Psychotherapy and Counseling Essentials

Sommers-Flanagan, J. & Sommers-Flanagan, R. (2015)

Chapter 1

History

Sigmund Freud has been called the father of modern psychotherapy.

[Q]: Can we give credit to one person for this title?

Early treatments for distress and psychological disturbance in humans can be grouped into four categories:

Biomedical approaches

Religious/spiritual approaches

Psychosocial approaches

Feminist/multicultural approaches

Biomedical Perspectives

Believes in helping people deal with psychological concerns through medical or biological methods

Examples:

Lobotomies

Electroconvulsive therapy (ECT)

Psychotropic medication

Vague nerve stimulation

Religious/Spiritual Perspectives

Believes in treating psychological concerns through religious or spiritual measures

Clergy, shaman, and other spiritual leaders were previously consulted

Examples of contemporary approaches linked to spirituality:

Dialectical behavior therapy (DBT)

Acceptance and commitment therapy (ACT)

Other Perspectives

Psychosocial Perspectives

Believes in treating psychological concerns through verbal interactions and relationship alterations that are designed to change thinking patterns, mood, and behavior.

Feminist/Multicultural Perspectives

Focuses on the importance of considering culture and gender when designing treatments

Believes in treating psychological concerns through relationship-building and community

Counseling and Psychotherapy

Please review the definitions on pages 7-9

[Q] Are there differences between counseling and psychotherapy?

One definition of both counseling and psychotherapy suggests that each is a process that includes a trained professional:

Abiding by accepted ethical guidelines

With skills and competencies for working with diverse clients who are in distress or have life problems leading them to seek help or personal growth

Who establishes an explicit agreement to work together towards mutually agreed upon/acceptable goals

Using theoretically-based or evidenced-based procedures that have been shown to facilitate human learning, human development, or reducing disturbing symptoms

Research on Counseling and Psychotherapy

Hans Eysenck:

Published article on the effectiveness of psychotherapy based on 50+ years of data

Found that 2/3 of patients will recover or improve to a marked degree without therapy

Found an inverse correlation between recovery and psychotherapy! (This means psychotherapy was found to be more DAMAGING than having no treatment at all!)

Critics discovered his research was greatly flawed.

Mary Smith & Gene Glass

Developed meta-analysis (a new statistical method for combining information across different studies)

Evaluated 375 outcome studies

Concluded that clients treated with psychotherapy improved more than 75% of clients who received no treatment

Later expanded to consider 475 studies finding that a patient treated with therapy was 80% “better off” than the untreated patient

Although they clearly showed that psychotherapy works, they didn’t have clear evidence to suggest if one theoretical orientation/technique was better than another (Dodo bird effect)

Therapeutic Factors (Lambert)

Lambert identified four types of factors and estimated the degree to which each factor accounted for therapeutic change:

Extratherapeutic factors

Therapeutic relationship

Expectancy

Techniques

Extratherapeutic Factors

Believed to account for about 40% of client success

Includes numerous client factors such as:

Severity of disturbance

Client resilience/ego strength

Client support systems

Motivation to change

Ability to identify goals for counseling

Therapeutic Relationship

Believed to account for about 30% of client success

Believed to be helpful in two ways:

Therapist factors such as unconditional positive regard and empathy promote positive response to therapy (Rogers)

Therapeutic alliance and an attachment between therapist and client, with the dyad working together for improvement, has been noted to promote positive response to therapy (Freud)

Expectancy

Believed to account for about 15% of client success

Can be viewed as hope or optimism that therapy will help.

Can be studied using placebos

Studies suggest that clients who receive placebos show more improvement than those who are untreated as well as those who take antidepressants

[Q] Why do you think this may be?

Techniques

Believed to account for about 15% of client success by Lambert

Others have found technique to account for much less of client success

Techniques include whatever measures the professional uses in working with the client, such as exposure, cognitive restructuring, or hypnosis

Techniques with scientific research supporting its use are called empirically validated treatments (EVTs). EVTs are required to be manualized and shown superior to placebos and at least equivalent to other treatments

ETHICAL ESSENTIALS

Competence and Informed Consent

Research suggests that competence can be developed through 3 strategies:

Working out your own issues

Working within a learning community

Engaging in skills practice and feedback

Informed consent = Clients’ rights to know about and consent to ways you intend to work with them. Also includes their right to know your training status, supervision arrangements (if applicable), techniques expected to be used, and expected length of time that counseling will occur.

Multicultural Competence

D. Sue & D. W. Sue suggested that often, traditional counseling and psychotherapy have reinforced cultural stereotypes and forced minority clients to fit into a dominant, White American frame

Multicultural competencies focus on being competent in 3 areas:

Self-awareness

Multicultural knowledge

Culturally specific techniques

Other Ethical Essentials

Confidentiality

Suggests privacy

Limits to confidentiality should be explained to clients before/during the first session

Multiple roles

Professionals should make all possible attempts to avoid due partially to power differential

Do no harm (the primary ethical mandate for all health professionals)

Doing No Harm

Research shows that psychotherapy results in negative outcomes for 3-10% of cases

Negative outcomes (causing client deterioration) is generally linked to 1 of 3 sources:

Therapist factors

Client factors

Specific psychological interventions

Therapist Factors

Most therapists are unaware of both their negative behaviors and negative treatment outcomes.

Research suggests 4 therapist factors may be linked to negative outcomes:

Therapists who show little empathy or warmth in their interactions with clients

Therapists who employ overly confrontational or intrusive therapy approaches

Therapists using inadequate or inaccurate assessment procedures (including culturally biased assessments)

Therapists whose personality or approach is a poor fit for a given client

Client Factors

Research suggests 3 client factors as potentially contributing to negative treatment outcomes:

Low client motivation

High client psychopathology (e.g., paranoia, antisocial behavior)

Limited client personal resources (e.g., limited IQ, insight, family/social support)

The best solution is for therapists to modify their approaches based on client!

Goodness-of-fit (between therapist/client & between client/technique) is important!

Examples of potentially harmful therapies

Rebirthing techniques (and other attachment therapies)

Recovered memory techniques

Boot camp interventions for conduct disorder

Grief counseling for people with normal bereavement reactions

Scared Straight interventions

How to Maximize Positive Outcomes

Try to use empirically supported treatments or evidence-based principles in your therapy practice.

Focus on building a positive relationship with your client.

Maintain high ethical standards

Maintain cultural sensitivity and multicultural competence

Remember to take care of yourself!

Maintain some flexibility in your approach and possibly tailor therapy techniques to your client and the situation