Research Issues in Counseling

The importance of evidence based practice

Psychology is invisible, abstract and difficult to define.
People can be a bit cynical about psychology.
Psychotherapy is an art as much as it is a science.
Therefore, psychology needs to emphasise its scientific credentials to ensure it is taken seriously in the 21st century.
This means that a core part of the first 4 years of psychology training is the most rigorous research training available- the highest compared to all other health practitioners in the country.

Bias in thinking

Psychologists are experts in thinking biases, but this does not make us immune.
Professional chauvinism- the practitioner thinks their therapy is the best.
Our cognitive biases and our instinct to rationalise our beliefs with logical fallacies prevent us from seeing how things actually are.
We start off with the conclusion that therapy works and then we find evidence that supports the conclusion we’ve already come to.
We need quality scientific evidence to reduce the change of bias (not eliminating bias).
We have bias in thinking and perceiving.
g. Colour vision stops at about 40 degrees
Look straight ahead at the lecture slides and try and perceive the colour of the person’s clothes sitting next to you.
We al think we can accurately perceive the colour of their clothing but our brain is playing a trick on us. Our brain has visual working memory and tries to remember the colour of the clothes or will simply presume what the colour is without actually knowing.
We jump to the conclusion.
Seeing is not an accurate way to gain knowledge
We cannot rely on personal experience.

Examples of ineffective interventions

We used to believe that psychological debriefing after a traumatic event would help an individual.
However, evidence shows that single session debriefing actually shown to be ineffective or even harmful.
Typically involves re-telling the story which leads to the story becoming more vivid and if the memory becomes more vivid the client is more likely to develop PTSD
We does work is playing Tetris after traumatic event beneficial.

Efficacy of psychotherapy

Psychotherapy is more effective than not treatment- mainly applicable to anxiety and depression
Mega-analyses (meta-analyses of meta-analyses)
Average effect size of Cohen’s d= 80 (large effect size- 69% success rate)
15% of the outcome variance accounted for by therapy.
More effective than influenza vaccine, statins in cardiology and some surgeries.

Relative efficacy of psychotherapies

Mega-analyses of 32 met-analyses of treatment approaches.
Differences between therapies yielded an effective size of d= 0.2 (small effect)
Results are consistent for anxiety and depression
When we look at who published the research, the relative efficacy seems to be negligible (d = 0 to 0.17).
Dropout rates are equivalent across treatments (19%)
Very controversial – due to professional chauvinism

Psychotherapy vs. antidepressants

Both psychotherapy and SSRIs are more effective than placebo in severe depression.
Psychotherapy and SSRIs do not differ in effective BUT this depends on severity, chronic/nonchronic.
Psychotherapy is considered better in the long term.
Psychotherapy has better long term outcomes at follow up.
Drop out rates are lower for psychotherapy.
Psychotherapies create less resistance to multiple administrations.
Medication is different if you use it for a period time then go off it and try to go back on it later in life it may not work.

How many sessions do people need?

Research from headspace.
N = 24,034 age 12-25 using CBT
60% of clients shows significant improvement
Did a 90 day follow up – the longer the clients did therapy the better their outcomes were at 90 day follow.
Very important to psychologists at the moment- medicare only gives 10 sessions but research shows that some people may need more to really benefit.

The placebo effect

The placebo effect is any therapy or component of therapy that is deliberately used of its nonspecific, psychological or psychophysiological effect.
The placebo effect may have greater implications for psychotherapy than any other form of treatment because both psychotherapy and the placebo effect function primarily through psychological mechanisms.
Good research should demonstrate superiority of placebo- placebo controlled randomised controlled trial.
In research, the placebo condition as a treatment in which the subjects have equal faith, but which would not be expected to lead behavioural change on any other grounds.
The more invasive the treatment the more effective it seems to be as a placebo.
It is nearly impossible to develop a truly suitable psychological placebo condition

Problems with placebo

A placebo is a theoretically inert intervention: a placebo is something that shouldn’t have an effect theoretically but it does anyway.
In psychotherapy, all change is due to psychological factors making it very difficult to evaluate.
If a psychological placebo is administered and change occurs, there must exist a psychological mechanism responsible for that effect, whether or not we have a current theory to explain it. This placebo is thus not inert, a statement that is self-contradictory.
Cannot do a double blind study because in psychology research the therapist would know they are acting in a placebo condition. Therapist is bias becomes a confound.
It turns out to be very difficult to create a psychological placebo condition whose credibility and expectancy generation in the client are equivalent to that of actual therapy conditions.

Instead of placebo, we use wait list controls or treatment as usual

Common factors

Factors that reliably lead to positive outcomes that are:
Inherent in any therapeutic situations Not specific to any one therapy approach.
Relationship: alliance, client feedback
Therapist skills: allegiance to the therapeutic approach (belief in effectiveness- if the therapist believes it will work it will be more effective), empathy
Client: severity, expectations of benefit, belief in credibility of therapy and therapist
80% of research dollars goes to techniques used in therapy.

Therapist characteristics

7% of the variance in patient outcomes is accounted for by whom the therapist is.
11-38% of therapists would not be producing therapeutic gains- their clients would on average end therapy worse off than when they started.
Up to 16% of therapists could be considered as harmful.
Between 29- 67% of clients had patients who reliably got better.

Factors that matter

Therapists belief in credibility of effectiveness of psychotherapy, (d=0.65 medium effect) • Empathy, as rated by client (d=0.74, medium effect)
treatment rigidly is harmful.

Collecting patient feedback

Regularly monitoring and tracking patient treatment response with standardized self report scales
Provide therapist with week to week summary of patient functioning
Improves therapist responsiveness to patients who are not getting better
Therapists are notoriously poor at seeing who is getting better without measures.
In a large study (Lambert, 2007) of treatment efficacy, 20% of patients deteriorated, but only 8% of patients who deteriorated were identified by therapists!
Meta-analysis of 13 studies (Labert & Shimokawa, 2011)
Effects of therapists collecting client feedback on outcomes=medium effect size (d=.55)
Providing therapists with feedback (rather than just collecting without therapist monitoring) reduced the number of patients who deteriorated by half! (20% vs 9%)

Major theorists

Figure

Theory

History/Background

Freud

Psychoanalysis

• 1856-1939

• Freud’s family background is a factor to consider in understanding the development of his theory.

• During his early 40s, Freud had numerous psychosomatic disorders, as well as exaggerated fears of dying and other phobias, and was involved in the difficult talk of self-analysis.

• He first examined his childhood memories and came to realise the intense hostility he had felt for his father.

• He also recalled his childhood sexual feelings for his mother.

• Freud had very little tolerance for colleges who diverged from his psychoanalytic doctrines.

• Carl Jung and Alfred Adler worked closely with Freud but each founded their own therapeutic schools after repeated conflict with Freud.

• He pioneered new techniques for understanding human behaviour and his efforts resulted in the most comprehensive theory of personality and psychotherapy ever developed.

Alfred Adler

Individual Psychology

• 1870-1937

• Grew up in Vienna

• He was a sickly child- at age 4 he almost died of pneumonia.

• Because he was ill so much during the first few years of his life, Adler was pampered by his mother.

• He developed a trusting relationship with his father but did not feel very close to his mother.

• He was extremely jealous older brother, Sigmund, which lead to a strained relationship between the two during childhood and adolescence.

• Adler’s early childhood experiences had an impact on the formation of his theory.

• Alder is an example of a person who shaped his own life as opposed to having it determined by fate.

• He was a poor student but with a determined effort Adler eventually rose to the top of his class.

• He spoke and wrote in simple, nontechnical language so that the general population could understand and apply his principles.

• He pioneered the practice of teaching professionals through live demonstrations with parents and children, before large audiences, now called open forum family counselling.

• He died of heart failure.

Carl Jung

Analytical Psychology

• 1875-1961

• Interested in the psychological changes that occur at mid life

• Coined the terms extraversion and introversion

• Developed the personal collective unconscious- archetypes

• His advice to a patient suffering from alcoholism led to the formation of AA.

• He broke away from Freud, rejecting his emphasis on sex as the sole source of behaviour motivation.

• He broke away from psychodynamic theories and formed his own theory called Analytical psychology.

• He believed the human psyche exists in three parts: the ego (conscious mind), the personal unconscious and the collective unconscious.

Carl

Rogers

Person-Centred Psychology

• 1902-1987

• A major person for humanistic psychology

• He was an introverted person and spent a lot of time reading and engaging in imaginative activity and reflection.

• His foundational ideas, especially the central role of the clienttherapist relationship as a means to growth and change, have been incorporated by many other theoretical approaches.

• Often called the father of psychotherapy research- he was the first to study the counselling process in depth by analysing the transcripts of actual therapy sessions.

• He was the first clinical to conduct major studies on psychotherapy using quantitative methods.

• He was the first to formulate a comprehensive theory of personality and psychotherapy grounded in empirical research.

• During the last 15 years of his life, he applied the PC approach to world peace by training policy makers, leaders, and groups in conflict.

Victor Frankl

Existentialism

• 1905-1997

• Born in Vienna

• From 1942-1945 he was a prisoner in the Nazi concentration camps at Auschwitz and Dachau, where his parents, brother, wife and children died.

• His compelling book Man’s search for meaning has been a bestseller around the world

• His experiences in the Nazi death camps confirmed his views.

• Frankl observed and personally experienced the truths expressed by existential philosophers and writers who hold that we have choices in every situation.

• Frankl believed that the essence of being human lies in search for meaning and purpose.

• He believed that love is the highest goal to which humans can aspire and that our salvation is through love.

• Frankl acknowledge his indebtedness to Freud, although he disagrees with the rigidity of Freud’s theory.

• He established his international reputation as the founder of what has been called the third school of Viennese psychoanalysis.

Yalom	Existentialism	• 1931- • Yalom has been a major figure in the field of group psychotherapy. • Yalom developed an existential approach to psychotherapy that addresses four givens of existence or ultimate human concerns: freedom and responsibility, existential isolation, meaninglessness and death. • Looked at the role of death anxiety in psychotherapy.
Aaron Beck	Cognitive Therapy	• 1912- • Beck used his personal problems as a basis for understanding others and for developing his cognitive theory. • Beck attempted to validate Freud’s theory of depression, but his research resulted in his parting company with Freud’s motivational model and the explanation of depression as selfdirected anger. • Through his research, he developed a cognitive theory of depression. • For Beck, negative thoughts reflect underlying dysfunctional beliefs and assumptions. • Beck believes clients can assume an active role in modifying their dysfunctional thinking and thereby gain relief from a range of psychiatric conditions. Beck is the pioneering figure in cognitive therapy, one of the most influential and empirically validated approaches to psychotherapy. • He developed assessment scales for depression, suicide risk, anxiety, self-concept and personality. • He is the founder of the Beck Institute.
Albert Ellis	Rational Emotive Behavioural Therapy	• 1913-2007 • He practiced psychoanalytically oriented psychotherapy, but eventually become disillusioned with the slow progress of clients. • He observed that they improved more quickly once they changed their ways of thinking about themselves and their problems. • Early 1955 he developed an approach to psychotherapy he called rational therapy and later rational emotive therapy and which is now known as rational emotive behaviour therapy.
Fritz Perls	Gestalt	• 1893-1970 • Born in Berlin, Germany, into a lower-middle class Jewish family. • He joined the German Army and served as a medic in WW1 • His experiences with soldiers who were assessed on the front lines led to his interest in mental functioning, which led him to Gestalt psychology. • After the war Perls worked with Kurt Goldstein at the Goldstein Institute for Brain-Damaged Soldiers in Frankfurt. • It was through this association that he came to see the importance of viewing humans as a whole rather than as a sum of discretely functioning parts. • He moved to Vienna and began his psychoanalytic training. • Personally, Perls was both vital and perplexing • People typically either responded to him in awe or found him harshly confrontational and saw him as meeting his own needs
		through showmanship.