeutic Alliance • Most common measure: Working Alliance Inventory • Meta-analyses show that alliance predicts outcome: e.g., Horvath & Bedi, 2002; n = 90 studies: mean r = .21

  18. Process-Outcome Research on Therapist Empathy • Therapist empathy is one of the strongest predictors of outcome • Bohart et al. (2002) meta-analysis • 47 studies: mean r = .32 • Accounts for about 10% of the variance in outcome

  19. Interpretation of r = .32 • 1. Optimist’s view: 10% is a lot! • One of the best predictors of outcome • Maybe even better that therapeutic alliance

  20. Interpretation of r = .32 • 2. Pessimist’s view: The glass is 90% empty! • Rogers’ “necessary & sufficient” predicts perfect correlation (r = 1.0) • r = .32 decisively refutes Rogers’ hypothesis

  21. Interpretation of r = .32 • 3. Optimist’s rebuttal: 10% is almost 100% of what we can reasonably expect from the real world • Client individual differences in problem severity and resources predict most of outcome • Measurement error • Restriction of range (not enough unempathic therapists!) • Other stuff

  22. Interpretation of r = .32 • 4. Pessimist’s plea: I still want the other 90%…

  23. Question 2: What does Qualitative Research Tell Us? • Rogers’ Process Equation was based on proto-qualitative research: • Years of careful observation of productive and unproductive therapy sessions • Systematic qualitative research is a relatively recent development • But mature enough now to allow a few small qualitative meta-analyses

  24. 1. Helpful and Hindering Factors • Greenberg et al. (1994) • Reviewed 14 studies of HPCE therapies • Selected 5 most frequent helpful and 3 most frequent hindering aspects • 14 categories of Helpful aspects, grouped into 4 larger domains

  25. Most Common Helpful Aspects in HPCE therapies • 1. Positive Relational Environment (7 out of 14 data sets; e.g., empathy) => • 2. Client's Therapeutic Work (13 sets) • Most common : Self-Disclosure, Involvement => • 3. Therapist Facilitation of Client's Work (6 sets; e.g., fostering exploration) => • 4. Client Changes or Impacts (12 sets) • Most common: Understanding/ Insight, Awareness/Experiencing

  26. Most Common Hindering Aspects • Much less common; difficult to study • Most common:Intrusiveness/ Pressure • Even in person-centered therapy • Also present: • Confusion/Distraction (derailing the client's process) • Insufficient Therapist Direction

  27. 2. Client Post-therapy Changes • Qualitative outcome • Jersak, Magana and Elliott (2000; in Elliott, 2002) • 5 studies, mostly Process-Experiential for depression or trauma

  28. Jersak et al. (2000) • Vitalizing the Self: Internal change • 4 subprocesses: • Leaving Distress Behind => • Increased Contact with Emotional Self => • Improved Self-esteem => • Increased Sense of Personal Power/Coping/Self-control • Describe the first phase of a metaphorical journey

  29. Jersak et al. (2000) • Changes in the Self’s Relationships to Others/World: • 3 subprocesses: • Defining Self with Others/Asserting Independence • Engaging with Others, • Experiencing the World More/Mobilizing Self to Act in the World • Describe the outward phase of the client’s journey

  30. 3. Effects of significant therapy events • Timulak (2007) • 7 studies, most HPCE • 9 common categories • All 7 studies: • Awareness/Insight/Self-Awareness • Reassurance/Support/Safety • More than half the studies: • Behavior Change/Problem Solution • Exploring Feelings/Emotional Experiencing • Feeling Understood.

  31. Implication: Qualitative Studies of HPCE • May be possible to integrate these 3 types of research into a model of HPCE change process • Framework: • Helpful (hindering) aspects => • Immediate effects (significant events) => • Qualitative outcome

  32. Question 3: How Can We Learn More?

  33. 1. Be Methodologically Pluralist • Most sensible course of action: • To encourage both kinds of research • Render politically expedient quantitative data to the government and professional bodies (“Caesar”) • Simulaneously carry out qualitative research that completely honors person-centered principles • Even in the same study

  34. 2. Follow Person-Centred Research Principles • E.g., Mearns & McLeod (1984) • (1) Empathy. Understand, from the inside, the research participant’s (client or therapist) lived experiencing • (2) Unconditional Positive Regard. Accept/prize the research participant’s experiencing, • (3) Genuineness. Be an authentic/equal partner with the research participant: participant = co-researcher; researcher = a fellow human being. • (4) Flexibility. Creatively and flexibly adapt research methods to the research topic and questions at hand

  35. Applying Person-centred principles to different types of research • Fairly easy to see application to qualitative research, e.g., • Clarifying expectations and other researcher pre-understandings; • Negotiating nature of participation with informant in a transparent, collaborative manner; • Carrying out data collection in a careful, intentional manner, including helping informant stay focused and clarifying their meanings; etc.

  36. Person-Centred Principles Apply Equally to Quantitative Research • Always put the participant’s needs ahead of yours • Treating participants disrespectfully and inconsistently leads to resentment and sloppy, invalid data • A questionnaire is a form of relationship

  37. Person-Centred Principles Apply Equally to Quantitative Research • A research participant will feel misunderstood and uncared for by a confusing questionnaire layout or an overly hot or noisy research room • An ill-prepared research packet or an anxious interviewer can betray a lack of genuine commitment by the researcher • All of our criticisms of quantitative research are really criticisms of bad research, of any kind

  38. 3. Focus on Change Process Research • Much current research on HPCE therapies does not focus on how change occurs • Needed as complement to outcome research & improve therapy • Select from different genres of change process research

  39. a. Important preliminary: Basic outcome research • What are the effects of HPCE therapies with specific client populations? • Can be quantitative or qualitative • Single client or group of clients • Standard questions or individualized • See Elliott & Zucconi (2006) for suggestions to implement in practice and training settings • Necessary starting point for Change Process research

  40. b. Process-Outcome Research • Quantitative genre: Measure process (e.g., empathy) => predict outcome • HPCE’s not studied enough with this approach: • Only 6 out of 47 studies in Bohart et al. (2002) empathy-outcome meta-analysis were HPCE therapies • Highly appropriate to naturalistic samples

  41. c. Helpful Factors Research • Qualitative genre: • Interview (e.g., Change Interview) • Helpful Aspects of Therapy (HAT) Form • Analyze with variety of methods, e.g., Grounded Theory, discourse analysis

  42. d. Micro-analytic Sequential Process Research • Examine turn-by-turn interaction between client and therapist • Quantitative: client and therapist process measures (e.g., client experiencing and therapist empathy) • Qualitative: Task analysis or Conversation analysis

  43. e. Complex Change Process Research Methods • Combine genres to develop richer picture • Balance strengths, limitations • Examples: • Assimilation Model (Stiles et al., 1990) • Task Analysis (Rice & Greenberg, 1984) • Comprehensive Process Analysis (Elliott, 1989) • Hermeneutic Single Case Efficacy Design (Elliott, 2002)

  44. 4. Get Involved! • Elliott & Zucconi (2006): International Project on Psychotherapy and Psychotherapy Training (IPEPPT) • The project is to stimulate practice-based research, especial in training centres • Have developed a set of sample research protocols to choose form

  45. Further Suggestions (Elliott & Zucconi, 2006) • (1) Contribute to dialogues on how to measure therapy and training outcomes within HPCE therapies • (2) Set an example for students and colleagues by carrying out simple research procedures with your own clients and in your own training setting • (3) Help to develop specialized research protocols for particular client populations (e.g., people living with schizophrenia)

  46. Further Suggestions (Elliott & Zucconi, 2006) • (4) Contribute to method research aimed at improving existing quantitative and qualitative instruments • (5) Take part in more formal collaborations with similarly-inclined training centers to generate data for shared research

  47. Robert Elliott:fac0029@gmail.com • Blog: pe-eft.blogspot.com

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