Psychotherapy in Community Counseling - Part Two

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Counseling 407
Community Counseling
Dr. Jeffrey K. Edwards, LMFT
Room 4040
1-773-442-5541
J-edwards1@neiu.edu or jke6245@aol.com
Office hours are Wednesdays 1-4 and
Thursdays 3-6.
Counseling 407
Day one Introduction
Counseling research Review or new?
Community Counseling - Definitions
Prevention - Models
Counseling Knowledge

Well-known facts that most therapists either
overlook, forget, or were never told. Or,
why counseling/psychotherapy myths about
who is better prevail.
Arm yourself with this information and you
will be an unstoppable Community/Family
Counselor.
this will wake you up.
Counseling and or Psychotherapy are
comparatively the same thing. They are
simply different names for doing the same
activities. However, there are many
professionals who have been trained to
believe that doing psychotherapy is more
scientific and rigorous, and should only be
provided by certain professions. (For a
comprehensive review see Neukrug, 2003)
this will wake you up.
Counseling/Psychotherapy works. More
than 40 years of outcome studies have
demonstrated effectiveness (Hubble,
Duncan and Miller, 1999).
However, nearly 50% of clients drop out of
treatment. There are few predictors of
premature dropout, except substance abuse,
minority status, and lower education
(Prochaska, 1999).
Smith et al. (1980) found that at the end of
treatment, clients were better off than 80%
of a control group that did not have
treatment.
Two studies showed that about 75% of
clients significantly improve after 26
sessions (six months) and that 50% show
significant improvement after only 8 to 10
sessions.
In fact, the average length of stay in
treatment is around 8 to 10 sessions, with a
modal number of 1.
In a famous research project at Keiser
Permenante 80% of those clients who
dropped out after one session, however,
reported that they had received the help they
needed after that one session.
Certain types of client problems are more
likely to relapse, notably those with
substance abuse problems, eating disorders,
recurrent depression, and personality
disorders (Asay and Lambert, 1999).
It seems, however that change is more likely
to last, if the client attributes their changes
to their own efforts ( Lambert & Bergin,
1994).
When therapy succeeds, the
convention is to attribute the positive
outcome to the therapy or
ministrations of the therapist. In
contrast, when therapy goes awry, or
at least yields disappointing results,
it has been customary to place the
failure in the client or the clients
personality (Hubble, Duncan, &
Miller, 1999).
1. Counseling/Psychotherapy models all
have the same effectiveness, more or less
(see comprehensive reviews in Hubble,
Duncan and Miller, 1999; Seligman,
1995).
2. This has been called the Dodo effect, by
Luborsky et al. (1975) - from Alice and
Wonderland, Everyone has won and all
must have prizes.
Effective therapy can be achieved in short
periods of time (5 to 10 sessions) with at least
50% of clients seen in routine clinical
practice.
A sizable minority (20% to 30%) requires
treatment lasting more than 25 sessions. Those
clients who are more likely to fail at brief therapy
efforts are those who are poorly motivated, hostile,
have poor relationships with others in their life.
Techniques that are critical, attacking,
rejecting, blaming etc. Are less effective
treatments (Najavits & Strupp, 1994)
Therapies that focus on the future, instill hope
early on, and enhance the clients hope and
placebo effect are more effective (Asay
& Lambert, 1999)
OK now, what does all this mean
to you?
How does this change
the way you will
practice?
What ideas do you
have for changing the
way you thought you
might work?
What excites you
about these concepts?
If techniques are not that important, then what
are the factors that contribute to positive
outcome? There are four:
1. Client Variables (40%);
2. The Therapeutic relationship (30%);
3. Expectancy and Placebo Effect (15%);
4. Technique (15%).

Common Factors in Counseling
Technique
15%
Expectancy
(placebo
Effect
15%
Extratheraputi
c
Change
40%
Theraputic
Relationship
30%
Client Variables (40%)

1. Severity of Symptoms (both
psychological and physical);
2. Motivation;
3. Psychological mindedness;
4. Ability to identify a focal
problem (Lambert and
Anderson, 1996).

1. Such things as insight, and
acquisition and practice of new
behaviors are also components
of the therapy that can and
should be attributed to the
client, perhaps upping the 40%
as high as 70% of the variable.

a withdrawn, alcoholic client, who is
dragged into therapy by his or her spouse,
possesses poor motivation for therapy,
regards ,mental health professionals with
suspicion, harbors hostility toward others, is
not nearly as likely to find relief as the client
who is eager to discover how he or she has
contributed to a failing marriage and
expresses determination to make personal
changes (Asay and Lambert, 1999).
The Therapeutic Relationship (30%)
Spontaneous Improvement

a significant number of people are helped
by friends, family, teachers, and clergy
who use a variety of supportive and HOPE
instilling techniques. Howard et. al (1986)
estimated that about 15% of clients
experience some improvement before the
beginning of treatment (Asay & Lambert,
1999).
Spontaneous Improvement
is influenced by

1. Length of time the problem has been
evident;
2. Underlying personality disorder;
3. Quality of social support, especially the
marital relationship (Andrews & Tennant,
1978; Mann, Jenkins, & Belsey, 1981).

The Necessary and sufficient conditions
Accurate Empathy
Positive Regard
Non possessive warmth
Congruence and genuineness.
These are client-perceived rather than
objective raters perceived.

There is significant research to show that
years of experience are not necessarily
correlated with effectiveness (Christiansen
& Jacobson, 1994), while some studies
have shown that self-help literature are in
some cases of equal benefit as therapy
(Gould & Clum, 1993).
It seems that the following components are
important to the therapeutic alliance:
Clients affective relationship with the therapist;
Clients capacity to work purposefully in
therapy;
Therapists empathic understanding and
involvement;
Client-therapist agreement on goals and tasks of
therapy (Gaston, 1990).
In the NIMH Study of Depression
Collaborative Research Program (1996), a
comparison between psychotherapy and
active and placebo pharmacology found
that the therapeutic alliance had a
significant effect on outcome. So what do
you think about that?
During a demonstration of bad
therapy techniques I did at Wheaton
College, I demonstrated bad posture,
bad eye contact, etc. When done, I
asked the class to evaluate, and they
were correct in their perceptions of my
techniques, however, the client saw
things differently. She said it was the
most profound experience of her life!!
Expectancy and Placebo Effect (15%)
Frank (1973) has suggested that people only
seek help when they have become demoralized
because of their own inability to solve their
problems. They feel powerless over their own
life situations.
Consistent research has demonstrated that a
large portion of improvement occurs during the
first 3 to 4 weeks of therapy, with 40 to 60%
change occurring before the client has their first
interview (Weiner-Davis, deShazer & Gingrich,
1987).
Expectancy and Placebo Effect (15%)

In summarizing several studies,
Lambert, Weber, & Sykes, (1993)
have shown that the average client in
therapy undergoing a placebo
treatment will have a better outcome
than 60% of a no-treatment group.
Expectancy and Placebo Effect
(15%)

I n several studies with
medications, the placebo effect
has been demonstrated to be
even greater than the 15%
usually assumed (Benson &
McCallie, 1979).
(15%)

I n a now classic study (Feldman, 1956) the
effectiveness of chlorpromazine was
prescribed by two groups of psychiatrists with
the following results - Those who were
enthusiastic had a 77% success rate, while
those who did not (psychodynamic) only
achieved a 10% success rate.
(15%)
The finding that drug efficacy
relates to prescribing
physician attitudes has been
replicated repeatedly
(Scovern, 1999).

Technique (15%)

Basing the following on the consistent
research findings that different types or
models of therapy have relatively the same
outcome, a number of points are made.
First, that training in specific models and
techniques is pointless (Strop & Anderson
(1997), and that staying true to a protocol
manual does not prevent a wide variety of
outcomes from the different therapists
using them (Luborsky et al. (1985).

Technique (15%)

Of more concern, and reported more in the research
is the finding that staying true to a manual may cause
other factors such as flexibility, warmth, and the
therapeutic alliance (see Ogles, Anderson, &
Lunnen, 1999). These problems along with a
multiplicity of others, causes a great deal of concern
when one regards the current trends by the American
Psychiatric Association, Managed Care
Organizations, and the American Psychological
Association to use Empirically supported treatment
for specific problems.
Models of Psychotherapy Used at
Internship Sites National
N = 854
Narrative
1%
Family
Systems
13%
Jungian
0%
Structural
1%
Adlerian
1%
Brief Strategic
8%
Client
Centered
9%
Cognitive
18%
Psychody
10%
Reality
6%
Solution
19%
Behavioral
14%
Stages of Change
James Prochaska
Precontemplation
Contemplation
Preparation
Action
Maintenance
Termination -
Precontemplation
are not intending to change, or take action,
usually in terms of the next 6 months.
Are not fully informed, or aware of
consequences.
May have tried to change in the past
without success.
No inherent motivation to change

Contemplation

People intend to change within the next 6
months.
Are aware of pros and cons of change vs. no
change.
Profound ambivalence.

Preparation

Plan to take action within the next month.
Have taken some action in the past year.
Have a plan for action.
These are the best people to recruit for
action oriented treatment.

Action

Have made specific, overt modifications in
their lifestyles within the past 6 months.
Behavior change has been equated with the
action stage.
Outcomes depend on neither the duration of
therapy nor the education or experience of
the therapist.

Maintenance

Working to prevent relapse, lasts from 6 months to
5 years.
Failure usually is associated with being under
prepared for the length of time maintenance takes.
The average American drinks, eats, smokes, and
takes drugs to manage distress (Mellinger, Balter,
Manheimer, Cisin, and Perry, 1978).
People struggling to overcome chronic conditions
will be at the greatest risk of relapse.
Medications
Beecher (1955) reviewed 15 single or double
bind studies that looked at the effects of
placebos on a variety of conditions. He
concluded that on average and across
studies, placebos produced satisfactory
relief in 35% of those treated (Scovern, 2001)
Since the mid 1980s there has been an 275%
increase of persons who have trained and
provide counseling/psychotherapy.

There still has not been a reduction in any of
the psychological or psychiatric illnesses.
A Community Counseling Model
The Upstream Model
A Model of Community
Counseling
This is the story of the Jeffreys River
Once upon a time, there was a river named
Jeffrey.
I wonder
why?
Counseling
One day someone came floating ..
Counseling
down the river, almost drown.
Counseling
A good Samaritan saw the drowning person
Help!
Counseling
helped him out and saved his life.
Thanks
Counseling
Soon, another person came floating down
the river, almost drown.
Help!
Counseling
and he too, was helped out and had his life
saved.
Thanks
Counseling
soon there were lots and lots of people
coming down the river drowning.
Help!
Help! Help!Help!
Please!!
Counseling
The Samaritan needed some help. So he
asked a friend.
Help!
Help!
Help!Help!
Please!!
Counseling
And soon there were lots and lots of people
helping all those other people coming down
the river drowning.
Counseling
Soon they were building hospitals, and
clinics.
Counseling
And then they had supervisors and
administrators
Counseling
And they had overseers who told them how much
they would paycalled Managed Care.

Counseling
And then one very smart person decided to
go up stream to see..
Counseling
what or who was causing all those people to
fall in the river.
It is me. I like to
push them into
the drink.
Counseling
And he told him to stop. So, he did!
Hey, stop
that!
OK, I will.
Counseling
And that is how a Preventative Public
Health model was born.
Thanks.
You are
welcome.
The Dawn of a New Day
Salaries for therapists
went through a shift.
During the Golden
Days (1980s) of
psychotherapy, the
cost of a service hour
went to around
$90.00. Now, the rate
has changed
"if you look up the creek in any weather, your
spirit fills, and you are saying, with an exulting
rise of the lungs, "Here it comes!"
There must be something wrong with a creekside
person who, all things being equal, chooses to
face downstream. It's like fouling your own nest.
For this and a leather couch they pay fifty dollars
an hour?...Look upstream Just simply turn
around; have you no will? The future is a spirit,
or a distillation of the spirit, heading my way.
Annie Dillard, Pilgrim at Tinker Creek, 1974
Cost per capita for Individual
Counseling
You do the math.
If you can see 30 clients a week at
$90 per hour, or see 100 client for
four hours at $100 per hour,
several times a week, who gets
the better deal?
Components
A new model of mental health/behavioral
health needs to be designed so that services
can be equitable for all.
The community has all the resources needed
to provide for its members;

Public Health Concepts
Is the mental health system set up to help those
who need it the most? Or is it set up to
subsidize the upper and upper middle classes?
Community Counseling is set up to help those
in need, and who are under-represented by
service delivery. They way mental health
systems are set up now, is to provide services to
the less needy, and to make more money for the
providers of services.
This is not a just way of operating.
Prevention
Public Health came about from the work of Health
Care professionals, like Physicians, Nurses and
other professionals, who study epidemiology, and
they then find ways to treat groups who have
similar problems.
Epidemiology
1. a branch of medical science that deals with the
incidence, distribution, and control of disease in a
population ;
2 : the sum of the factors controlling the presence
or absence of a disease or pathogen .
Examples of Epidemiology and
Prevention Work
Snow, Edwin Miller America's first
professional city medical health officer he, took on
the serious problems with cholera epidemic of
1854 in Providence, in which he investigated
about 150 cases. There was no health authority in
the city, so he personally undertook action to curb
the epidemic. He drew up a report sharply
criticizing the city's complete lack of sanitary
precautions and recommended measures to deal
with the problem.

Prevention Work
SIDS 50% reduction of deaths by placing
babies on their backs.
SIDS with Native Americans did not
respond in kind, but further investigation
found that many mothers were also binge
drinking, and by swaddling the babies in the
colder months so they get too hot.

Prevention Work
The nations highways are safer now
because of epidemiology and Public Health
concepts. The director of National
Highways was a PH Doc, and he studied the
roadways where there were a preponderance
of vehicular accidents. After serious
consideration, the roads were banked to
allow cars to travel at the existing speeds
without running off of the road.
Components
Mental Health and Mental
Illness: A Public Health
Approach Surgeon General
Report:
http://www.surgeongeneral.gov/library/men
talhealth/chapter1/sec1.html

Definitions of Prevention

The classic definitions used in public health
distinguish between primary prevention,
secondary prevention, and tertiary prevention
(Commission on Chronic Illness, 1957).
Primary prevention is the prevention of a
disease before it occurs; secondary prevention
is the prevention of recurrences or
exacerbations of a disease that already has
been diagnosed; and tertiary prevention is the
reduction in the amount of disability caused by
a disease to achieve the highest level of
function. Surgeon Generals Report, 2002
The Institute of Medicine report on
prevention identified problems in applying
these definitions to the mental health
field (IOM, 1994a).

The problems stemmed mostly from the
difficulty of diagnosing mental disorders
and from shifts in the definitions of
mental disorders over time.
Consequently, the Institute of Medicine
redefined prevention for the mental
health field in terms of three core
activities: prevention, treatment, and
maintenance (IOM, 1994a).
Prevention, according to the IOM report,
is similar to the classic concept of primary
prevention from public health; it refers to
interventions to ward off the initial onset
of a mental disorder. Treatment refers to
the identification of individuals with
mental disorders and the standard
treatment for those disorders, which
includes interventions to reduce the
likelihood of future co-occurring disorders.
The Institute of Medicine report on
prevention

And maintenance refers to interventions
that are oriented to reduce relapse and
recurrence and to provide rehabilitation.
(Maintenance incorporates what the
public health field traditionally defines as
some forms of secondary and all forms of
tertiary prevention.)

The Institute of Medicine report on prevention
(IOM, 1994a).

Albee (1993) has suggested that Public
Health measures have done more to
provide the population with good health
and the eradication of disease than
conventional medical interventions.
Public health relies on larger scale
preventions; no one-on-one therapy has
ever eradicated a disease.
Critique of a medical definition of Mental Health
Prevention
Those who are in power have decided
that all human problems are organic
(brain problems, either in structure or
chemically) control how reimbursement
will occur (through the use of DSM)
rather than seeing them as social,
psychological or interact ional problems
(Albee, 1993).
Prevention
The conventional medical system has
much to gain financially by using the
individual treatment model (Albee, 1993).
The organic
Prevention
Assignment for next week.
Read the first two chapters in your book.
Do a library search on Ovid/PsychLit re:
Prevention in Mental Health limited
between 1980 and 2000 (20 years). Look
for trends and begin to look critically at the
topics.

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