How YOU Can Tell if PSYCHOLOGICAL Treatments Are Good (Usually)

Dear Readers,

While it is true that the COUNSELING techniques for demonstrating empathy, doing clarification, "confronting" the client APPROPRIATELY, and even doing some APPROPRIATE interpretation (after much exploratory dialog) are more loosely-validated techniques, these are seemingly the most important things in *most* treatment. These techniques are more loosely validated (or as I used to say "not well-validated"), *YET* they are among the few things that consistently relate to improvement in counseling/therapy (I.E. treatment), overall. (I shall provide citations and some quotes about all this soon.)

True, the exact nature of the application of these techniques is (at the present time) relatively unclear and they certainly have not been well demonstrated to show cross-helper reliability (even in the nature of the exact technique). Also, when and exactly to what behaviors these techniques apply is also relatively unclear (and thus there is little *demonstrated* interrater reliability here). **STILL**, overall, it is precisely the *use* of these COUNSELING techniques that are among the things most typically associated with improvement from counseling/therapy. Now, I am talking about improvement gotten through seeing mental health professionals OVERALL (the typical, usual, or "average" client, if you wish).

Here, in the following summary, is the nature of some of the strongest
techniques used by professional mental health practitioners. I am
typically quoting Sexton and Whiston (1989) from their meta-analysis of
many studies, including other meta-analyses on this OVERALL topic. But
my summary also includes additional information and citations, and
comments from me. These appear in brackets. (Note also that "*"s are
added by me, as is any capitalization):

"There was a significant relationship between the counseling relationship
and positive client outcome in 80% of the studies reviewed [by Orlinsky and
Howard (1986)]... [Specifically, in part, this means:], "...the more the
counselor conveys empathy, the greater the positive outcome (*especially
as measured from the CLIENT's perspective*) (Luborsky et all,
1988)"..."Counselor engagement and counselor credibility, when measured
from the client's perspective (Beutler et. al. 1975 and Ryan and Gizynski,
1971) were related to positive outcome. Additionally positive regard (Feitel,
1968) [is important]"..."The reciprocal quality of a helping alliance also
**seems essential** to positive outcome...[in] 80% of the studies reviewed
by Orlinsky and Howard" [(Clearly we are talking about counseling here, as I
define it (and as several authors also do.)]

"Luborsky et al. (1988) found a long wait between applying for and getting
counseling was related to negative outcome"...[and] "Client outcome was
enhanced when a more collaborative rather than authoritarian style was
initiated (Cooley and LaJoy, 1980, Rudy, 1983)"..."Active client
involvement in counseling was found to be *very important* to positive
client outcome. In particular, outcome is enhanced when clients develop a
problem-solving attitude (Luborsky et al, 1988; O'Malley, Suh, & Strupp,
1983)"..."and [when they] become actively engaged in experiences that help
them master problematic situations (Luborsky)"... [Also, in essence,
developing a more internal locus of control helps.]..."

Those that experienced a greater range of emotions had more positive
outcomes (Luborsky; Nixon, 1982)" ...[Some good level of anxiety is also
helpful -- Meehl argues this is one of the main jobs of the "therapist".][And]"...
there seems to be a general trend indicating that greater initial anxiety is
related to better outcome (Kernberg, et al., 1972; Learner and Fiske,
1973)." ..."*Neither* client client insight or self-exploration [(which
basically includes "exploration of the past")] was [generally] related to
successful counseling outcome (Morgan, et al., 1982; Luborsky)...."When
clients were directed to attend to their affective states, it was
sometimes, but not always helpful (Nichols, 1974)." "Little was
accomplished when counselors used "immediacy", ...[and] under conditions
of low empathy and genuineness this may even be harmful." [This is
interesting, because "immediacy" is a skill that counselors-in-training are
coached, again and again, to try to achieve and it is thought to be very
important; but, it is considered an advanced or difficult skill (citation:
Ivey, any year in the last 25).]..."[Somewhat similarly,] "confrontation"
was often but not consistently found related to [positive]
outcome"...

[About asking questions:] "Orlinsky and Howard (1986) suggested that
when counselors directed the conversation to the client's presenting
problems, outcome was enhanced". [Good counselors are taught to
ask mainly open-ended questions.]..."The use of questions to explore
aspects of a client's experience rather than to gather information was
also found to be frequently helpful (O'Malley et al. , 1983)"

Finally, "encouraging independence also seemed important (Luborsky)."
"...The most important aspect of counseling technique MAY BE the
skillfulness in which the intervention is used and implemented (Feifel &
Eells, 1983; Nash et al., 1965; Sachs, 1983). Sloane suggested
skillfulness of the counselor was important in 70% of cases." [This
should give you a idea of the minimum % of cases where COUNSELING is
important -- a MINIMUM.].

"SUMMARY: ...Counseling sessions tend to be more successful in a
framework that includes collaboratively structured [(i.e. mutual)] roles
for which **FOR WHICH THE CLIENT IS PREPARED AHEAD OF TIME**
and which begins soon after a client's request for service."

Other facts: "...there are indications that the counselor's mental
health may be associated with positive results." "The client's openness in
the relationship with the counselor ...and acceptance of the counselor"
[are important aspects of client involvement]... "and are related to
positive results." [50% of the benefit of weekly sessions should come
within the first 2 - 6 months.] "There is little support for giving
advice or being directive [(this is **NOT** what counseling is BY ANY
reasonable definition)].

Final summary: Usually when there is no skillful counseling, there are
less good results. AND, when treatment is missing counseling components
the result is worse outcomes, in the majority of treatment cases
(presumably, worse with each component that is missing -- though they are
inter-related).

P.S. Among the exceptions to this general rule about counseling being
very important (the topic of the main post above) *could be* some
behavioral treatments (therapies) that are good for treating *some
conditions*. Typically these conditions involve easy to pin-point anxiety
problems (e.g. simple phobias, SOME shyness problems, gross deficits in
skills, childhood tantrums). These sort of problems, while quite common,
are not the majority of problems (by any means). Other partial exceptions
are when you are getting cognitive-behavioral or RET interventions for
irrational thinking. While treatments involving these still typically involve
much counseling (as described above), more pointed and clear techniques
are also obviously being used. OTHERWISE, pay MUCH attention to my
summary of how to assess COUNSELING in your treatment.