Title: Counseling 407 Community Counseling
1Counseling 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.
2Counseling 407Community Counseling
- Day one Introduction
- Counseling research Review or new?
- Community Counseling - Definitions
- Prevention - Models
3Counseling 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.
4Counseling 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)
5Counseling 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).
6Counseling 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.
7Counseling 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.
8Counseling 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).
9When 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).
10Counseling Knowledge
- Counseling/Psychotherapy models all have the same
effectiveness, more or less (see comprehensive
reviews in Hubble, Duncan and Miller, 1999
Seligman, 1995). - This has been called the Dodo effect, by Luborsky
et al. (1975) - from Alice and Wonderland,
Everyone has won and all must have prizes.
11Counseling 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.
12Counseling 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)
13OK 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?
14Counseling 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).
15Counseling Knowledge
16Client Variables (40)
- Severity of Symptoms (both psychological and
physical) - Motivation
- Psychological mindedness
- Ability to identify a focal problem (Lambert and
Anderson, 1996).
17Client Variables (40)
- 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.
18Client 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).
19The 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).
20The Therapeutic Relationship (30)Spontaneous
Improvementis influenced by
- Length of time the problem has been evident
- Underlying personality disorder
- Quality of social support, especially the marital
relationship (Andrews Tennant, 1978 Mann,
Jenkins, Belsey, 1981).
21The 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.
22The 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).
23The 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).
24The 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?
25The 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!!
26Expectancy 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).
27Expectancy 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.
28Expectancy 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).
29Expectancy 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.
30Expectancy and Placebo Effect (15)
- The finding that drug efficacy relates to
prescribing physician attitudes has been
replicated repeatedly (Scovern, 1999).
31Technique (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).
32Technique (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.
33(No Transcript)
34Stages of ChangeJames Prochaska
- Precontemplation
- Contemplation
- Preparation
- Action
- Maintenance
- Termination -
35Precontemplation
- 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
36Contemplation
- People intend to change within the next 6 months.
- Are aware of pros and cons of change vs. no
change. - Profound ambivalence.
37Preparation
- 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.
38Action
- 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.
39Maintenance
- 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.
40Counseling 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)
41Counseling 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.
42A Community Counseling ModelThe Upstream Model
43A 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?
44A Model of Community Counseling
- One day someone came floating ..
45A Model of Community Counseling
- down the river, almost drown.
46A Model of Community Counseling
- A good Samaritan saw the drowning person
Help!
47A Model of Community Counseling
- helped him out and saved his life.
Thanks
48A Model of Community Counseling
- Soon, another person came floating down the
river, almost drown.
Help!
49A Model of Community Counseling
- and he too, was helped out and had his life saved.
Thanks
50A Model of Community Counseling
- soon there were lots and lots of people coming
down the river drowning.
Help!
Help!Help! Please!!
Help!
51A Model of Community Counseling
- The Samaritan needed some help. So he asked a
friend.
Help!
Help!
Help!Help! Please!!
52A Model of Community Counseling
- And soon there were lots and lots of people
helping all those other people coming down the
river drowning.
53A Model of Community Counseling
- Soon they were building hospitals, and clinics.
54A Model of Community Counseling
- And then they had supervisors and administrators
55A Model of Community Counseling
- And they had overseers who told them how much
they would paycalled Managed Care.
56A Model of Community Counseling
- And then one very smart person decided to go up
stream to see..
57A 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.
58A Model of Community Counseling
- And he told him to stop. So, he did!
OK, I will.
Hey, stop that!
59A Model of Community Counseling
- And that is how a Preventative Public Health
model was born.
You are welcome.
Thanks.
60The 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
61"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
62Cost 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?
63Community 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
64Public 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.
65Prevention
- 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 .
66Examples 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.
67Examples 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.
68Examples 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.
69Community Counseling Components
- Mental Health and Mental Illness A Public Health
Approach Surgeon General Report - http//www.surgeongeneral.gov/library/mentalhealth
/chapter1/sec1.html
70Definitions 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
71The 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).
72Prevention, 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
73And 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).
74Albee (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
75Those 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
76The 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
77Assignment 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. -