Effectiveness of Counselling & Psychotherapy

Effectiveness of Counselling & Psychotherapy
http://counsellingresource.com/lib/therapy/types/effectiveness/[09/07/2014 16:47:36]
ARTICLE CONTENTS
Overall Effectiveness vs. Individual
Effectiveness
What Effectiveness Research Might Mean for
Clients
Counsellors
Further Reading on the Effectiveness of
Counselling and Psychotherapy
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Evaluating Therapeutic Effectiveness
in Counselling And Psychotherapy
By Dr Greg Mulhauser, Managing Editor
Despite clear evidence demonstrating the effectiveness of
counselling and psychotherapy, pinning down specific reasons
for effectiveness or identifying particularly effective
approaches remains tricky. (NOTE: The review of Hubble, et al
1999 includes a great deal of additional information on the
topic of effectiveness in therapy.)
Overall
Effectiveness vs.
Individual
Effectiveness
Research evidence
about the effectiveness
of counselling and
psychotherapy overall is
relatively unambiguous:
counselling does work.
For a wide range of
types of psychological
distress, both subjective
client reports and more
objective
measurements
indicate that
counselling and
psychotherapy are
effective, both in the
short term and over
longer time periods.
For certain kinds of
psychological
distress, such as
depression, some
evidence also suggests that the
benefits of counselling can interact
positively with
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medications
such as anti-
depressants: in
other words,
counselling
and
medication
together
sometimes
offer better
results than
either
counselling or
medication on
their own.
What is more ambiguous, however, is the research evidence on the
effectiveness of specific types of counselling or psychotherapy.
Overall, no one therapeutic approach stands out as offering better
results than any other the so-called dodo bird verdict.
(However, evidence from efficacy studies is gradually accumulating
to indicate that some kinds of distress are particularly well
addressed by certain approaches; clients with panic disorders, for
instance, often respond particularly well to cognitive behavioural
therapy.) At first glance, it might seem that this failure to
discriminate between therapeutic approaches in terms of overall
effectiveness could be attributed simply to the fact that different
people will respond in their own ways to different types of
counselling: if clients choose the right or wrong types of therapy
only by accident, this might result in particular types offering good
results in some areas and bad results in others, with the overall result
that no one type of counselling would stand out. But because
studies are typically designed to detect and isolate these types of
regularities, we know that random choice about therapy type does
not, by itself, provide a sufficient explanation of the evidence.
While no one type of therapy stands out in terms of overall
effectiveness, however, individual counsellors clearly do. Within
given approaches, research shows very significant variation
between individual counsellors. Indeed, the evidence suggests that
the abilities of individual therapists may be a more significant factor
in determining outcome than therapeutic orientation! So there may
not be a clear answer to the question of whether there are better
or worse therapeutic orientations, but there certainly are better and
worse therapists. Pinning down exactly why this is so exactly what
kinds of factors account for the variation in individual results is
much more difficult. The research evidence cannot yet help the
client to understand exactly why one therapist might be better or
worse for them than any other. Worse, there is no evidence that
any of the various counsellor accreditation schemes serve to pick
out better therapists, and neither years of counsellor experience nor
duration of their training have any strong bearing on therapeutic
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outcome. (Indeed, some research has even suggested that
counsellors in training and newly-qualified counsellors are more
effective than their more experienced peers!)
What
Effectiveness
Research Might
Mean for
Clients
If the aggregate
effect of all main
types of counselling
and psychotherapy
is positive, and if the
individual
therapeutic
approaches do not
distinguish themselves clearly in terms of overall effectiveness, does
this mean that therapeutic orientation is irrelevant from an
individual clients point of view? Definitely not!
While the quality of the relationship which a client can establish
with a particular counsellor probably heads the list of factors to
consider when entering counselling, the match between an
individual clients preferences and a particular style of counselling
remains extremely important. This match (or mismatch) can strongly
influence how the client feels about the process and the
relationship and consequently bears on how easy it is for that client
to make progress. Virtually all relevant empirical studies agree that
clients benefit more when they are committed to working within
the therapeutic approach offered in their particular counselling
environment and some studies suggest that client variables such
as this account for about 40% of therapeutic change, more than
any other factors. A client who doubts whether a cognitive model
adequately represents their experience probably will find less
benefit from cognitive or cognitive behavioural therapy, while a
client who would like their counsellor to give them a great deal of
advice and instruction may not get very much from person-centred
counselling. By analogy, while it is probably possible to walk 5 miles
in shoes that are either much too big or painfully small or have too
much traction or not enough, the right choice of footwear can
make it much easier to do so in comfort, enjoying the scenery
along the way, and having some energy left at the end. Likewise,
many different kinds of shoes will do for such a walk, but some will
be a help while others may actually be a hindrance. Some time
spent considering the different types of counselling and
psychotherapy available before embarking on a therapeutic
journey will be time well spent.
As for the question of individual counsellor effectiveness, perhaps
the most important lesson to be drawn from the research is that
clients should make up their own minds based upon their own
experience with a counsellor, rather than relying entirely on
evidence such as paper qualifications, years of experience, or
recognition via professional accreditation schemes. (The section
About Counselling and Psychotherapy includes some suggestions
both on finding counsellors and on selecting one.) Remember that
the quality of the relationship which the client can establish with the
counsellor probably heads the list of factors influencing therapeutic
outcome, so at the end of the day, the clients judgement of this
relationship probably carries the most weight.
Counsellors
One of the more pernicious conclusions occasionally drawn from
the absence of evidence favouring any one type of counselling or
psychotherapy over any other is that individual counsellors neednt
concern themselves very much with orientation. This line of thought
seems to go along with a kind of therapeutic relativism which
suggests that everything has its value, and no way of working with
a given client is really better than any other. Similarly, one
sometimes hears the view expressed that critically evaluating the
theoretical differences between approaches is unimportant, and
one can just be entirely pragmatic: do what works. Perhaps the
most defeatist approach is that there is just no point learning about
various therapeutic approaches, given that none has ever
demonstrated a clear overall advantage over others.
There are good reasons for rejecting each of these responses. First
among them is that there is no justification for inferring from the
evidence that a specific individual client (as opposed to the
aggregate set of all clients) will be helped just as much by one
approach as by any other. We dont yet have the evidence to
answer unambiguously the question of what works for which types
of clients, but that doesnt relieve the counsellor of the responsibility
to consider what will work for his or her specific clients. Moreover,
the absence of evidence about overall differences in effectiveness
does not imply that there are no differences in how to be effective.
(Indeed, there patently are differences in counsellor effectiveness,
but research has yet to separate out the most relevant variables at
work.) The same is true of why a given approach or counsellor is
effective. In fact, some theorists and researchers have gone to
considerable effort to account for the success of a given approach
in terms of what it might accomplish in light of the theoretical
model espoused by another. There may be considerable benefits
for the client (not least among them, speed and cost) if the
counsellor is effective because he or she is getting it right by
design, rather than by accident.
(As one example of accounting for the success of one approach in
terms of another, the cognitive therapist and former
psychoanalyst Aaron Beck provides convincing arguments in
terms of cognitive therapy for why the therapeutic interventions of
a psychoanalyst might have a successful outcome; the cognitive
explanation is entirely consistent with the falsity of psychoanalytic
theory. In other words, the psychoanalyst might be acting on an
entirely mistaken view of the clients psychology, yet these
misguided interventions might inadvertently hit right on target in
terms of eventual outcome.)
The response that counsellors should just be pragmatic, doing what
works, is actually very credible. But even here, it is difficult to see
how a counsellor could just do what works without some grasp of
the theoretical underpinnings of whatever overall approach or
technique he or she might be inclined to employ with a given
client. It is preferable for the client if any suggestions from the
counsellor that a particular approach might be helpful are made
on the basis of some informed view of why it might work: a
counsellors suggestion of a particular way of working should not be
made by default, it should be both deliberate and informed. In
other words, it may be true that one should do what works, but
doing that requires some effort to understand and evaluate
underlying theory.
One last curious conclusion about the evidence is worth addressing.
Namely, some proponents of person-centred theory suggest that it
is unsurprising that different therapeutic orientations do not differ in
terms of aggregate effectiveness. They suggest that only individual
therapists who manifest the core conditions of person-centred
theory will be effective, and that anyone from any orientation
could do a good job of offering the core conditions. The evidence
does not support this conclusion: these conditions have been
researched along with many others, and there is no evidence to
suggest that success can be picked out just by looking at the core
conditions. (It is entirely possible that the view is true, but for now it
remains an item of faith, not a conclusion correctly derived from
reliable empirical evidence.) Moreover, if it were true, it would
imply an interesting conclusion which person-centred proponents
would presumably find unpalatable: namely, that counsellors who
successfully manifest the core conditions are no more likely to be
found in the ranks of the person-centred tradition than within any
other therapeutic tradition. In other words, it would imply than
person-centred counsellors are no more likely to be person-centred
than any other type of counsellor.
Finally, all this might strike some practitioners as being entirely
tangential to their own take on counselling and psychotherapy. For
some, scientific research is irrelevant anyway, and even if the
particular benefits of a given approach became empirically
evident, they would still prefer to maintain the purity of their own
particular therapeutic orientation and their own ways of dealing
with individual clients. (One psychologist wrote that one can no
more argue someone out of a counselling model by advancing
empirical evidence than one could argue them out of a religious
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s
belief.) One way of getting at whether there is any tension in this
view and there neednt necessarily be any at all is by way of
a question which is worth asking for any counsellor: what would it
take to convince you that you are approaching a given client in
the wrong way? The client telling you so? A scientific study? The
client telling you so twenty times? Twenty scientific studies?
Alternatively: what would it take to convince you that a given
client would benefit more from something other than what you are
doing?
These questions will probably be answered differently by every
counsellor or psychotherapist.
Further Reading on the Effectiveness of Counselling
and Psychotherapy
The annotated bibliography contains pointers to additional
literature in this area. Probably the single best source of specific
research data on the effectiveness of counselling and
psychotherapy is Bergin and Garfield (1994). In that volume,
Lambert and Bergin (1994) include useful results on individual
counsellor effectiveness, while Beutler et al. (1994) cover cross-study
correlational data indicating that levels of experience and therapist
training are almost irrelevant to therapeutic outcome. The data on
client variables contribution to therapeutic change come from
Asay and Lambert (1999). Seligman (1995) comments on the 1995
Consumer Reports survey on the effectiveness of psychotherapy
and clearly explains the distinction between controlled efficacy
studies and the less-stringent effectiveness study.
UK readers especially may be interested in the Department of
Healths treatment guidelines, which summarize some of the
available data about best matches between specific types of
psychological distress and specific types of therapy. See Beck
(1976) for details of the comparisons mentioned above between
psychoanalysis and cognitive therapy. The psychologist quoted
above on counselling models and religious beliefs is Legg (1998), p.
4.
TAGS: COGNITIVE THERAPY AND CBT, EFFECTIVENESS, NEWS
AND RESEARCH, PERSON-CENTRED, THERAPY
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