Counselling and psychotherapy: Evidence and future directions

Counselling and psychotherapy: Evidence and future directions

Lawrie Moloney and Stephen Andrew
9 March 2016

This webinar focused on the evidence for the effectiveness of counselling and psychotherapy, and the factors that contribute to its success.

Counselling and psychotherapy

Audio transcript: Counselling and psychotherapy: Evidence and future directions

Audio transcript (edited)

Molony

Thanks Cathryn. I'm Lawrie and beside me is Stephen, and we'll be just introducing ourselves in a moment. So the structure of our presentation, you see there that we'll introduce ourselves. We've then got nine propositions we're going to put to you about counselling and psychotherapy, and that will be followed by a Q&A session so you're invited to write in any of your questions or comments as we're speaking. As Cathryn has said, this seminar or webinar is based on that discussion paper that was released yesterday through CFCA, which is part of the Australian Institute of Family Studies.

Just very briefly, that paper addresses these issues. We're not going to get through all of this in the webinar but I say it just to let you know there's a slightly larger scope. It starts with a historical introduction. We then look at the terms, counselling and psychotherapy, and what differences and similarities there are. We actually in the paper look at or regard counselling as the default term. The paper then looks at the fact that counselling works and looks at the evidence of that. It has a discussion around couples and family therapy because that raises a number of conundrums around the question of whether it works, whether counselling works. It does work in couples and family work, but the issues are a little more complicated.

Importantly, the paper then looks at how counselling works and we're going to talk a fair bit about that today. Towards the end of the paper we look at the critical nature of client feedback and the implications of all of this for the future of recruitment, training and accountability. So all the studies that we talk about in the webinar, and many more than that, of course, can be found in the paper. As Cathryn has said, it's a free download from the CFCA website, which is a website within the Australian Institute of Family Studies website. Two key references we're going to look at today or use today are those two: The Heart and Soul of Change and The Great Psychotherapy Debate. So let's just quickly introduce ourselves. Stephen, would you like to say something about yourself?

Andrew

Thanks Lawrie and welcome to everybody who's listening and taking part in the webinar today. As Cathryn mentioned, I've been working in counselling and psychotherapy as a psychologist for the last 20 years. I have a private practice and alongside that I've also been teaching therapists of many different types over the years, thoroughly enjoyed that. And yeah, I guess the central question for me in this whole area is around the therapeutic relationship and what happens when two or more people sit in a room together with the aim of assisting or helping or bringing about some sort of psychological change. It intrigues me no end and it's great to be a part of this process today to talk about it some more.

Molony

Thanks Stephen. Well I had a similar, I guess, fascination with what happens in therapy. I started my psychology practice, I guess, as a clinical psychologist. I did clinical psychology way back in the 70s at Melbourne University. Gained quite a bit from that but I think I've always struggled with some of the underlying presumptions that we were taught within that sort of framework and that will, I suppose, become clearer as we go on today. It was one of the incentives to produce the paper that we've just talked about and one of the incentives for me to produce this webinar for us today.

Andrew

So our plan here today is to introduce these 9 propositions and then expand on them before hopefully having time to attend to some of the questions they may have raised for you, so don't hold back on the questions.

Molony

Okay so if we look at just the first proposition, we're going to run through these quickly and then come back to them, this first proposition makes the point that while counselling and psychotherapy might be seen to have taken a new approach, they also of course continue along tradition of interventions that have been aimed at healing human suffering and human distress.

Andrew

Proposition 2 speaks to what has been popularly called the Dodo bird effect and this is a metaphor from Lewis Caroll about equivalence. "Everyone has won and all must have prizes", he once wrote. We argue that the fact that all mainstream models of intervention have been shown to be as effective as each other is telling us that we have to look elsewhere to discover the key ingredients to successful counselling.

Molony

Proposition 2 speaks to what has been popularly called the Dodo bird effect and this is a metaphor from Lewis Caroll about equivalence. "Everyone has won and all must have prizes", he once wrote. We argue that the fact that all mainstream models of intervention have been shown to be as effective as each other is telling us that we have to look elsewhere to discover the key ingredients to successful counselling.

Andrew

So looking now at Proposition 4, if there is no evidence that can tie these different modes of intervention with different results, we're left with the question: "What are the core ingredients of good counselling?" We will be presenting evidence that these core ingredients can be found in the person of the counsellor and in the way counsellors, assisted by their training, experience and willingness to self-reflect, are able to find points of connection with clients and with clients' understandings of their own distress.

Molony

So the good news in Proposition 5 is that despite the evidence that we've been on a bit of a wild goose chase, I think, in trying to compare the efficacy of different models of intervention, the counselling process itself often works very well.

Andrew

Proposition 6 challenges the conventional way of thinking where counselling students are introduced to and appraise varying counselling modalities, and that as time goes on, they improve their skills in delivering a limited number of evidence-based modalities. But the evidence shows that top performing counsellors simply don't work in that way.

Molony

Okay and Proposition 7. Good counselling begins with the presumption that at some level clients know what they need. Just like good educators, good counsellors develop personal and relationship skills that help them create the conditions for clients' own understandings to emerge, to be reshaped if necessary and to be acted upon.

Andrew

So consistent with what Lawrie has just proposed, the research also suggests that following rule of thumb. The more precise and the more frequent the feedback from the client, and the more that counsellors are prepared to correct their approaches in response to their clients' feedback, the more successful counselling and psychotherapy is likely to be.

Molony

So finally we suggest that the research points to counselling as an interpersonal process, a journey that clients take with their counsellors and while it may be helpful to recognise and even classify the nature of clients' distress, perhaps using something like DSM as a guide, there's no evidence to suggest a consistent link between classification and the employment of any particular pre-determined intervention. We argue that these findings have significant implications for the way in which counsellors are recruited into the field, for the way in which they're trained and for the way in which counselling outcomes are measured.

Andrew

So let's return to that first proposition. Lawrie, we grew up in an era when counselling and psychotherapy were just part of the landscape, but people have always had problems. So what were the conditions that persuaded us to seek help from counsellors and psychotherapists as we know them today?

Molony

Okay, look I think it's useful to start with a few big picture observations. Since we human beings banded together to provide support for each other and protection from real perceived enemies, we've appointed individuals or sometimes individuals have assumed the role of what John McLeod has called guides to living. So over the centuries, these individuals have had many names – shamans, priests, diviners, witches, spiritualists, elders, just to name a few. Things changed in western countries with the Industrial Revolution. This brought about a large-scale shift from life in mainly small villages to life in larger, more anonymous societies. Some of that's been outlined by just those two references we've put at the bottom.

A lot of social historians such as Albie and Giddens have suggested that these more anonymous societies created fewer social and moral constraints. Individuals weren't scrutinised in the same way as they had been and along with the spectacular advances that science was bringing came a weakening of the old certainties that had been buttressed by class and religious teaching. In essence, the moral and social compass was shifting from externally imposed obligations to an emphasis on internally driven personal responsibilities, and for good or bad, counselling and psychotherapy began to place greater emphasis on the person rather than God or magic or even social sanctions.

Andrew

So, Lawrie, are you saying in essence that it was science that led to the Industrial Revolution, and science and the Industrial Revolution that created the conditions for counselling and psychotherapy?

Molony

Yeah, I think there's something of a real paradox here. You know, one of the major criticisms about the behaviour which is levelled against psychodynamic therapists is that they're not scientific enough. In fact, some would say they're not scientific at all. But what's emerged is that science and the science that underpins counselling is very different to the sort of science that underpins medical practice, which is often assumed to be a sort of benchmark for effective counselling. In a key quote from one of the chapters in The Heart and Soul of Change that we had up earlier, Hubble and his colleagues put it this way. Psychotherapy doesn't work in the same way as medicine. Bluntly put, the existence of specific psychological treatments for specific disorders is a myth.

Andrew

In their book, The Great Psychotherapy Debate, Wampold and Imel have, in fact, catalogued how over the years a great deal of practice and research energy has gone into delivering counselling in a manner that parallels the delivery of medical services. So typically, a medical model of intervention begins with careful systematic observation, the purpose of which is to reach a diagnosis. As a result of the diagnosis, we make an intervention that previous studies suggest will cure or at least ameliorate the condition. In this medical model, consistency demands that the intervention be delivered in a standardised manner. Careful attention is paid to issues such as dosage and to the conditions under which the dose is delivered, but in the medical model, questions such as who delivers the intervention are considered to be largely, if not totally, irrelevant.

Molony

And consistent with this model, an enormous amount of counselling research has attempted to compare outcomes of one or more treatment models with a no treatment group. In this research model, clients and control subjects are carefully selected for evidence of a particular problem such as depression. Counsellors are then selected and often trained to deliver a standardised version of that particular counselling intervention. The assumption has been that in a manner similar to improvements noted after a standardised medical intervention, improvements following counselling are primarily due to the efficacy of the standardised treatment.

But what's been found over and over again, however, is that there is no proof that any improvements made can be linked to the intervention model itself. So, for example, psychodynamic approaches work just as well or just as badly depending on the skills of the practitioner as CBT or anything else. But as we've noted, the good news is that all applications of well-recognised models of intervention were considerably better than making no intervention.

Andrew

Okay, looking now at Proposition 4 in a bit more detail. A common factors explanation for the success of counselling was originally hypothesised almost 80 years ago by Saul Rosenzweig. In the first chapter of The Heart and Soul of Change, there was a great interview with Rosenzweig conducted not long before he died. He was only a young man when he proposed the common factors hypothesis. The likely mechanisms that were thought to drive these proposed common factors was first most famously articulated by Lambert in 1986. Although acknowledging we still lacked strong empirical evidence, Lambert proposed four broad mechanisms of change, which he ranked in importance on the basis of their estimated contribution to outcome, and you can see these now up on the current slide.

The largest piece of this pie – the extra therapeutical variables – that is, all the factors that impact on improvement but are independent of the counselling intervention. The next largest, which I think is in blue – client counsellor factors, also referred to as the therapeutic alliance or therapeutic relationship. This was to account for approximately 30 per cent of the change. Then there were two smaller pieces, two smaller segments – hope expectancy and placebo effects. Some of this is brought by the client, but some is influenced by the approach taken by the counsellor. And the last piece of the puzzle – model or technique.

Molony

There's been further research since Lambert's analysis and a lot of that's summarised in the two key publications that we've mentioned – The Heart and Soul of Change and The Great Psychotherapy Debate. In particular, Bruce Wampold's investigations have been especially influential in broadening our appreciation of the potency of the client therapist and the alliance factors. In fact, Wampold's research has reduced even the limited impact of model differences further. He's found that the differences between models accounts for only about 1 per cent of the variance, not the 15 per cent that Lambert had originally speculated.

Effect size on this slide now is one way, it's not the only way, but it's one way of measuring counselling and psychotherapy outcomes and effect sizes in counselling outcome studies have generally varied between .75 and .85, so an average of .8. An average of .8 means that the average score on the outcome measures used to assess functioning of those who received the counselling intervention is .8 standard deviations better than those who are not recipients of the intervention. Another way of thinking about effect size of .8 is that the average client receiving counselling and psychotherapy would be better off than about 79 per cent of comparable individuals who received no interventions. Now that's a pretty encouraging result. It's one that researchers like Wampold claim is often as good as, and sometimes better, than the effect sizes achieved in many medical interventions.

Andrew

It's probably worth noting that these effect sizes in individual counselling are fairly consistent, but there is some controversy when it comes to estimating effect sizes in couple and family work. Though quite a few researchers also claim effect sizes in couple and family work at around .8, others have come up with more modest scores. The AIFS discussion paper covers this issue and points the reader in the direction of some of the key research papers. The paper also discusses the fact that measuring outcomes when multiple clients are involved is certainly a more challenging task than when individuals are involved. So to summarise, there is little doubt that mainstream couples counselling and family therapy work and probably work very well but exactly how well they work and how to measure how well they work remains somewhat contested.

Molony

And just before we leave questions related to whether counselling works, it's worth quickly mentioning that the literature makes a distinction between efficacy and effectiveness. Put sort of fairly simply, efficacy studies are those in which the nature of the problem is clearly defined and the intervention is also clearly stipulated. Effectiveness studies are those in which there may be less formal attention paid to defining the nature of the problem and in which the nature of the intervention is also less formally controlled. In the AIFS discussion paper, there wasn't enough space to explore the reasons why outcome measures tend to be better with efficacy studies but we do direct readers to a recent article in which Kim Helford and a couple of his colleagues have given this issue quite a lot of serious thought.

So moving on to Proposition 6. In speaking to the proposition so far, we've been mainly directing you to key research results. The discussion paper provides more references on each of these topics and deals with some of the contrary arguments, and, of course, you can follow these up, accept them or reject them, the arguments about these at your leisure. But this particular proposition is quite a challenging one and I think a bit counterintuitive. You know, a common sense view would be that extra years of training and extra years of practice should correlate with greater effectiveness. At the same time, we think this proposition brings us to the heart of what it means to deliver effective counselling.

So in this case, we thought it would be worth just spelling out the results of one of the key studies that led us to make this claim. This is a 2009 study by Anderson and colleagues, and that's also referenced in the discussion paper. So in the study, using a sample of 25 providers that were treating clients in a university counselling setting, the clinicians were asked to respond to a series of video simulations. Their responses were scored on an instrument called the facilitating interpersonal skills scale. Each simulation presented a difficult clinical situation and each situation was complicated by a client's anger or dependency or passivity or confusion or need to control the interaction. So in the first instance, the author has found the differences in outcome were attributable to counsellors' possession of deep domain specific knowledge.

Andrew

So if you're working, as I worked for a number of years, with people struggling with gambling problems, these results suggest that it helps if you have a solid understanding of how individuals become addicted to gambling and a solid understanding of the often tortured path towards recovering.

Molony

Well so far, so good, but in this same study, differences in client outcomes between counsellors were found to be unrelated to their gender, theoretical orientation, professional experience or overall social skills.

Andrew

Now it's important to recognise that this was not in itself a new finding, rather the study added to our knowledge base. The fact that the best results were obtained by counsellors who exhibited deeper, broader, more accessible and more interpersonally nuanced knowledge as measured on the facilitating interpersonal skills scale.

Molony

So over and above the advantage of having specialised knowledge and experience, and regardless of the client's style of relating, counsellors who achieved the best results were those who were able to respond collaboratively and empathically. These counsellors were also considerably less likely to make remarks or comments that distanced themselves from the client or that caused offence. And this flows on to our next proposition.

Andrew

I'm going to read this to you. "Relationship with client or clients supported by personal qualities of the counsellor – for example, wisdom, compassion, empathy, non-judgmental curiosity – are at the heart of effective counselling." You know, it's possible and maybe even likely that some of the many effective healers through our history may have had qualities like this. Did they recognise that these qualities were the main source of their success? Or did they believe that it was the potions or the rituals or the appeal to higher powers that were the most important part of the process? Or did they believe that the two were inseparable? There is a tension between the legacy of culturally informed wisdoms and the results of scientific inquiry, and it's too big a topic to cover here, but one difference between the past and the present is that since about the middle of last century, we have tried to formally measure the success of our interventions.

Molony

Typically we've measured success by comparing client outcomes with outcomes among control groups who received no intervention. But in addition, we've conducted many thousands of studies that have carefully compared different forms of intervention and as we've noted, the results of these have been that in all well conducted interventions, all work but none has been shown to work better than another.

Andrew

So where does that leave us? Let's think about what we mean by evidence-based practice, a phrase I'm sure you've all heard. In thinking about it, let's also consider how definitions of evidence-based practice in medicine would look quite different. About a decade ago, the American Psychological Association (APA) defined evidence-based practice as, and I quote, "The integration of the best available research with client expertise in the context of patient characteristics of culture and preferences".

A little further on, the APA said this, and I quote again, "Psychotherapy is a collaborative enterprise in which patients and clinicians negotiate ways of working together that are mutually agreeable and likely to lead to positive outcomes. Thus, patient values and preferences – for example, goals, beliefs, preferred modes of treatment, are a central component of evidence-based practice." So if we're to take these APA statements seriously, we should not be surprised at another set of findings.

Molony

The APA's use of the terms like collaborative enterprise and mutually agreeable ways ultimately means that our work with clients must always be an iterative process that is one informed by careful attention to each client's construction of reality. In this regard the APA has made another very important observation. That is that the application of research evidence to a given patient always involves probabilistic inference. Therefore, ongoing monitoring of patient progress and adjustment of treatment as needed is essential.

Andrew

This APA conclusion is supported by a number of recent studies, and these studies are noted in the AIFS discussion paper, which have shown increased rates of reliable change in clients as well as reduced deterioration rates in both individual and couples counselling following the employment of routine client feedback using validated instruments.

Molony

So here's the rub. The research would suggest that effective counsellors formally or implicitly understand the iterative nature of counselling. For a variety of reasons, maybe personal, maybe institutional or maybe something else, they may say they are adopting a CBT or a psychodynamic or a systemic or humanistic approach or whatever. But in truth, effective counsellors are continually tracking their clients carefully and respectfully, and in so doing, they're continually making subtle adjustments to their understanding of what their clients are presenting and what their clients need.

Andrew

And that doesn't of course mean that effective counsellors are working in a theoretical vacuum. As Kurt Lewin, the founding father of field theory, famously said, and I quote, "There is nothing so practical as a good theory". But just is true is the advice from Salvador Minuchin, the founder of structural family therapy, who set out a clear model for working with families, but also suggested that we "never marry our hypotheses".

Molony

I like that. You know, I once spent a few days in Milan being part of Luigi Boscolo's reflective team and many of you will know that the Milan systemic model includes the idea that once you come to an understanding of the dynamics keeping the family in a state of distress, you deliver an intervention, a bit like a doctor writing a prescription, and then you finish the session. Well late one night, Luigi was working with an argumentative Jewish family. He consulted the two of us who had remained in the one-way screen room late that night, and then he went back and delivered his intervention to the family. But rather than leaving the room immediately as he would normally have done, Luigi hesitated. It was enough time for the family to gang up and challenge his intervention. Now he could've played the role of the expert at that moment and simply walked out, but instead, he re-engaged with the family in an effort to better understand the source of their concerns. I think in those final 15 minutes, he did his best work.

Now that's Kottler in the picture, not Luigi, who unfortunately died last year, but Kottler captures something of this process in his most recent edition of The Therapist in the Real World, where he talks about what I would call myth of theoretical purity. It is, he says, after all a myth that many of us are applying any theoretical paradigm in its pure and unadulterated form. The reality is that each of us is unique in the ways we interpret and apply concepts, no matter what we call ourselves. So if our techniques and use of theory need to be informed by feedback from our clients, the final question we need to consider is how much we can trust ourselves to really hear and act on that feedback.

Andrew

And the research on this isn't very encouraging. Typically, as Kim Helford and his colleagues have demonstrated, we tend to overestimate client progress, and studies have shown we also typically overrate our own effectiveness. So we're going to begin to wind up this more formal part of the webinar by suggesting that not only should we consider bringing a feedback-informed approached to our work, but that to keep us honest and in the name of client empowerment, we need to consider the routine use of feedback instruments that are validated, are sufficiently brief for both clients and counsellors to be willing to use them every time they meet, are sufficiently brief for agencies and their funding bodies to also be willing to endorse their everyday use, that are easily and freely available and can be employed across a wide range of clients in a wide range of settings and languages.

Molony

At a seminar like this we're a little bit wary of being seen to be promoting one particular method but as far as we can tell, Scott Miller and his associates at the International Center for Clinical Excellence have come closest to meeting these criteria, and they've produced six manuals on what they call feedback-informed treatment. All of these manuals are referenced in the AIFS discussion paper.

Andrew

Scott Miller and his colleagues define feedback-informed treatment as a pan-theoretical approach but one that operationalises the American Psychological Association's take on evidence-based practice that we discussed earlier.

Molony

So we've come to the final proposition that focusing on counsellor qualities and clients' feedback, and simultaneously decoupling the links between diagnosis and treatment has significant implications for future recruitment and training and for monitoring counsellor and agency accountability. We can summarise much of what we've presented in this webinar with the following three observations.

Firstly, the benefits of psychotherapy accrue through social processes rather than the application of techniques. Secondly, the relationship, broadly defined, is the bedrock of psychotherapy effectiveness. And thirdly, feedback-informed counselling processes, especially when supported by the routine use of validated user-friendly feedback instruments, lead to increased rates of reliable change in clients as well as reduced deterioration rates in both individual and couples counselling. The evidence that, broadly speaking, counselling works but that the mechanisms by which it works bear little, if any, relationship to a priori selection of one interventional model over another has profound implications, we think, for future training and future practice.

Andrew

So how do we train counsellors and ourselves to become and remain responsive to the unique circumstances and issues that clients bring to counselling, informed but not enslaved by theory, purposeful in our actions while at the same time being willing to suspend or even abandon a line of approach if it seems unhelpful or if other promising approaches emerge? We recognise that counsellors must begin their professional lives somewhere. Most counsellors begin their training by learning the theory and practice of one or maybe two of the mainstream approaches while perhaps learning at least something about the existence of other models. And this can be a defensible approach but it is not defensible if the rationale for promoting the methods and theories is that they are supported by superior "evidence".

Molony

When an assumption like this is implicitly or explicitly underpinning the training, counsellors could be forgiven for concluding that there's no need to extend their knowledge, their skills or even their life experiences beyond the models they've been taught. They're likely to have been assessed on these models and they might even feel a sense of disloyalty for venturing into areas of counselling theory or practice that are not emphasised in their training, let alone drawing on the wisdom contained from other disciplines or the wisdom that we have from other areas. It's interesting that as far as I can tell, there's been little research on how counsellors select a particular training approach at the beginning of their careers or on how loyalty to a particular approach is developed or maintained.

Andrew

An important pedagogical challenge for trainers and training institutions is how to strike a realistic and responsible balance between the needs to engender confidence by practising skills within a limited number of frameworks and to expose students to a wider variety of approaches. Counselling needs to be seen as a lifelong pursuit. What is being taught and practised at any given time needs to be seen not as the end goal but as the therapeutic equivalent to learning musical scales. Regardless of how the balance is struck, the evidence is now clear. The model or models being employed at any given time must always be subservient to close attention and close responses to what the clients themselves are communicating.

Molony

Thanks Stephen. I absolutely love this picture. I guess it could tell us all sorts of things or we could interpret it in all sorts of ways. One thing it says to me is that if we're feeling comfortable in our role as counsellors, we're probably not performing at our best.

END OF TRANSCRIPT

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Slide outline: Counselling and psychotherapy: Evidence and future directions
  1. Child Family Community Australia (CFCA)
    • Counselling and Psychotherapy: Evidence and future directions
    • Professor Lawrie Moloney Dr. Stephen Andrew
    • The views expressed in this webinar are those of the presenters, and may not reflect those of the Australian Institute of Family Studies, or the Australian Government
  2. Structure of presentation
    • Presenters – one minute profiles
    • Nine propositions about counselling and psychotherapy*
    • Q&A
    • * Based on Moloney, L. (2016) Defining and delivering effective counselling and psychotherapy, released on CFCA website March 8 (yesterday).
  3. Moloney, L. (2016) Defining and delivering effective counselling and psychotherapy
    • Historical introduction to counselling and psychotherapy
    • Analysis of terms, counselling and psychotherapy
    • Defining counselling (default term)
    • Counselling ‘works’ – review of the evidence
  4. Moloney, L. (2016) Defining and delivering effective counselling and psychotherapy (cont)
    • Conundrums around couple and family counselling
    • How counselling ‘works’ (contextual vs medical model)
    • The critical nature of client feedback
    • Implications for recruitment, training and accountability
  5. References
    • All studies mentioned in webinar (and many more) can be found in:
    • Defining and delivering effective counselling and psychotherapy
    • URL: https://aifs.gov.au/cfca/publications (Free download from CFCA website!!)
  6. Key references in presentation
    • Duncan, B., Miller, S., Wampold, B., & Hubble, M. (Eds.) (2014). The heart and soul of change. Delivering what works in therapy. Washington, DC: American Psychological Association.
    • Wampold, B. & Imel, Z., (2015). The great psychotherapy debate. The evidence for what makes psychotherapy work. New York: Routledge.
  7. Presenters’ Orientation
    • Lawrie Moloney
    • Stephen Andrew
  8. Nine propositions
    • 1. Counselling (and psychotherapy) have maintained a centuries-old tradition of providing culturally appropriate responses to "problems of living".
    • 2. Thousands of studies comparing efficacy of differing models of counselling shows no demonstrable differences.
  9. Nine propositions
    • 3. These studies have wrongly presumed a medically informed model of how counselling works.
  10. Nine propositions (cont)
    • 4. Rather than specific treatment modalities, common therapeutic factors determine good outcomes in counselling.
    • 5. Regardless of modality, counselling ‘works’; average effect sizes of around .8 compare with many medical interventions.
  11. Nine propositions (cont)
    • 6. No convincing evidence that gender, qualifications, theoretical orientation, professional discipline or even years of counselling experience impact noticeably on outcomes.
    • 7. Relationship with client(s) supported by personal qualities of the counsellor (e.g., wisdom, compassion, empathy, non-judgmental curiosity), are at the heart of effective counselling.
  12. Nine propositions (cont)
    • 8. Counselling outcomes are significantly enhanced by eliciting, recording and actively responding to client feedback, preferably via routine use of validated client-feedback protocols.
  13. Nine propositions (cont)
    • 9. Focusing on counsellor qualities and client feedback, while decoupling links between ‘diagnosis’ and treatment modality, has implications for future recruitment, training and accountability.
  14. First Proposition
    • Counselling (and psychotherapy) are "modern" continuations of a centuries-old tradition of providing culturally appropriate responses to "problems of living".
    • See Albee, G. (1977). The Protestant ethic, sex and psychotherapy. American Psychologist, 32, 150–61. Giddens, A. (1991). Modernity and self identity. Self and society in the late modern age. Cambridge: Polity Press.
  15. Propositions 2 & 3
    • Thousands of studies comparing efficacy of differing models of counselling show no demonstrable differences.
    • These studies wrongly assume a medically informed model of how counselling works.
  16. Proposition 4
    • Rather than specific treatment modalities, common therapeutic factors determine good outcomes in counselling. Lambert’s hypothesised "common factors"
  17. Lambert's hypothesised "common factors"
    • Percentage of improvement in therapy clients as a function of therapeutic factors (Asay and Lambert, 1999)
      • Client variables and extra-therapeutic events: 40%
      • The therapeutic relationship: 30%
      • Expectancy and placebo effects: 15%
      • Technique and model factors: 15%
  18. Proposition 5
    • Regardless of modality, overwhelming consensus is that counselling "works".
    • Average effect sizes of around .8 compare with effect sizes in many medical interventions.
  19. Proposition 6
    • No convincing evidence that gender, qualifications, theoretical orientation, professional discipline or even years of counselling experience impact noticeably on outcomes.
  20. Proposition 7
    • Relationship with client(s) supported by personal qualities of the counsellor (e.g., wisdom, compassion, empathy, non-judgmental curiosity), are at the heart of effective counselling.
  21. Alliance at the heart of counselling
    • Image: Man on couch talking to goldfish in fishbowl. "You don't say much, but I'm told it's the therapeutic relationship that counts."
  22. Defining evidence-based practice (1)
    • The integration of the best available research with clinical expertise in the context of patient characteristics of culture and preferences. (APA Presidential Task Force on Evidence-Based Practice [2006, p.273]) 
    • Diagram: Clinical expertise, Best research evidence and Patient values & preferences all contribute to EBP
  23. Defining evidence-based practice (2)
    • Psychotherapy is a collaborative enterprise in which patients and clinicians negotiate ways of working together that are mutually agreeable and likely to lead to positive outcomes. Thus, patient values and preferences (e.g., goals, beliefs, preferred modes of treatment) are a central component of [evidenced based practice]. (APA Task Force, 2006, p. 280)
  24. Proposition 8
    • Counselling outcomes are significantly enhanced by eliciting, recording and actively responding to client feedback, preferably via routine use of validated client-feedback protocols.
  25. The place of probabilistic inference
    • "The application of research evidence to a given patient always involves probabilistic inference. Therefore ongoing monitoring of patient progress and adjustment of treatment as needed is essential" (APA Task Force, 2006, p. 280).
  26. The myth of theoretical purity
    • "It is, after all, a myth that any of us are applying any theoretical paradigm in its pure and unadulterated form; the reality is that each of us is unique in the ways we interpret and apply concepts, no matter what we call ourselves." (Kottler, 2015, p. 29)
  27. Using feedback instruments that:
    • are validated
    • are brief
    • can be employed widely
    • are freely available
    • are available in multiple languages
  28. Defining Feedback Informed Treatment
    • "A pantheoretical approach for evaluating and improving the quality and effectiveness of behavioural health services. It involves routinely and formally soliciting feedback from consumers regarding the therapeutic alliance and outcome of care using the resulting information to inform and tailor service delivery. [It] is not only consistent with but operationalizes the American Psychological Association’s (APA) definition of evidence-based practice."
  29. Proposition 9
    • Focusing on counsellor qualities and client feedback, while decoupling links between "diagnosis" and treatment modality, has significant implications for future recruitment and training and for monitoring accountability.
  30. Summary statement
    • Benefits accrue through social processes
    • Counsellor-client relationship is the bedrock
    • Feedback informed processes produce better results
    • Feedback via validated instruments is even better
  31. How do we train ourselves to be:
    • Responsive?
    • Informed?
    • Purposeful?
    • Flexible?
  32. Questions?
    • Join the Conversation
    • You can continue the conversation started here today and access a range of related resources, including the CFCA Paper on this topic, on the CFCA website: www.aifs.gov.au/cfca/news-discussion

This webinar was held on 9 March 2016.

Access the accompanying CFCA Paper: Defining and delivering effective counselling and psychotherapy

This webinar focussed on the evidence for the efficacy/effectiveness of counselling and psychotherapy, the factors that contribute to its success, and the importance of incorporating client feedback into practice.

We suggest that to achieve consistently effective results, we must move away from medically grounded models of practice. Rather than promoting standardised interventions for formally diagnosed conditions (all of which are equally effective), the evidence points to the need to pay close attention to how counsellor/therapist expertise is developed and maintained. We review research suggesting that effectiveness is closely linked to persistent, highly engaged, deliberate practice, informed by a willingness to seek, document and respond empathically to client feedback. We conclude by considering the advantages and challenges associated with feedback-informed approaches to the art, craft and science of counselling and psychotherapy.

Further reading

About the presenters

Lawrie Moloney

Professor Lawrie Moloney is a Senior Research Fellow at the Australian Institute of Family Studies and an Adjunct Professor in the School of Public Health at La Trobe University. He is a registered psychologist, family mediator and family therapist. Having served as a Director of family court counselling in the early years of the Family Court of Australia, Lawrie then spent 24 years in the university sector, mainly teaching counselling and counselling psychology. He is Editor in Chief of the Journal of Family Studies and has authored more than 200 publications, many related to children, parenting and divorce.

Stephen Andrew

Dr Stephen Andrew is a psychologist who has spent over 20 years training psychotherapists, working in private practice and counselling in the Gambler’s Help network. He is deeply curious about the role the therapeutic alliance plays in client outcomes, and recently completed his Doctor of Clinical Science at La Trobe University. Stephen’s forthcoming book is titled Searching for an Autoethnographic Ethic.