Counseling 407
Community Counseling
Dr. Jeffrey K. Edwards, LMFT
Room 4054
[email protected] or [email protected]
Office hours are Wednesdays 4-7 and
Thursdays 1-4.
Counseling 407
Community Counseling
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
Counseling Knowledge
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)
Counseling Knowledge
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).
Counseling Knowledge
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
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
Counseling Knowledge
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.
Counseling Knowledge
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,
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 client’s
personality (Hubble, Duncan, &
Miller, 1999).
Counseling Knowledge
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.”
Counseling Knowledge
Effective therapy can be achieved in short
periods of time (5 to 10 sessions) with at least
50% of clients seen in routine clinical
A sizable minority (20% to 30%) requires
treatment lasting more than 25 sessions. Those
clients who are more likely to fail at brief
efforts are those who are poorly motivated,
have poor relationships with others in their life.
Counseling Knowledge
Techniques that are critical, attacking,
rejecting, blaming etc. Are less effective
treatments (Najavits & Strupp, 1994)
Therapies that focus on the future, instill
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?
Counseling Knowledge
If techniques are not that important, then
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%).
Counseling Knowledge
Common Factors in Counseling
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).
Client Variables (40%)
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.
Client Variables (40%)
“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).
The Therapeutic Relationship (30%)
Spontaneous Improvement
is influenced by
1. Length of time the problem has been
2. Underlying personality disorder;
3. Quality of social support, especially the
marital relationship (Andrews & Tennant,
1978; Mann, Jenkins, & Belsey, 1981).
The Therapeutic Relationship (30%)
The Necessary and sufficient
Accurate Empathy
Positive Regard
Non possessive warmth
Congruence and genuineness.
These are client-perceived rather
than objective raters’ perceived.
The Therapeutic Relationship (30%)
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,
The Therapeutic Relationship (30%)
It seems that the following components
are important to the therapeutic alliance:
Client’s affective relationship with the
Client’s capacity to work purposefully in
Therapist’s empathic understanding and
Client-therapist agreement on goals and tasks
of therapy (Gaston, 1990).
The Therapeutic Relationship (30%)
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
The Therapeutic Relationship (30%)
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
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
In several studies with
medications, the placebo effect
has been demonstrated to be
even greater than the 15%
usually assumed (Benson &
McCallie, 1979).
Expectancy and Placebo Effect
In 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.
Expectancy and Placebo Effect (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.
Technique (15%)
Of more concern, and reported more in the
is the finding that staying true to a manual may
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
when one regards the current trends by the
Psychiatric Association, Managed Care
Models of Psychotherapy Used at
Internship Sites National
N = 854
Brief Strategic
Stages of Change
James Prochaska
Precontemplation –
Contemplation –
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
 May have tried to change in the past without
 No inherent motivation to change
Contemplation –
 People intend to change within the next 6
 Are aware of pros and cons of change vs.
no change.
 Profound ambivalence.
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.
 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.
Counseling Knowledge
Beecher (1955) reviewed 15 single or
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,
Counseling Knowledge
Since the mid 1980’s there has been an
275% increase of persons who have
trained and provide
There still has not been a reduction in any
of the psychological or psychiatric
A Community Counseling
The Upstream Model
A Model of Community
 This is the story of the Jeffrey’s River –
 Once upon a time, there was a river named
I wonder
A Model of Community
 One day …someone came floating ..
A Model of Community
 down the river, almost drown.
A Model of Community
 A good Samaritan saw the drowning person
A Model of Community
 helped him out and saved his life.
A Model of Community
 Soon, another person came floating down
the river, almost drown.
A Model of Community
 and he too, was helped out and had his life
A Model of Community
 soon there were lots and lots of people
coming down the river drowning.
A Model of Community
 The Samaritan needed some help. So he
asked a friend.
A Model of Community
 And soon there were lots and lots of people
helping all those other people coming down
the river drowning.
A Model of Community
 Soon they were building hospitals, and
A Model of Community
 And then they had supervisors and
A Model of Community
 And they had overseers who told them how much
they would pay…called Managed Care.
A Model of Community
 And then one very smart person decided to
go up stream to see…..
A Model of Community
 what or who was causing all those people to
fall in the river.
It is me. I like to
push them into
the drink.
A Model of Community
 And he told him to stop. So, he did!
Hey, stop
OK, I will.
A Model of Community
 And that is how a Preventative Public Health
model was born….
You are
The Dawn of a New Day
 Salaries for therapists
went through a shift.
During the “Golden
Days” (1980’s) of
psychotherapy, the
cost of a service hour
went to around $90.00.
Now, the rate has
"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
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?
Community Counseling
 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 it’s 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.
 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
Examples of Epidemiology and
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.
Examples of Epidemiology and
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.
Community Counseling
 Mental Health and Mental Illness:
A Public Health Approach –
Surgeon General Report:
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).
The Institute of Medicine report on
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
(IOM, 1994a).
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.)
Critique of a medical definition of Mental Health
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
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).
Critique of a medical definition of Mental Health
The conventional medical system has
much to gain financially by using the
individual treatment model (Albee, 1993).
The organic
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.