PersonCentred Approaches to Psychological Therapy: A Review of the Contemporary Evidence

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Person-Centred Approaches to Psychological
Therapy A Review of the Contemporary Evidence

• Mick Cooper
• Professor of Counselling
• University of Strathclyde
• mick.cooper_at_strath.ac.uk

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Overview

• Empirically supported (EST) / evidence-based
  perspective little evidence for PCT
• Limitations of EST perspective
• The Dodo bird hypothesis evidence for the
  equivalent efficacy of PCT
• Common factors and principles of change
  approaches support for PCT
• Pluralistic framework PCT and relational
  therapies have an essential place

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Empirically supported perspective

• Developed in US in 1990s
• Basis of current UK government recommendations,
  esp. NICE guidelines
• Psychological treatments medical treatments
• Fundamental question
• Which psychological treatments have been shown to
  be efficacious?
• Draws on evidence from rigorously controlled
  trials (randomised, manualised treatments) with
  specific groups of clients

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PCT from an EST perspective

• Empirically-based NICE/DoH guidelines do not
  recommend PCT for any disorder (cf. CBT)
• In DoH guidelines, Counselling (meaning a
  supportive, nondirective, short-term form of
  therapy)
• recommended for clients who are having
  difficulty adjusting to life events, illnesses,
  disabilities or losses
• evidence of effectiveness with mixed
  anxiety/depression and generic psychological
  distress presenting in primary care (NICE
  guidelines also recommend for young people with
  mild or moderate depression)
• specific client groups (e.g. bereavement
  reactions, mild post-natal depression) may also
  benefit from counselling

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Why is PCT not recommended as an EST?

• Few studies at required level of rigour have been
  conducted
• But, no evidence ? evidence against
• Perhaps the best predictors of whether a
  treatment finds its way to the empirically
  supported list are whether anyone has been
  motivated (and funded) to test it and whether it
  is readily testable in a brief manner (Westen et
  al., 2004, p.640).

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Evidence that PCT is possibly efficacious with

• Anxiety
• Depression
• Schizophrenia
• Severe personality disorders
• Health-related problems
• (Elliott et al., 2004)

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Overall effect size (ES) for PCT

• From pre-PCT to post-PCT ES 0.91 (large
  change), maintained at follow-up
• Difference between PCT against control treatment
  ES 0.78
• 80 of clients better off after PCT than average
  client in untreated control group
• (Elliott, in press)

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80
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But isnt there evidence against..?

• Numerous rigorously controlled studies find
  supportive or nondirective counselling (as
  control) to be less effective than CBT e.g.
• Foa et al. (1991) CBT more efficacious than
  supportive counselling for women who had been
  raped

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Problems with counselling control

• Most studies conducted by proponents of CBT ?
  Research allegiance effects
• calculated to account for around 2/3rds of
  outcomes in comparative studies (Luborsky et al.,
  1999)

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How can researcher allegiance affect outcome?

• File drawer problem null results dont get
  published
• Distorted analysis of data (esp. therapist
  factors not taken into account)
• Use of outcome measures that are more resposive
  to particular therapies (e.g. cognitive slant of
  BDI)
• Control counselling is nothing like real
  counselling (e.g. counsellors instructed to
  change topic if client mentions assault Foa et
  al., 1991)
• Counselling delivered by practitioners aligned
  to experimental treatment ? questionable
  commitment to, or belief in, counselling

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Despite this

• Nondirective/supportive counselling controls
  often do remarkably well
• In some instances more effective than
  experimental treatment e.g.
• Clients under 21 years of age being treated for
  first episode psychosis did better in supportive
  counselling than CBT
• (Haddock et al., 2006)

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Dodo bird verdict

• Meta-analyses of studies comparing efficacy of
  different therapies (particularly where bona
  fida) consistently find few differences
• Effect size ? 0.2 (e.g. 0.2 of a standard
  deviation between mean of superior and
  inferior treatment)

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PCT vs. CBT

• 20 direct comparative studies (Elliott, in press)
• Average difference in improvement
• ES 0.19 in favour of CBT
• Trivial clinical difference (Elliott, in press)
• 10 difference in success rates e.g. 45 vs. 55
• 42 of clients in PCT do better than average CBT
  client

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and 0.2 ES does not take into account allegiance
effects

• Of 20 comparative studies
• 10 by CBT advocates
• 9 by neutral parties
• 1 by PCT advocates
• Comparative ESs
• CBT-based studies .39 in favour of CBT
• Neutral studies .04 in favour of PCT
• (Elliott, in press)

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E.g. data from neutral study (King et al. 2000)

• Rigorous, comparative RCT of therapy in primary
  care. Clients depression mixed
  anxiety/depression, n464

At 12 months, those choosing NDC significant more
satisfied
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E.g. data from comparative effectiveness (i.e.
real world) study (Stiles et al., 2006)

• 1309 clients at 58 primary and secondary care
  NHS sites

Pre-post diff. in CORE-OM score
CBT
PCT
CBT1
PDT 1
PCT1
PDT
(psychodynamic)
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norrecent developments in PCA and humanistic
field

• Data on modern process-guiding experiential
  therapies e.g., Emotion-focused therapy (EFT)
  Gestalt therapy, psychodrama (Elliott et al,
  2004)
• Pre-post ES (n 64) 1.17 (cf. 0.91 for PCT)
• ES against control (n 16) 1.18 (cf. 0.78 for
  PCT)
• ES against non-experiential controls (n 34)
  0.27
• 49 no significant differences
• 38 studies experiential clients did at least ES
  .4 better
• 13 studies experiential clients did at least ES
  .4 worse
• ES against CBT (n 14) 0.2

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Common factors approach

• Given approximate equivalence of different
  therapies
• Move away from grand prix research designs to
  exploration of helpful factors across different
  therapies

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PCT from a common factors stance

• PCT emphasis on client agency and motivation
  consistent with common factors research (see
  Bohart Tallman, 1999)
• PCT emphasis on positive therapeutic relationship
  consistent with common factors model (see
  Norcross, 2002)

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Empathy

• One of three demonstrably effective elements of
  therapeutic relationship
• Evidence from almost 100 studies suggesting that
  it accounts for about 4 of variance in outcomes
• ES about .20 in small to medium range
• (Bohart et al., 2002)

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Positive Regard

• One of seven promising and probably effective
  elements of therapeutic relationship
• around 50 of studies conducted found significant
  positive relationship with outcome
• therapist characteristics akin to positive
  regard are at least moderately associated with
  ex-clients perceptions of improvement
• (Farber and Lane, 2002)

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Congruence

• Also one of seven promising and probably
  effective elements
• 34 of relevant studies found positive
  correlations between with outcome
• support for the contribution of congruence to
  patient outcome is mixed
• (Klein et al., 2002)

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Principles of Therapeutic Change that Work

• Div. 12 APA (Clin. ?) and SPR collaborative
  project and publication
• Ed. Castonguay and Beutler (2006, OUP)
• Empirical analysis of which
• Participant characteristics (therapists and
  clients)
• Relational conditions
• Techniques
• likely to lead to change universally and for
  clients with specific disorders (e.g., PDs)?
• Relationship Technique dimension
• Beyond either/or to both/and

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E.g., depressive disorders

• Participant factors
• Pretreatment readiness for change (universal)
• Lower age (specific to depressive disorders)
• Therapeutic relationship
• High levels of empathy
• Use of self-disclosures
• Techniques and interventions
• Initial and ongoing assessment
• Identifying and challenging dysfunctional
  thoughts
• Skilful use of non-directive interventions

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PCT from a change principles stance

• PCT includes many universal and specific
  principles of change
• Some change principles not so consistent with
  classical PCT stance eg.
• Assessment
• Structured approach
• Challenging dysfunctional thoughts
• But not totally inconsistent with contemporary,
  flexible, responsive PCT

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Pluralistic framework

• Cooper and McLeod (in press)
• Beyond common factors and change principles
  frameworks
• Different clients (even with same diagnosis) want
  and need different things at different points in
  time
• Asking which therapy is best is like asking which
  is the best flavour of ice cream. Some people
  will swear that vanilla or pistachio are
  superior and surveys would undoubtedly find that
  one flavour comes out on top. But to deduce from
  this that we should all only ever eat one flavour
  of ice cream would be seen by most people as
  utterly nonsensical. WE know that different
  people have different preferences at different
  points in time, and it is this diversity that
  gives life its richness and vitality.

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Different clients have different preferences

• E.g., King et al. (2000) Clients could
  specifically opt for
• CBT
• The therapists task is to identify thoughts,
  feelings and behaviours that affect your mood and
  to help you to develop practical ways to develop
  a more positive approach to those thoughts,
  feelings and behaviours
• Counselling
• The therapists task is to give you the
  opportunity to talk about what is troubling you,
  so that you can explore your thoughts and
  feelings about it, in a way that is not always
  possible with family and friends

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Patient preference choicesn 137, of 464
eligible clients (King, 2000)
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Pluralistic framework What is helpful depends on
what goal/problem is

• PCT and relational therapies likely to be
  particularly helpful in such circumstances as
• Client wants space to talk and reflect
• Absence of in-depth relating (current or
  previous) at heart of clients problems
• Q. Is this relevant to a significant proportion
  of clients?

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Research shows clients desire, and highly value,
opportunity to talk and be listened to

• E.g., Survey of 457 secondary school pupils
  What would you want from a counsellor? (Cooper,
  2004)
• Listening ear most popular response
• (cf. advice, self-understanding,
  problem-solving)
• Even in CB therapies When patients who have
  completed cognitive-behavioural treatments are
  asked to indicate what had helped them to
  overcome their problems, they will answer,
  talking with someone who listens and
  understands (Keijsers, 2000 291).

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Increasing evidence that many forms of distress
related to lack of in-depth relating

• Loneliness
• Lack of genuine human contact
• Depression
• Lack of intimate, rewarding relationships and
  relational stress-buffers
• Anxiety
• Lack of mutually affirming relationships, sense
  of support
• Psychotic relapse
• Critical, hostile, unsupportive communications
• (Segrin, 2001 Mearns and Cooper, 2005, Ch. 2)

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Links to contemporary developmental psychology

• Research by Stern, Trevarthen, Beebe, etc. on
  innate human need, and potentiality, for
  inter-relating (not just attachment)
• (see Mearns and Cooper, 2005, pp. 7-12)

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• Clear empirical evidence that there is a place
  for person-centred and relational therapies

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Summary

• Controlled and comparative research shows PCT
  relatively efficacious
• Common factors research shows PCT and relational
  therapies based on effective factors
• Pluralistic framework PCT and relational
  therapies not right for everyone all of the time
  but for some clients some of the time, can be
  very helpful
• ? Agenda of choice

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• Thank you

Mick Cooper Professor of Counselling University
of Strathclyde mick.cooper_at_strath.ac.uk Slides
available from www.strathclydecounselling.com
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