Counseling 407
Community Counseling
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Dr. Jeffrey K. Edwards, LMFT
Office 4054
Phone 773-442-5541
Office Hours – Wednesdays 1-4, Thursdays 3-6
Counseling 407
Community Counseling
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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.
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
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.
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 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, 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 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).
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
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%).
Counseling Knowledge
Common Factors in Counseling
Technique
15%
Expectancy
(placebo
Effect
15%
Theraputic
Relationship
30%
Extratheraputic
Change
40%
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%)
“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
evident;
2. Underlying personality disorder;
3. Quality of social support, especially the
marital relationship (Andrews & Tennant,
1978; Mann, Jenkins, & Belsey, 1981).
The Therapeutic Relationship (30%)
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The Necessary and sufficient conditions
Accurate Empathy
Positive Regard
Non possessive warmth
Congruence and genuineness.
These are client-perceived rather than
objective raters’ perceived.
The Therapeutic Relationship (30%)
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It seems that the following components are
important to the therapeutic alliance:
Client’s affective relationship with the therapist;
Client’s capacity to work purposefully in
therapy;
Therapist’s empathic understanding and
involvement;
Client-therapist agreement on goals and tasks of
therapy (Gaston, 1990).
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 life!!
Models of Psychotherapy Used at
Internship Sites National
Structural
1%
N = 854
Adlerian
1%
Behavioral
14%
Solution
19%
Brief Strategic
8%
Reality
6%
Client
Centered
9%
Psychody
10%
Narrative
1%
Cognitive
18%
Jungian
0%
Family
Systems
13%
Things to think about!
The mortal wound of psychotherapy
occurred when it made objects-to-be-fixed
of the people it was trying to help.
Gerald May, M. D. (1990)
Counseling Knowledge
Since the mid 1980’s there has been an
275% increase of persons who have
trained and provide
counseling/psychotherapy.
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 that?
• there are well over 260 models of
counseling/psychotherapy, and most people
seeking help have only a vague idea of
what to expect.
•
Edwards, J.K. & Heath, A.W. (2006). Unveiling the Mysteries of
Psychotherapy: A consumers guide to mental health services. Haworth Press,
Inc.
• Most psychiatric conditions do not have a
clear etiology, rather they are defined as
either syndromes or patterns of symptoms
that include emotion, cognition, perception,
and/or behaviors.
•
Sahler, O.J.Z., & Carr, J.E. (2003) (Eds.). The Behavioral Sciences and Health
Care. Hogrefe & Huber, Cambridge, MA.
• The problem raised by the term “mental” disorders has been
much clearer than its solution, and, unfortunately, the term
persists in the title of DSM-IV because we have not found an
appropriate substitute. A categorical approach to classification
works best when all members of a diagnostic class are
homogeneous, when there are clear boundaries between
classes, and when the different classes are mutually exclusive.
Nonetheless, the limitations of the categorical classification
system must be recognized. In DSM-IV, there is no
assumption that each category of mental disorders is a
completely discrete entity with absolute boundaries dividing it
from other mental disorders or from no mental disorder.
There is also no assumption that all individuals described are
having the same mental disorder are alike in all important
ways.
•
American Psychiatric Association, Diagnostic and Statistical Manual for Mental Disorders, Fourth
Edition, Text Revision Washington DC. APA, (2000). - p. xxx and
xxxi
• In the last fifteen years, HMO’s, insurers,
pharmaceutical companies, hospital corporations,
physicians, and other segments of the industry
contributed $479 million to political campaigns –
more than the energy industry ($315 million),
commercial banks ($133 million), and big tobacco
($52 million). More telling is how much the health
care industry spends on lobbying. It invests more
than any other industry except one, according to
the nonpartisan Center for Responsive Politics.
From 1997 to 2000, the most recent year for which
complete data is available, the industry spent $734
million lobbying Congress and the executive
branch.
• Barlett & Steele, (2004). Critical Condition
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?
A Community Counseling Model
The Upstream Model
A Model of Community
Counseling
• This is the story of the Jeffrey’s River –
• Once upon a time. There was a river.
named Jeffrey.
I wonder
why?
A Model of Community
Counseling
• One day …someone came floating ..
A Model of Community
Counseling
• down the river, almost drown.
A Model of Community
Counseling
• A good Samaritan saw the drowning person
Help!
A Model of Community
Counseling
• helped him out and saved his life.
Thanks
A Model of Community
Counseling
• Soon, another person came floating down
the river, almost drown.
Help!
A Model of Community
Counseling
• and he too, was helped out and had his life
saved.
Thanks
A Model of Community
Counseling
• soon there were lots and lots of people
coming down the river drowning.
Help!
Help!
Help!Help!
Please!!
A Model of Community
Counseling
• The Samaritan needed some help. So he
asked a friend.
Help!
Help!
Help!Help!
Please!!
A Model of Community
Counseling
• And soon there were lots and lots of people
helping all those other people coming down
the river drowning.
A Model of Community
Counseling
• Soon they were building hospitals, and
clinics….
A Model of Community
Counseling
• And then they had supervisors and
administrators…
A Model of Community
Counseling
• And they had overseers who told them how much
they would pay…called Managed Care.
A Model of Community
Counseling
• And then one very smart person decided to
go up stream to see…..
A Model of Community
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.
A Model of Community
Counseling
• And he told him to stop. So, he did!
Hey, stop
that!
OK, I will.
A Model of Community
Counseling
• And that is how a Preventative Public
Health model was born….
You are
Thanks.
welcome.
Community Counseling
Components
• The community has all the resources needed
to provide for it’s members;
• Finding out what the community needs, and
then what their resources are starts the
process.
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.
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.
Prevention
• According the Albee and Ryan-Finn (1993)
prevention is “doing something now to
prevent or forestall something unpleasant or
undesirable from happening in the future or,
alternatively, doing something now that will
permit or increase desirable future
outcomes.
Three types of Prevention
• Primary
• Secondary
• Tertiary
• Primary prevention
involves prevention of the
of the disease or injury
itself, generally through
reducing exposure or sisk
factor levels.
Three types of Prevention
• Primary
• Secondary
• Tertiary
• Secondary prevention
attempts to identify and
control disease process in
their early stages, often
before signs and
symptoms become
apparent.
Three types of Prevention
• Primary
• Secondary
• Tertiary
• Tertiary prevention seeks to
prevent disability through
restoring individuals t their
optimal level of functioning after
damage is done.
• Turnock, B. J. (1997). Public
Health: What It Is and How It
Works. Maryland: Aspen
Publications.
Risk and Protective Factors
CONTEXT
RISK FACTORS
PROTECTIVE FACTORS
Individual
. low verbal skills
. favorable attitudes toward antisocial behavior
. psychiatric symptomatology
. cognitive bias to attribute hostile intentions to
others
. intelligence
. being firstborn
. easy temperament
. conventional attitudes
. problem solving skills
Family
. lack of monitoring
. ineffective discipline
. low warmth
. high conflict
. parental difficulties, e.g., drug abuse,
psychiatric conditions,
criminality
. attachment to parents
. supportive family environment
. marital harmony
Peer
. association with deviant peers
. poor relationship skills
. low association with prosocial peers
. bonding with prosocial peers
School
. low achievement
. dropout
. low commitment to education
. aspects of the schools, such as weak structure
and chaotic environment
. commitment to schooling
Neighborhood & Community
. high mobility
. low community support (neighbors) . neighbors,
church, etc.
. high disorganization
. criminal subculture
. ongoing involvement in church
activities
strong indigenous support
network
A Public Health approach looks to:
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Epidemiology to find need
Prevention over direct service
Capacity building of services
Multi-Model ways of service delivery
Advocacy for those in need, and cost
containment of the escalating health care
costs.
"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
Community Counseling
Components
• Mental Health and Mental
Illness: A Public Health
Approach – Surgeon General
Report:
• http://www.surgeongeneral.gov/library/ment
alhealth/chapter1/sec1.html
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).
• Salaries for therapists
went through a shift.
During the “Golden
Days” (1980’s) of
psychotherapy, the
cost of a service hour
want to around
$90.00. Now, the rate
is changed
Cost per capita for Individual
Counseling
Managed care attempts to contain the overspending of funds in the pot. It is a
balancing act, that has caused major
problems for many people, not the least the
providers of service.
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.
• Log yourself onto the blackboard page!!