History

1
History WHAT WORKS?

• (Effective Ingredients of Counseling)

2
HISTORY OF COUNSELING

• Ancient Greece, Persia, China, Africa
  (philosopher, poet, priest, physicians,
  shaman/healers)
• 100 years ago - the talking cure did not exist
• Freud develops theories - 1909
• Psychologys influence on counseling
• Vocational guidance (Parsons 1909)
• APGA (1913) formed from 3 smaller groups
  National Vocational Guidance Association

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HISTORY (continued)

• Post-World War II - Rogers (and others) influence
  development of counseling
• ACA (after a series of name changes)
• One time - 80 school counselors
• Today - majority non-school counselors
• Licensing movement begins - 1973 (Virginia)
• Today - all states except California Nevada
  have some form of counselor licensing

4
What is psychotherapy?

• Psychotherapy isthe informed planful
  application of techniques derived from
  established psychological principles, by persons
  qualified through training experience to
  apply these techniques with the intention of
  individuals to modify such personal
  characteristics as feelings, values, attitudes
  and behaviors which are judged by the therapist
  to be maladaptive or maladjustive. Meltzoff
  Kornreich, 1970, p.4

5
WHAT IS COUNSELING?

• The application of mental health, psychological,
  or human development principles through
  cognitive, affective, behavioral, or systematic
  intervention strategies that address wellness,
  personal growth, or career development, as well
  as pathology. (ACA, 1987)

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Who are our clients?(de Shazer, S., Miller, S.,)

• Caseloads Counselor Client Success
• 15 Customers seller 90 (repeat/refer,
  (give homework) move-on)
• 65 Browsers showperson 50 customers
• Complainants (detail symptoms, externalize,
  bond)
• 20 Visitors listener/educator 1 continue
• average client attends 3 sessions

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Group exercise

• In a first or second session, how can you
  determine whether you can predict that a client
  has potential for positive outcomes?
• Some clients come to counseling involuntarily
  (court order, coerced, etc.).
• What can you do to increase the odds of
  therapeutic success?
• Think about yourself - coming at someone elses
  instance. What would improve your chances for
  success?

8
Previous outcome research

• Negative outcome material in literature ignored
• Helper incompetence (good therapistgood results,
  bad therapistbad results)
• Caseload size effects outcomes
• Therapist more important than approach
• Most studies done in lab-like settings, not real
  world
• (Mohr, 1885, Strupp, Hadley, Gomez, Schwartz,
  1977)

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Types of outcome research

• Meta analysis (weakest, but has value)
• Synthesizes research studies into conclusion(s)
• Does not compare apples to apples
• Efficacy studies (internal validity)
• Controlled studies (delayed TX group)
• Pre/post testing
• Effective studies (external validity-generalizable
  )
• Client response/experience

10
More research

• Paraprofessionals got better results than
  professionals (Durlac, Hadley, Rogers, 1988)
• Patient involvement homework (McFall, 2000)
• greater, faster improvement more sessions
• Choosing goal
• Client choice - 75 remain in TX
• Therapist choice - 20 remain (Rokke, 1999)
• DSM IV- low correlation with outcomes, little
  help in treatment selection, little reliability
  or consistency in diagnosis
• therapists do not like it or find it useful

11
ESTs or ESRs? (Gurman Messer, p.12)

• ESTs (Empirically Supported Treatments, a.k.a
  EVTs)
• Nathan Gorman (1998) Identifying treatments,
  role power of therapeutic techniques
• ESRs (Empirically Supported Relationships)
• Norcross (2002) The therapist as a person exerts
  large effects on the outcome
• Wampold (2001) Relationship established may be
  more powerful than particular intervention.
• Even symptom focused approaches are still in
  context of human relationship.

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Significant studies

• Talk therapy outperforms all others including
  medication
• Antidepressants no better than placebos (Kirsch
  Sapperstein (1998) Meta analysis)
• Meta analysis (1987-1999) shows more than half of
  47 studies showed antidepressants no more
  effective than placebos (Kirsch, I. Moore,T.,
  2005)
• Very few studies on effectiveness of
  antidepressants on kids
• NIAA Project Match (1997) studied 12 Step,
  Motivational interviewing, Cognitive-Behavioral
  therapy
• found minimal or no TX12 Step TX.
• Alcoholism - 17 sobriety after 5 years

14
Client Dropouts (Torrey, 1986)

• Greater than 50 clients dropout prematurely
• Interpretive therapies (psychodynamic) 5 times
  greater than more supportive therapies
• Nine qualities recurring prior to dropping out
• Thoughts were clearly articulated by client
• Frustration with therapy expressed (unmet
  expectations)
• Problems were addressed by focusing on client
  (transference)
• Client resisted this focus (verbalized or shut
  down)
• Counselor persisted with transference issue

15
Dropouts (continued)

• Client/therapist in a power struggle (sharp,
  blunt, sarcastic, impatient responses by both)
• Although most interpretations were plausable,
  client DID NOT want to address them
• Therapist ended session encouraging continuing TX
  client reluctantly agreed
• Client NEVER returned

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BRADS SITUATION

• What are Brads
• World view?
• Feelings?
• Culture?
• What was his presenting complaint/ problem?
• Whiner?
• Feel sorry?
• Cant relate to his problem?
• What clues exist about building a relationship

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CONCERNING BRAD

• ASSIGNING NUMBERS FOR EACH TO TOTAL 100
• What is the source of his discomfort?
• Intrapersonal (self)?
• Interpersonal (Relationship with others)?
• Societal (environmental factors)
• Where will you be most successful?
• Thinking (cognition)?
• Emotion (affect/feelings)?
• Behavior (what he does)?
• What are the 10 most important questions you
  would like to ask

18
THE THERAPEUTIC ALLIANCE

• Alliance working as a team
• Client feels valued liked
• Client perceives a warm accepting relationship
• Healing setting need to appear competent
• Coherent rationale/procedure agreement on goals
• Agree what went wrong the vision of the
  improved life
• Myth/ritual (Frank Frank, 1991 )

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COMMON FACTORS

• 79 of people in therapy get better (Wampold, B.
  E. 2001, p.14) maintain this over time
  (Nicholas Berman, 1983)
• Common factors exist in ALL therapies
• Emotionally charged/confiding relationship
• Healing setting (w/belief in the help trust)
• Rationale/conceptual scheme (both believe works)

• Specific factors part of a theoretical approach

20
What makes people better?(Lambert, M. J.
Bergin, A. E., 1994, Lambert, M. J. Barley, D.)

• 40 Extra-therapeutic change (events, support)
• 30 Common factors (client-therapist
  relationship/congruence, found in most therapies)
• Highest correlation is where client rates
  counselor highly
• Difficult to separate therapist variables,
  facilitative conditions, therapeutic alliance
• 15 Expectancy (placebo effects/ hope
  expectations)
• 15 Specific therapeutic technique

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CONTRIBUTIONS

• Clients
• Positive expectations
• Distressed vs. being sent (Norcross, 1990)
• Counselors
• Accurate empathy
• Unconditional positive regard
• Non-possessive warmth
• Genuineness
• more is not necessarily better

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Stages of Change(Prochaska, DiClemente
Norcross, 1992 )

• Pre-contemplation (Most of the 40 of clients who
  drop out leave here. Denial?)
• Contemplation (Thinking about a problem, change
  possible?)
• Preparation (Ready to do something)
• Action (Engages, makes short-term changes)
• Maintenance (Works to prevent relapse)

23
Valid Therapies Must Contain(Torrey, 1986)

• Shared world view (Rumpelstiltskin effect - name
  it)
• Personal qualities (Medicinal mensch)
• Client expectations (Edifice complex)
• Learning mastery (Superman effect)
• Since 1960 - approximately 250 models of
  counseling (currently, 7th psychoanalytic model)

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The Case of Marianna

• How does the counselor combine EST and Common
  Factors?
• How does Marianna want her life to change?
• How do the use of core conditions and the EST of
  systematic desensitization help her move toward
  her goal?

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CHARACTERISTICS OF THE EFFECTIVE COUNSELOR

• Thinking about all that you have heard and the
  article in the workbook, come to consensus on
• adjectives that describe the effective therapist
• what you believe to be the 4 or 5 most important
  traits
• be prepared to defend your decisions.