Toward Effective Counseling and Psychotherapy

Training and Practice

Robert Carkhuff

• Publisher: Routledge
• Year: 2017
• eBook ISBN: 9781351301466
• Topic: Psychologie
• Subtopic: Histoire et théorie en psychologie

The field of counseling and psychotherapy has for years presented the puzzling spectacle of unabating enthusiasm for forms of treatment whose effectiveness cannot be objectively demonstrated. With few exceptions, statistical studies have consistently failed to show that any form of psychotherapy is followed by significantly more improvement than would be caused by the mere passage of an equivalent period of time. Despite this, practitioners of various psychotherapeutic schools have remained firmly convinced that their methods are effective. Many recipients of these forms of treatment also believe that they are being helped.

The series of investigations reported in this impressive book resolve this paradoxical state of affairs. The investigators have overcome two major obstacles to progress in the past--lack of agreement on measures of improvement and difficulty of measuring active ingredients of the psychotherapy relationship. The inability of therapists of different theoretical persuasions to agree on criteria of improvement has made comparison of the results of different forms of treatment nearly impossible. The authors have solved this intractable problem by using a wide range of improvement measures and showing that, regardless of measures used in different studies, a significantly higher proportion of results favor their hypothesis than disregard it.

Overall, this book represented a major advance at the time of its original publication and is of continuing importance. The research findings resolve some of the most stubborn research problems in psychotherapy, and the training program based on them points the way toward overcoming the shortage of psychotherapists.

Section I Theoretic And Research Bases For Training And Practice In Psychotherapy And Counseling

IN this first section we have tried to review the body of research evidence and theoretical convergence that forms the foundation for the current approach to training and practice. The focus is on the question: “What are the effective ingredients of successful therapeutic efforts?”

Chapter 1 sets the stage for the remainder of the book by asking the basic question “Are counseling and psychotherapy indeed effective ways of helping the client or patient toward constructive personality and behavioral change?” After evaluating the current available research evidence pro and con, the chapter comes to four conclusions: (1) the therapeutic endeavor is, on the average, ineffective; (2) therapy itself is a non-unitary phenomenon; (3) some counselors and therapists are significantly helpful while others are significantly harmful, with a resulting average helpfulness not demonstrably better than the effect of having no professional treatment; and (4) through research it is possible to identify the major ingredients of helpful and harmful therapy, and thus markedly increase the average effectiveness of counseling and psychotherapy.

Chapter 2 attempts to identify the elements of effective therapeutic encounters as specified by widely divergent theorists. The search is for common elements cutting across divergent theories (which, in their own expositions, focus heavily on their major differences.) The chapter also focuses on what these theories, whether psychoanalytic, client-centered, behavioristic, or eclectic, have to say about the person and the characteristics of an effective therapist.

Although most theorists concern themselves in their writings with discussing the client, three characteristics of an effective counselor emerge from the divergent viewpoints:

(1) An effective therapist is integrated, nondefensive, and authentic or genuine in his therapeutic encounters.

(2) An effective therapist can provide a non-threatening, safe, trusting or secure atmosphere by his acceptance, unconditional positive regard, love, or non-possessive warmth for the client.

(3) An effective therapist is able to “be with, ” “grasp the meaning of, ” or accurately and emphathically understand the client on a moment-by- moment basis.

The theoretical convergence of widely divergent theorists is illustrated by direct quotations from their writings. From their own statements and in their own language it can be seen that the major representatives of existing “schools” of psychotherapy and counseling recognize the central therapeutic importance of these three basic ingredients; each adds his own emphasis to the developing clinical and theoretical meanings of the concepts of accurate empathy, nonpossessive warmth, and genuineness. Finally, the chapter includes research scales that have attempted to capture and quantify the essential meaning of these three concepts. The scales are presented both because of their potential value in specifying the concepts more concretely and because most of the research findings in the succeeding chapter were based upon them, and they are central to the present approach to training discussed in Section II.

Chapter 3 reviews the mounting research evidence that confirmed the importance of these three central therapeutic ingredients. The research reviewed also tends to confirm the conclusions reached in Chapter 1: that counseling and psychotherapy as currently practiced are both for better and for worse, but on the average are ineffective. The findings go further (and confirm the conclusions of Chapters 1 and 2) by indicating that counselors and therapists who offer high levels of empathy, warmth and genuineness produce positive changes in their clients, while therapists who offer low lovels of these “therapeutic conditions” produce deterioration or no change in their clients.

Chapter 4 discusses the implications of recent research conducted by learning-oriented experimentalists and therapists. Although the evidence reviewed suggests that “behavior therapy” is not demonstrably more therapeutically effective than any other approach, this chapter suggests that many of its specific basic principles, if carried out within the context of high levels of the central therapeutic ingredients discussed in Chapters 2 and 3, can markedly enhance the effectiveness of traditional or interpersonal approaches to counseling or therapy. The viewpoint that a behavioristic approach (except for the language) need not be antagonistic, and may even be complementary, to a more humanistic approach is presented with evidence suggesting its applicability to psychotherapy in general and client-centered counseling in particular.

Chapter 5 views the person who comes for psychotherapeutic help. Research evidence concerning characteristics of successful and unsuccessful clients or patients is reviewed. The conclusions drawn are that, although some of the evidence is conflicting, the client most likely to benefit is the one who (1) has a high degree of inner or “felt” disturbance but a low degree of behavioral or “overt” disturbance; (2) has a high degree of readiness, positive expectancy, or hope for personal improvement; and (3)engages in deep and extensive self-exploration.

Since the available research evidence and major theoretical views discussed converge in indicating that the client’s level of self-exploration is due in part to the influence of the therapist and can therefore be changed, depth of self-exploration is viewed as a fourth major ingredient of effective therapeutic encounters.

The Depth of Self-Exploration Scale, on which much of the research has been based, is presented. This scale, along with scales for accurate empathy, nonpossessive warmth and genuineness presented in Chapter 2, is an integral part of the present approach to training discussed in Section II. It provides a crude but convenient moment-by-moment method of evaluating the client’s response to therapy and the therapist’s or trainee’s skill in engaging the client in the therapeutic process.

Chapter 6 reviews existing approaches and viewpoints in the training of counselors and therapists and thus sets the stage for the succeeding chapters on training. The heavy emphasis in existing viewpoints toward either a didactic or an experiential approach is discussed in the context of the goal of training—producing a technician skilled in the use of techniques but, above all, an open and flexible person who has self-awareness and yet is sensitively attuned to the client both in receiving and communicating vital personal messages.

Chapter 1 Counseling And Psychotherapy: Differential Antecedents With Differential Consequences?

An Introductory Note

LIKE any presentation of existing literature, the present book is to some degree selective and biased in content and viewpoint, since it has grown out of the human, and therefore selective, readings of literally thousands of articles and countless books and chapters. In attempting to cite the relevant evidence for a particular conclusion, rarely does space allow for more than the briefest description of the evidence. This seems to be one unfortunate but necessary part of writing a book, and in many ways is grossly unfair, since some of the evidence cited in a sentence or paragraph has been presented by the original authors in a book which is itself a condensation of years of thought and research involving dozens of people. Then, too, a small study of 14 or 29 clients may be given more space here than a better study involving hundreds of patients because it is better known, because it seems to require more comment, or because the findings are simply more complex. Finally, the reader should bear in mind that no single presentation can hope to include all of the available evidence; this is an aim but not an actuality. In the course of preparing this book we, like all authors, have had the experience of finding studies that were important or even central to an issue during a chance rereading of old and new journals or books—after we had finished that portion of the writing. Books, unlike research and practice, are not continuing evolving and changing processes—and to that extent they fail to reflect reality.

Although we have endeavored to be “objective, ” in a very real sense this ideal cannot be met in practice: we are left with the simple fact that what follows throughout both this chapter and this book reflect the evidence and the most probable conclusions as we see them.

Toward Evaluating The Overall Effects Of Counseling And Psychotherapy

Counseling or psychotherapy is aimed at producing constructive behavioral and personality change. Its rapid growth over recent decades implies that the procedures involved are indeed highly effective; certainly the client, or patient, as well as the professional counselor or psychotherapist, seems convinced of its value. It has become a principal part of clinical psychology, psychiatry, social work, school counseling, marriage counseling, rehabilitation counseling, and vocational counseling; and is a principal activity of parole officers, group workers, recreation and playground counselors, anti-poverty workers, welfare workers, clergymen, educators, family physicians, and nurses.

This book, which focuses on training and practice, obviously implies that at least some kinds of counseling and psychotherapy are of significant value, and that some significant aspects of the process are now known and can be learned.

However, a considerable amount of evidence also seems to suggest that counseling or psychotherapy is not superior to “no treatment.” Eysenck (1960) went so far as to suggest that it could be described like the “wondrous cure” developed by Galen, the father of modern medicine. Galen promoted his remedy as follows: “All who drink this remedy recover in a short time, except for those whom it does not help, who all die and have no relief from-any other medicine. Therefore, it is obvious that it fails only in incurable cases.”

This assertion that psychotherapeutic approaches were ineffective in helping either the disturbed child or the neurotic or disabled adult raised a considerable controversy (Eysenck, 1952, 1955, 1961; DeSharmes, Levy, and Wertheimer, 1954; Luborsky, 1954; Meehl, 1955; Rosenzweig, 1954; Sanford; 1954; Shoben, 1956; Strupp, 1963; Teuber and Powers, 1953).

However, after a careful review of the relevant research literature, it now appears that Eysenck was essentially correct in saying that average counseling and psychotherapy as it is currently practiced does not result in average client improvement greater than that observed in clients who receive no special counseling or psychotherapeutic treatment. (This is in spite of Eysenck’s inclusion of questionable data and indiscriminate pooling of data from reports with divergent criteria for treatment and outcome.) Frank (1961) and others have noted that statistical studies consistently report that about two-thirds of neurotic patients improve immediately after treatment regardless of the type of psychotherapy received, but that the same improvement rate has been found for comparable clients who have not received psychotherapy. However, some other relatively well-controlled studies show that certain counselors or therapists do produce beneficial effects beyond that observed in equivalent control groups.

Putting together these two bodies of evidence, it logically follows that if psychotherapy has no overall average effect, but that there are valid specific instances where it is indeed effective, then there must also be specific instances in which it is harmful. That is, to achieve this average, if some clients have been helped, then other clients must have been harmed. This suggestion that psychotherapy and counseling can be for better or for worse is the major starting point for the present approach to practice and training. Much of the recent research evidence supporting the “for better or for worse” hypothesis will be reviewed in Chapter 3, in the context of specific aspects of the therapeutic relationships that lead to constructive or deteriorative personality and behavioral changes in the client. This chapter, though, will attempt to review the literature suggesting that, as currently practiced, average counseling and psychotherapy is ineffective, but some is indeed effective. This implies that differences in effectiveness between therapists are much larger than differences between therapy or counseling and no treatment.

Evidence For Average Ineffectiveness Of Counseling And Psychotherapy

The single largest controlled study of the effects of counseling, guidance, or psychotherapy was one of more than 600 delinquency-prone boys, reported by Teuber and Powers (1953). The initial 650 boys were individually matched in pairs on such variables as age, intelligence, school grades, delinquency ratings and socioeconomic background. One member of the pair was assigned randomly to the treatment group, the other to the control group. Although there was some turnover in counselors and therapists during the eight years of treatment, much of the treatment was supportive therapy in which the individual counselor attempted to develop a friendly and supportive relationship with the boys. Both psychoanalytically oriented and client-centered counselors participated in the treatment program. As expected, the treatment group looked quite successful, but analysis of the data also indicated that the control group showed equivalent positive changes. In fact, the evidence suggested a slight difference in outcome favoring the control group. This negative finding occurred despite the facts that a majority of the boys in the treatment group personally reported their belief in the value of the counseling, guidance, and psychotherapy, and that the counselors themselves considered their therapeutic relationships highly effective.

A second major report attempted to analyze statistically the results of treatment of war neuroses that occurred during World War II. That study by Brill and Beebe (1955) made highly sophisicated comparisons between large numbers of neurotic soldiers receiving individual therapy and similar large groups of neurotic soldiers receiving routine hospital care, rest and sedation, or no treatment. Their findings in general indicated that the percentage of patients who improved was slightly higher for the nontreated group. The only positive findings related to improvement were sociological factors: the unskilled and poorly educated soldier was less likely to improve and more likely to become worse. It should also be noted that there was an overall tendency for both control and treated patients to show improvement over time. With most measures of outcome utilized by Brill and Beebe, the patients receiving only uest and sedation appeared to show slightly greater improvement than those receiving either individual therapy or no treatment.

A third major study of psychotherapy was reported by Barron and Leary (1955). Of 150 neurotic patients who had applied and been accepted for treatment in a psychiatric clinic, 23 were placed on a waiting list and thus served as a control during a six-month period of observation. Eighty-five were assigned to group therapy and 42 were assigned to individual therapy. All patients in treatment received a minimum of three months of therapy; they all were tested on the MMPI (Minnesota Multi- phasic Personality Inventory) initially and after treatment. T...

Table of contents

• Cover Page
• Title Page
• Copyright
• Dedication
• Contents
• Foreword
• Preface
• Section I Theoretic And Research Bases For Training And Practice In Psychotherapy And Counseling
• Section II Toward an Integrated Didactic and Experiential Approach to Training
• Section III Toward the Mature Therapist and Counselor
• References
• Index