Counseling 407Community Counseling • Dr. Jeffrey K. Edwards, LMFT • Room 4054 • 1-773-442-5541 • Jfirstname.lastname@example.org or email@example.com • Office hours are Wednesdays 4-7 and Thursdays 1-4.
Counseling 407Community Counseling • Day one – Introduction • Counseling research – Review or new? • Community Counseling - Definitions • Prevention - Models
Counseling Knowledge Well-known facts that most therapists either overlook, forget, or were never told. Or, why counseling/psychotherapy myths about who is better prevail. Arm yourself with this information and you will be an unstoppable Community/Family Counselor.
Counseling Knowledgethis will wake you up. Counseling and or Psychotherapy are comparatively the same thing. They are simply different names for doing the same activities. However, there are many professionals who have been trained to believe that doing psychotherapy is more scientific and rigorous, and should only be provided by certain professions. (For a comprehensive review see Neukrug, 2003)
Counseling Knowledgethis will wake you up. Counseling/Psychotherapy works. More than 40 years of outcome studies have demonstrated effectiveness (Hubble, Duncan and Miller, 1999). However, nearly 50% of clients drop out of treatment. There are few predictors of premature dropout, except substance abuse, minority status, and lower education (Prochaska, 1999).
Counseling Knowledge Smith et al. (1980) found that at the end of treatment, clients were better off than 80% of a control group that did not have treatment. Two studies showed that about 75% of clients significantly improve after 26 sessions (six months) and that 50% show significant improvement after only 8 to 10 sessions.
Counseling Knowledge In fact, the average length of stay in treatment is around 8 to 10 sessions, with a modal number of 1. In a famous research project at Keiser Permenante 80% of those clients who dropped out after one session, however, reported that they had received the help they needed after that one session.
Counseling Knowledge Certain types of client problems are more likely to relapse, notably those with substance abuse problems, eating disorders, recurrent depression, and personality disorders (Asay and Lambert, 1999). It seems, however that change is more likely to last, if the client attributes their changes to their own efforts ( Lambert & Bergin, 1994).
When therapy succeeds, the convention is to attribute the positive outcome to the therapy or ministrations of the therapist. In contrast, when therapy goes awry, or at least yields disappointing results, it has been customary to place the failure in the client or the client’s personality (Hubble, Duncan, & Miller, 1999).
Counseling Knowledge • Counseling/Psychotherapy models all have the same effectiveness, more or less (see comprehensive reviews in Hubble, Duncan and Miller, 1999; Seligman, 1995). • This has been called the Dodo effect, by Luborsky et al. (1975) - from Alice and Wonderland, “Everyone has won and all must have prizes.”
Counseling Knowledge Effective therapy can be achieved in short periods of time (5 to 10 sessions) with at least 50% of clients seen in routine clinical practice. A sizable minority (20% to 30%) requires treatment lasting more than 25 sessions. Those clients who are more likely to fail at brief therapy efforts are those who are poorly motivated, hostile, have poor relationships with others in their life.
Counseling Knowledge Techniques that are critical, attacking, rejecting, blaming etc. Are less effective treatments (Najavits & Strupp, 1994) Therapies that focus on the future, instill hope early on, and enhance the clients hope and placebo effect are more effective (Asay & Lambert, 1999)
OK now, what does all this mean to you? • How does this change the way you will practice? • What ideas do you have for changing the way you thought you might work? • What excites you about these concepts?
Counseling Knowledge If techniques are not that important, then what are the factors that contribute to positive outcome? There are four: • Client Variables (40%); • The Therapeutic relationship (30%); • Expectancy and Placebo Effect (15%); • Technique (15%).
Client Variables (40%) • Severity of Symptoms (both psychological and physical); • Motivation; • Psychological mindedness; • Ability to identify a focal problem (Lambert and Anderson, 1996).
Client Variables (40%) • Such things as insight, and acquisition and practice of new behaviors are also components of the therapy that can and should be attributed to the client, perhaps upping the 40% as high as 70% of the variable.
Client Variables (40%) “a withdrawn, alcoholic client, who is ‘dragged into therapy’ by his or her spouse, possesses poor motivation for therapy, regards ,mental health professionals with suspicion, harbors hostility toward others, is not nearly as likely to find relief as the client who is eager to discover how he or she has contributed to a failing marriage and expresses determination to make personal changes” (Asay and Lambert, 1999).
The Therapeutic Relationship (30%)Spontaneous Improvement “a significant number of people are helped by friends, family, teachers, and clergy who use a variety of supportive and HOPE instilling techniques. Howard et. al (1986) estimated that about 15% of clients experience some improvement before the beginning of treatment” (Asay & Lambert, 1999).
The Therapeutic Relationship (30%)Spontaneous Improvementis influenced by • Length of time the problem has been evident; • Underlying personality disorder; • Quality of social support, especially the marital relationship (Andrews & Tennant, 1978; Mann, Jenkins, & Belsey, 1981).
The Therapeutic Relationship (30%) The Necessary and sufficient conditions • Accurate Empathy • Positive Regard • Non possessive warmth • Congruence and genuineness. These are client-perceived rather than objective raters’ perceived.
The Therapeutic Relationship (30%) There is significant research to show that years of experience are not necessarily correlated with effectiveness (Christiansen & Jacobson, 1994), while some studies have shown that self-help literature are in some cases of equal benefit as therapy (Gould & Clum, 1993).
The Therapeutic Relationship (30%) It seems that the following components are important to the therapeutic alliance: • Client’s affective relationship with the therapist; • Client’s capacity to work purposefully in therapy; • Therapist’s empathic understanding and involvement; • Client-therapist agreement on goals and tasks of therapy (Gaston, 1990).
The Therapeutic Relationship (30%) In the NIMH Study of Depression Collaborative Research Program (1996), a comparison between psychotherapy and active and placebo pharmacology found that the therapeutic alliance had a significant effect on outcome. So what do you think about that?
The Therapeutic Relationship (30%) During a demonstration of “bad” therapy techniques I did at Wheaton College, I demonstrated bad posture, bad eye contact, etc. When done, I asked the class to evaluate, and they were correct in their perceptions of my techniques, however, the “client” saw things differently. She said it was the most profound experience of her life!!
Expectancy and Placebo Effect (15%) Frank (1973) has suggested that people only seek help when they have become demoralized because of their own inability to solve their problems. They feel powerless over their own life situations. Consistent research has demonstrated that a large portion of improvement occurs during the first 3 to 4 weeks of therapy, with 40 to 60% change occurring before the client has their first interview (Weiner-Davis, deShazer & Gingrich, 1987).
Expectancy and Placebo Effect (15%) In summarizing several studies, Lambert, Weber, & Sykes, (1993) have shown that the average client in therapy undergoing a placebo treatment will have a better outcome than 60% of a no-treatment group.
Expectancy and Placebo Effect (15%) In several studies with medications, the placebo effect has been demonstrated to be even greater than the 15% usually assumed (Benson & McCallie, 1979).
Expectancy and Placebo Effect (15%) In a now classic study (Feldman, 1956) the effectiveness of chlorpromazine was prescribed by two groups of psychiatrists with the following results - Those who were enthusiastic had a 77% success rate, while those who did not (psychodynamic) only achieved a 10% success rate.
Expectancy and Placebo Effect (15%) • The finding that drug efficacy relates to prescribing physician attitudes has been replicated repeatedly (Scovern, 1999).
Technique (15%) Basing the following on the consistent research findings that different types or models of therapy have relatively the same outcome, a number of points are made. First, that training in specific models and techniques is pointless (Strop & Anderson (1997), and that staying true to a protocol manual does not prevent a wide variety of outcomes from the different therapists using them (Luborsky et al. (1985).
Technique (15%) Of more concern, and reported more in the research is the finding that staying true to a manual may cause other factors such as flexibility, warmth, and the therapeutic alliance (see Ogles, Anderson, & Lunnen, 1999). These problems along with a multiplicity of others, causes a great deal of concern when one regards the current trends by the American Psychiatric Association, Managed Care Organizations, and the American Psychological Association to use Empirically supported treatment for specific problems.
Stages of ChangeJames Prochaska • Precontemplation – • Contemplation – • Preparation • Action • Maintenance – • Termination -
Precontemplation – • are not intending to change, or take action, usually in terms of “the next 6 months.” • Are not fully informed, or aware of consequences. • May have tried to change in the past without success. • No inherent motivation to change
Contemplation – • People intend to change within the next 6 months. • Are aware of pros and cons of change vs. no change. • Profound ambivalence.
Preparation • Plan to take action within the next month. • Have taken some action in the past year. • Have a plan for action. • These are the best people to recruit for action oriented treatment.
Action • Have made specific, overt modifications in their lifestyles within the past 6 months. • Behavior change has been equated with the action stage. • Outcomes depend on neither the duration of therapy nor the education or experience of the therapist.
Maintenance – • Working to prevent relapse, lasts from 6 months to 5 years. • Failure usually is associated with being under prepared for the length of time maintenance takes. • The average American drinks, eats, smokes, and takes drugs to manage distress (Mellinger, Balter, Manheimer, Cisin, and Perry, 1978). • People struggling to overcome chronic conditions will be at the greatest risk of relapse.
Counseling Knowledge Medications Beecher (1955) reviewed 15 single or double bind studies that looked at the effects of placebos on a variety of conditions. He concluded that on average and across studies, placebos produced ‘satisfactory relief’ in 35% of those treated (Scovern, 2001)
Counseling Knowledge Since the mid 1980’s there has been an 275% increase of persons who have trained and provide counseling/psychotherapy. There still has not been a reduction in any of the psychological or psychiatric “illnesses.”
A Model of Community Counseling • This is the story of the Jeffrey’s River – • Once upon a time, there was a river named Jeffrey. I wonder why?
A Model of Community Counseling • One day …someone came floating ..
A Model of Community Counseling • down the river, almost drown.
A Model of Community Counseling • A good Samaritan saw the drowning person Help!
A Model of Community Counseling • helped him out and saved his life. Thanks
A Model of Community Counseling • Soon, another person came floating down the river, almost drown. Help!
A Model of Community Counseling • and he too, was helped out and had his life saved. Thanks
A Model of Community Counseling • soon there were lots and lots of people coming down the river drowning. Help! Help!Help! Please!! Help!