Dee McKiernan Counselling Psychologist

Cert, B.A., MSc

Overview
Introductions Module Descriptor Discussion

What is Counselling Psychology? About Counselling Psychology What do Counselling Psychologists do? Who do they work with?

TYPES OF PSYCHOTHERAPY

Types of psychotherapy:

Psychodynamic psychotherapy: - tries to understand how interpersonal patterns developed in childhood contribute to psychological problems Cognitive-behavioral psychotherapy: - tries to identify and alter problematic thinking and behavior that contributes to psychological problems Humanistic Psychotherapy: - offers supportive relationship where the client can explore problematic experiences and draws on a potential for change naturally present in the client

Types of psychotherapy:

Integrative psychotherapy: - combines previous types of therapy

Researching outcome of psychotherapy

Does it work?

Outcome Measurement instruments

Perspective

taken:

Clients (they find changes) Significant others and Institutional data (less likely to find changes) Physiological data (small changes), Behavioral data (if relevant can be sensitive to change) Therapists (likely to see changes, but it depend on context), Extern expert raters (if do not know about therapy likely to find changes, if know even more likely Lambert, Hill, 1994

Outcome Measurement instruments

Measured construct: Personality questionnaires Symptom self-reports Individual problems formulated by client Mental health constructs (e.g. selfesteem)

When do we talk about change?

Reliable Change Index: pre-post difference is significantly bigger than error of measurement of the used instrument
Cut-off score client gets to the norm

Clinically significant change: there is a reliable change that goes beyond particular cut-off score (Jacobson, Truax, 1991)

Size of the measured change:

Effect size: difference of the means of compared groups is divided by their average standard deviation
Effect sizes (Cohens d): small effect=0,3; medium effect=0,5; large effect=0,8

Example of Pre - Post difference

Figure 2.1.1. Distributions of BDI scores of our illustrative example with the pretreatment mean score 25 (standard deviation 7) and posttreatment mean score 10 with the same standard deviation. Post-treatment Pre-treatment

BDI

RANDOMIZED CLINICAL TRIALS

Randomized clinical trials (RCT)

Randomization and experimental control

Forms of control group:

placebo (double-bind condition problematic), waiting list alternative treatment other bona fide psychotherapy

Randomized clinical trials (RCT)

Combined and dismantled designs Types of measurement instruments Acceptability of treatment Follow-up (optimally at least 2 years) Cost-effectiveness

Randomized clinical trials (RCT)

Two psychotherapies for depression (cognitive and interpersonal) were compared with antidepressants and drug placebo Roughly 50% patients who started psychotherapy were without depression after 4 months Approx. 25% or slightly more after 2 years

Elkin et al. (1989)

Alternatives to RCT:
Experimental case studies and complex case studies Trials based on clients preferences Naturalistic studies Surveys mapping consumers satisfaction Qualitative outcome studies

What do we know :

Average client treated in psychotherapy is better off than 80% of untreated people (Smith et al., 1980) Psychotherapy can alleviate moderate and mild forms of depression CBT is very powerful in treatment of some anxiety disorders (e.g. panic disorder, Craske & Barlow, 2001)

About 5-10% of clients can get worse in the course of therapy (Ogles & Lambert, 2004)
Long term psychotherapy with clients with personality disorders can bring significant improvement (Bateman & Fonagy, 2004)

DOSE EFFECT

Dose-effect research:

How many sessions are needed for improvement or full recovery (Kopta et al., 1994 client with depression and anxiety disorders)
Acute distress: 50% recovery in 5 sessions, Chronic distress: 50% recovery in 14 sessions, Characterological changes: for 50% recovery, more than

hundred sessions needed

The most common symptoms (Kopta et al., 1994): 50% recovered in 11 sessions, 75% recovered in 58 sessions

Examples of dose-effect research:

Figure 2.5.2. The clinically significant recovery in time based on the sample of approximately 6.000 patients, who completed psychotherapy (results regardless of diagnosis; mostly patients with affective, adjustment and anxiety disorders) (adapted from Lambert, Hansen, & Finch, 2001).

Percentage of patients

Therapy session

Process research
How does it work?

How is it studied?

Audio and video tapes and their transcripts are analyzed with different instruments, often used by the experts The client and the therapist respond to measures that are administered between the sessions or just after the session Sometimes the client and the therapist are invited to comment on the tape of the session

Process-outcome research:

What must happen in therapy, so the outcome was good Some findings: The quality of therapeutic relationship significantly predicts the outcome (Horvath & Bedi, 2002) Perfectionist clients have problem to form a stable alliance (Blatt et al., 2002) Clients with insecure attachment have problem to form a stable alliance (Meyer & Pilkonis, 2002)

More Findings:

Empathy of the therapist as perceived by the client predicts therapy outcome (Bohart et al., 2002)

Internalizing people benefit from relationships and insight oriented therapies and externalizing people from directive and behaviorally oriented therapies (Beutler et al., 2002)
Interpretations can be helpful for people who have reasonably good relationships (Crits-Christoph & Connoly-Gibbons, 2002)

Descriptive process research:

Investigates impact of interventions Investigates significant moments Intensive case studies that were successful
Some findings: - the clients defer to their therapists (Rennie, 1990) - the clients have strategies for the sessions and evaluate the therapists whether they are compatible with these strategies (Rennie, 1990)

Descriptive process research:

Some findings: The therapist admission of his/her contribution to the tension in the therapeutic relationship helps resolve this tension (Safran & Muran, 1996) The clients can tolerate if the therapist interpretation is not totally perfect (Elliott, 1984)

Successful interpretation is delivered in parts to the client (Elliott, 1984)

Therapeutic ruptures

Example of findings from a study of the conflicts in therapeutic relationship

Table 6.1. The model of therapeutic work with the clients confrontation (adapted from Safran & Muran, 2000).

1. Identification of confrontation marker (confrontation can be

2.

3.

4.

5.

6.

present in the clients complaints about the therapist as a person, or professional). Disembedding (the therapists may admit own contribution to the problematic interaction, the therapist re-establishes the analytical space, facilitates greater explicitness in the clients demands, etc.). Exploration of construal (the therapist facilitates the expression of the patients needs, expectations, wishes, perceptions present in the conflict, etc.). Avoidance of aggression (the client avoids direct expression of anger because of own anxiety and guilt; it may make the aggression indirect; the therapist should facilitate the clients awareness of this fact). Avoidance of vulnerability (the therapist facilitates the clients awareness of the fact that the anger prevents an awareness of own vulnerability triggered by the therapeutic interaction). Vulnerability (the clients expression of vulnerable feelings and wishes often connected to hopelessness, however, now it is not hopelessness communicated cynically and aggressively, but truly).

Testing theories of therapeutic change:

The therapy sessions are assessed as to their compatibility with proclaimed theories Some findings: - the conflicts that clients have in relationships in their life repeat themselves in the relationship with their therapist (Luborsky & Crits-Christoph, 1990) - if the conflicts are worked through in therapy, the client psychopathology resolves as well (Luborsky & CritsChristoph, 1990) - the clients test their therapists if they can handle problematic situations that the clients cannot handle; if the therapists do, it leads to improvement in the clients functioning (Weiss & Sampson, 1986)

Testing therapeutic change:

Some findings: - the clients who experienced deeper emotions in emotion-focused therapy for depression show more improvement than the clients who experienced less emotions (Greenberg & Watson, 2005) - the clients who explore fruitfully their feelings and reflect on their meaning benefit from client-centred therapy (Sachse & Elliott, 2001)

QUESTIONS

THANK YOU VERY MUCH