Lecture 9 common factors in counselling

1. What Works in
Psychotherapy: Common
Factors
Introduction to
Counseling
Kevin Standish

2. Learning Outcomes
Describe some of the common
factors within different
approaches to counselling
Describe the models and
methods
 Evaluate the relevance of the
common factors as a unifying
force within counselling
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3. 33
Counselling training
 Helps organize, develop, and
skillfully use abilities we
already have:
 Empathy
 Communication
 Support
 Understanding
 Respect
 Trust

4. 44
Psychotherapy Research
Thousands of research studies of
psychotherapy
 Increase
understanding of
what works
 Increase confusion
about what works
due to conflicting
results
Meta-analytic research studies:
studies of studies

5. 55
Quiz
Question 1:
 Does
psychotherapy
work?
YES
 40-70% of clients who
receive psychotherapy
show substantial
benefit
 At the end of therapy
the average treated
person is better off
than the average
untreated person.

6. 66
Conclusions from Meta-analytic
Studies
Common Factors associated with
Psychotherapy Outcome
 “Extra-therapeutic” Factors (87%)
 Therapeutic Factors (13%)
 Therapeutic Alliance (8%)
 Therapeutic Allegiance (4%)
 Therapy model or technique (1%)
Wampold, B.E. 2001. The Great Psychotherapy Debate: Models,
Methods, and “Findings. Erlbaum.

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Conclusions from Meta-analytic
Studies
Common Factors associated with
Psychotherapy Outcome
 “Extra-therapeutic” Factors (40%)
 Therapeutic Alliance (30%)
 Therapy Model or Technique (15%)
 Placebo Effect (15%)
Hubble, Duncan, Miller 1999. The Heart and Soul of Change: What Works
in Therapy. APA

8. 88
Psychotherapy Models or
Techniques
Account for a small amount of the variance in
psychotherapy outcomes
 Virtually all psychotherapy models and techniques
are effective with some people, some of the time
 Differences in outcome between models is
consistently small or negligible
 Outcome differences between therapists using the
same model have been found to be 2-3 times greater
than the differences between models

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Therapeutic Relationship and
Alliance
Therapeutic Relationship
 Trust
 Warmth
 Empathy
 Understanding
 Acceptance
 Genuineness
 Kindness
Therapeutic Alliance
 Client’s emotional
relationship to the
therapist
 Client’ capacity to work in
therapy
 Therapist’s empathic
understanding &
involvement
 Client-therapist
agreement on therapy
tasks and goals

10. 1100
Therapeutic Relationship and
Alliance
The most important therapeutic
factors in a positive
psychotherapy outcome
 A positive therapeutic relationship is
considered crucial for a successful outcome
in any type of psychotherapy
 A strong therapeutic alliance is considered a
necessary condition for therapeutic change
to occur

11. Therapeutic Relationship and Alliance
Dynamic not static: relationship
and alliance change over time
More predictive of
psychotherapy outcome than
diagnosis
More predictive of
psychotherapy outcome than
model or technique
 Predictive of client dropout
1111

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Therapeutic Relationship and
Alliance
The conclusion for therapists:
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rreellaattiioonnsshhiipp..

13. Therapeutic Relationship Alliance
and Therapy Model Technique
The therapeutic model or
technique used by a therapist
is primarily effective if it
matches the client’s “theory of
change”:
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The client’s
View of the problem
View of the change process
Goals and expectations

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Therapeutic
Relationship/Alliance and
Therapy Model/Technique
 The more therapy models and techniques a
therapist can understand and use, the more
options the therapist has for helping a wider
range of clients.
 An effective therapist should be able to use a
variety of therapeutic models and techniques
instead of assuming that each client will
respond equally well to a particular model or
technique.

15. 1155
Therapeutic
Relationship/Alliance and
Therapy Model/Technique
A psychotherapist
should use a
psychotherapy
model or
technique to fit the
client, rather than
trying to make the
client fit a
particular model or
technique.

16. 1166
3 Styles of Listening
1. Passive Listening – less effective
Listening to another person
Being interested in what that person
has to say
Trying to understand what that
person has to say
NOT communicating to that person
that we are interested and
understand

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3 Styles of Listening
2. Competitive or Combative
Listening –
Least effective
 Not really listening
 Thinking about what we want to say next
 More interested in expressing our point of
view than in understanding the other person

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3 Styles of Listening
3. Active Listening – Most
Effective, powerful
 Active Listening involves three
main components:
1. Listening to another person
2. Communicating to that person that we
are interested in what they have to say
3. Communicating to that person that we
understand what they have to say

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Building a strong therapeutic
relationship
Active Listening Techniques
 Stop talking
 Let the client relax, take their time, explain things in their own way
 Physically show that you are interested
 Face the client
 Open posture, e.g., don’t fold arms
 Maintain eye contact
 Reflect their body position (mirroring)
 Remove distractions, stop whatever else you are doing
 Empathize: consider their point of view, “stand in their shoes”
 Don’t let you own emotions interfere or distract you
 Be cautious about disagreeing, criticizing, or arguing
 Ask questions to clarify, or encourage the client to say more or give an
example
 Don’t try to problem-solve (that may come later)

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Building a strong therapeutic
relationship
Active Listening Techniques
Paraphrasing
Summarize or repeat the facts of the
situation
State your understanding of the
thoughts, beliefs, feelings and
emotions you heard

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Building a strong therapeutic
relationship
Active Listening Techniques
 Paraphrasing example:
Client: “It seems like I cry all day. I don’t
want to talk to anyone, even my friends. I
don’t want to do anything, all I want to do
is stay in my bed and sleep.”
Therapist: “So you’re crying all the time,
you don’t want to do anything or talk to
anyone, and all you want to do is sleep. It
sounds like you are feeling __________.”

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Building a strong therapeutic
relationship
Active Listening Techniques
 If you are not sure you understand, express that to
the client: “I’m not sure I understand”, and ask for
clarification: “could you tell me more?”, or “could
you give me an example?”
OR
 If you are not sure you understand, try paraphrasing
anyway; if we are genuinely interested and trying to
understand, clients will usually appreciate the effort
and clarify for us: “No, I’m not really feeling sad. I
just feel empty.”

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Building a strong therapeutic
relationship
Active Listening Techniques
If you disagree or disapprove of
what the client is saying
Try to be nonjudgmental
Try to be accepting
Try to be respectful
Try to understand their point of view
Don’t try to shame or embarrass the
other person

24. 2244
Building a strong therapeutic
relationship
Active Listening Techniques
 Don’t begin to problem-solve too soon
 Often, if you continue to practice active
listening, the client will develop their own
solution to their problems
 In psychotherapy it is almost always
preferable to help clients develop their own
solutions to problems
 Helps clients feel better about themselves
 Helps clients feel more confident in managing
future problems

25. 2255
Building a strong therapeutic
relationship
Active Listening Techniques
 It is okay to not have the solution to every
problem or a perfect understanding of the
client.
 Clients are the experts on themselves
 Let the client teach you and guide you

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Extra-therapeutic Factors
Account for major portion of improvement that occurs during
psychotherapy
How can a therapist use these factors in
psychotherapy?
 Listen for , invite, and use information about extra-therapeutic
factors
 What is different about better or worse days
 Ask about any between session improvement
 Help clients see any changes, and maintenance of changes, as
a consequence of their own efforts
 Even if clients attribute changes to luck, therapist skill,
medication, or some other factor, ask:
 How they adopted the changes in their lives
 What they did to use the changes to their own benefit
 What they will do in the future to maintain the changes
 Ask about what happens in the client’s life that is helpful
 Encourage clients to explore and use resources in their life
and community

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The Client is Central
 The capacity for self understanding,
problem-solving, and growth, resides
primarily in the client
 The most effective therapists are ones who
allow or help their clients develop their own
understanding and solutions to problems
(It’s a relief to know that I don’t have to have all the
answers)

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The Client is Central
Quiz
Question 2
 Who is better at
identifying whether a
client is making progress
in psychotherapy, the
therapist or the client?
THE CLIENT
 Research shows that
therapists are remarkably
bad at judging whether a
client is making progress
in psychotherapy.
 The client’s experience of
meaningful change ,
especially early in therapy
(first 4-5 sessions) is one
of the best predictors of a
positive therapy outcome.

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The Client is Central
Quiz
Question 3
 Who is better at
accurately rating the
quality of the therapeutic
relationship and
therapeutic alliance, the
therapist or the client?
THE CLIENT
 Research shows that the
client’s rating is clearly
superior to the therapist’s
in predicting
psychotherapy outcomes.
 Research shows that the
client’s rating is clearly
superior to the therapist’s
in predicting
psychotherapy dropouts.

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Assessing and Tracking
Psychotherapy Progress and the
Therapeutic Relationship/Alliance
 Psychotherapy Effects: Progress in
psychotherapy
 Continuously changing over the course of
treatment
 Faster or slower
 Better or worse
 Psychotherapy Fit: The quality of the
therapeutic relationship and therapeutic
alliance
 Continuously changing over the course of
treatment

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Assessing and Tracking
Psychotherapy Progress and the
Therapeutic Relationship/Alliance
 Psychotherapeutic processes, models, and
techniques are best informed and directed by
systematic and ongoing assessment of the “fit” and
the “effect” of any given therapeutic relationship.
 Therapeutic processes, models, and techniques are
not well informed and directed by:
 Static concepts such as diagnosis
 Unreliable or inaccurate theories and impressions of the
therapist

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Assessing and Tracking
Psychotherapy Progress and the
Therapeutic Relationship/Alliance
 Routinely check with clients about whether
they believe progress is being made:
Therapist: “How do you feel we’re doing?”
OR
Therapist: “Let’s look at your goals. Do you
feel like we are making progress?”
OR
Therapist: “You look less overwhelmed. Are
you feeling that way?”

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Assessing and Tracking
Psychotherapy Progress and the
Therapeutic Relationship/Alliance
Routinely check with clients about
the relationship and alliance
Is the therapist's approach helpful?
Do they talk about what they want to
talk about?
Do they feel heard, understood, and
respected?

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Assessing and Tracking
Psychotherapy Progress and the
Therapeutic Relationship/Alliance
 Use of rating scales (example)
 Outcomes Rating Scale (ORS)
 Measures “Effect”
 Four rating scale items, 1-2 minutes to administer and score
 Administered, scored, and graphed at beginning of every
session
 Discuss and use improvement, decline, or no change
 Session Rating Scale (SRS)
 Measures “Fit”
 Four rating scale items, 1-2 minutes to administer and score
 Administered, scored, and graphed at end of every session
 Discuss any low scores

35. Outcome Rating Scale (ORS)
Looking back over the last week, including today, help us understand how you have
been feeling by rating how well you have been doing in the following areas of
your life, where marks to the left represent low levels and marks to the right
indicate high levels. If you are filling out this form for another person , please fill
out according to how you think he or she is doing.
Individually
(Personal well-being)
I----------------------------------------------------------------------I
Interpersonally
(Family, close relationships)
I----------------------------------------------------------------------I
Socially
(Work, school, friendships)
I----------------------------------------------------------------------I
Overall
(General sense of well-being)
I----------------------------------------------------------------------I
Institute for the Study of Therapeutic Change
_______________________________________
www.talkingcure.com
© 2000, Scott D. Miller and Barry L. Duncan
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36. Session Rating Scale (SRS V.3.0)
Please rate today’s session by placing a mark on the line nearest to the descriptions that best
fits your experience.
I did not feel
heard,
understood, and
respected.
Relationship
I-------------------------------------------------------------I
I felt heard,
understood, and
respected.
We did not work
on or talk about
what I wanted to
work on or talk
about.
Goals and Topics
I-------------------------------------------------------------I
We worked on
and talked about
what I wanted to
work on and talk
about.
The therapist's
approach is not
a good fit for
me.
Approach or Method
I------------------------------------------------------------I The therapist’s
approach is a
good fit for me.
There was
something
missing in the
session today.
Overall
I------------------------------------------------------------I
Overall, today’s
session was
right for me.
Institute for the Study of Therapeutic Change
www.talkingcure.com
© 2002, Scott D. Miller, Barry L. Duncan, & Lynn Johnsaon
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Chart # Client Name Therapist Date of Intake 1 2 3 4 5 6
1 220321RH Walton 1/12/2007 17.8 18.1 22 23.6 24.6 26.8
2 DAH Walton 1/23/2007 30.1 28.6 27.8
3 219632 Walton 2/4/2007 24.1 24.9 23.9 24.8
4 220012 FAL Walton 2/10/2007 5.4 7.9
5
6
SRS Graph
40
38
36
34
32
30
28
26
24
22
Score
20
ORS 18
16
14
12
10
8
6
4
2
0
Session Number 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Series1
SRS Graph
40
38
36
34
32
30
28
26
24
22
20
18
16
14
12
10
8
6
4
2
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Session Number
ORS Score
Series1

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Conclusion
 Therapeutic Relationship and Alliance
o Of all therapeutic factors, it is the single best predictor of
therapeutic outcome
 Client is Central
o Therapist follows the client’s lead
o Client’s theory of change is crucial
o Active listening
 Ongoing, systematic assessment of client’s rating
of “effect” and “fit”
o Client-directed, outcome informed treatment is the best
guide to treatment decisions
You already have the basic abilities needed to be a
good psychotherapist
o Relax and enjoy your work

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