Counseling 407 Community Counseling

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Counseling 407Community Counseling

• Dr. Jeffrey K. Edwards, LMFT
• Room 4054
• 1-773-442-5541
• J-edwards1_at_neiu.edu or jke6245_at_aol.com
• Office hours are Wednesdays 4-7 and Thursdays
  1-4.

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Counseling 407Community Counseling

• Day one Introduction
• Counseling research Review or new?
• Community Counseling - Definitions
• Prevention - Models

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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.

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Counseling Knowledgethis 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)

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Counseling Knowledgethis 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).

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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.

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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.

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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).

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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 clients
personality (Hubble, Duncan, Miller, 1999).
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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.

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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
• practice.
• A sizable minority (20 to 30) requires
• treatment lasting more than 25 sessions. Those
• clients who are more likely to fail at brief
  therapy
• efforts are those who are poorly motivated,
  hostile,
• have poor relationships with others in their
  life.

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Counseling Knowledge

• Techniques that are critical, attacking,
• rejecting, blaming etc. Are less effective
• treatments (Najavits Strupp, 1994)
• Therapies that focus on the future, instill hope
• early on, and enhance the clients hope and
• placebo effect are more effective (Asay
• Lambert, 1999)

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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?

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Counseling Knowledge

• If techniques are not that important, then what
• are the factors that contribute to positive
• outcome? There are four
• Client Variables (40)
• The Therapeutic relationship (30)
• Expectancy and Placebo Effect (15)
• Technique (15).

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Counseling Knowledge
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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).

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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.

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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).

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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).

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The Therapeutic Relationship (30)Spontaneous
Improvementis 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).

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The Therapeutic Relationship (30)

• The Necessary and sufficient conditions
• Accurate Empathy
• Positive Regard
• Non possessive warmth
• Congruence and genuineness.
• These are client-perceived rather than
  objective raters perceived.

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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, 1993).

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The Therapeutic Relationship (30)

• It seems that the following components are
  important to the therapeutic alliance
• Clients affective relationship with the
  therapist
• Clients capacity to work purposefully in
  therapy
• Therapists empathic understanding and
  involvement
• Client-therapist agreement on goals and tasks of
  therapy (Gaston, 1990).

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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?

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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!!

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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).

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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.
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Expectancy and Placebo Effect (15)

In several studies with medications, the placebo
effect has been demonstrated to be even greater
than the 15 usually assumed (Benson McCallie,
1979).
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Expectancy and Placebo Effect (15)

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.
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Expectancy and Placebo Effect (15)

• The finding that drug efficacy relates to
  prescribing physician attitudes has been
  replicated repeatedly (Scovern, 1999).

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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. (1985).

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Technique (15)

• Of more concern, and reported more in the
  research
• is the finding that staying true to a manual may
  cause
• 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
  concern
• when one regards the current trends by the
  American
• Psychiatric Association, Managed Care
• Organizations, and the American Psychological
• Association to use Empirically supported
  treatment
• for specific problems.

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Stages of ChangeJames Prochaska

• Precontemplation
• Contemplation
• Preparation
• Action
• Maintenance
• Termination -

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Precontemplation

• are not intending to change, or take action,
  usually in terms of the next 6 months.
• Are not fully informed, or aware of consequences.
  
• May have tried to change in the past without
  success.
• No inherent motivation to change

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Contemplation

• People intend to change within the next 6 months.
• Are aware of pros and cons of change vs. no
  change.
• Profound ambivalence.

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Preparation

• 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.

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Action

• 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.

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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.

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Counseling Knowledge

• Medications
• Beecher (1955) reviewed 15 single or double
• 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, 2001)

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Counseling Knowledge

• Since the mid 1980s there has been an 275
  increase of persons who have trained and provide
  counseling/psychotherapy.
• There still has not been a reduction in any of
  the psychological or psychiatric illnesses.

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A Community Counseling ModelThe Upstream Model
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A Model of Community Counseling

• This is the story of the Jeffreys River
• Once upon a time, there was a river named
  Jeffrey.

I wonder why?
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A Model of Community Counseling

• One day someone came floating ..

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A Model of Community Counseling

• down the river, almost drown.

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A Model of Community Counseling

• A good Samaritan saw the drowning person

Help!
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A Model of Community Counseling

• helped him out and saved his life.

Thanks
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A Model of Community Counseling

• Soon, another person came floating down the
  river, almost drown.

Help!
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A Model of Community Counseling

• and he too, was helped out and had his life saved.

Thanks
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A Model of Community Counseling

• soon there were lots and lots of people coming
  down the river drowning.

Help!
Help!Help! Please!!
Help!
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A Model of Community Counseling

• The Samaritan needed some help. So he asked a
  friend.

Help!
Help!
Help!Help! Please!!
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A Model of Community Counseling

• And soon there were lots and lots of people
  helping all those other people coming down the
  river drowning.

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A Model of Community Counseling

• Soon they were building hospitals, and clinics.

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A Model of Community Counseling

• And then they had supervisors and administrators

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A Model of Community Counseling

• And they had overseers who told them how much
  they would paycalled Managed Care.

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A Model of Community Counseling

• And then one very smart person decided to go up
  stream to see..

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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.
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A Model of Community Counseling

• And he told him to stop. So, he did!

OK, I will.
Hey, stop that!
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A Model of Community Counseling

• And that is how a Preventative Public Health
  model was born.

You are welcome.
Thanks.
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The Dawn of a New Day

• Salaries for therapists went through a shift.
  During the Golden Days (1980s) of
  psychotherapy, the cost of a service hour went to
  around 90.00. Now, the rate has changed

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"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
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Cost per capita for Individual Counseling
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?
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Community Counseling Components

• 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 its members

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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.

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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 .

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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.

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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.

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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.

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Community Counseling Components

• Mental Health and Mental Illness A Public Health
  Approach Surgeon General Report
• http//www.surgeongeneral.gov/library/mentalhealth
  /chapter1/sec1.html

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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

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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).

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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
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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.)
The Institute of Medicine report on prevention
(IOM, 1994a).
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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
Prevention
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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
Prevention
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The conventional medical system has much to gain
financially by using the individual treatment
model (Albee, 1993).The organic
Critique of a medical definition of Mental Health
Prevention
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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.