The mechanisms

of

Chan ge

Thom Field, M.Ed., NCC Doctoral student, James Madison University

Virginia Counselors Association, November 11, 2011
E-mail: fieldta@dukes.jmu.edu

Overview
This presentation will review new evidenced-based approaches to the change process in counseling, with practical tools for improving therapeutic services to clients.

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INTRODUCTION
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Introduction
Lets humanize the topic a little

What are your personal and professional experiences with change?

(Hand exercise)
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Introduction
Change = mysterious, ephemeral, abstract, temporal, phenomenological Change = difficult to quantify How can we standardize the mysterious?

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Introduction
Evidence-based practice has been misguided Saying Treatment X works for Disorder X misses the point entirely, because
This research is time-limited and often biased One size fits all It doesnt describe why change occurs Meta-analyses have provided contradictory findings

We need to consider a new model for EBP

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How Change Occurs

One of the older and most popular models for change is the Transtheoretical Model (Prochaska and DiClemente, 1982) Adapted from the addictions field Motivational Interviewing has developed strategies based on the stages of change (Miller & Rollnick, 2002, p. 201-216)

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Maintenance

Action

Relapse & Recycle

Planning

Contemplatio n

Pre-contemplation

The Transtheoretical Model of Change (Prochaska & DiClemente, 1982)

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THE MECHANISMS OF THE CHANGE PROCESS

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Brief History of Common Factors Research

The Dodo-bird hypothesis: Saul Rosenzweig (1936) No salient disparities in effectiveness between psychotherapies when differences between studies are controlled
Has consistently been validated by meta-analyses (Robinson, Berman, & Neimeyer, 1990; Shapiro & Shapiro, 1982; Wampold et al., 1997; Wampold, Minami, Baskin, & Tierney, 2002).

All have won and must have prizes!

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Confused?
Lets make a simpler graphic. Time for some basic math:
Therapist = 46-69 % of 13% 8% Alliance = 38-54% of 13% 7% Expectancy/Allegiance = 30%+ of 13% 4% + Model/Technique = 8% of 13% 1%
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6-

5-

0-

A Simpler Graphic

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Client Effects (87%)

Clients = primary agent of change

What this means for us.

Client-directed treatment Work on client goals Autonomy

Extra-therapeutic factors
My own experiences as a client

Practical Tools Recruit feedback Provide an explanation of your approach, and offer the client choices & options Self-monitoring (weight, thoughts, moods, budget) A strengths-based approach
Resiliency Competence

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Client Effects (87%)

Some questions to ponder about your client:
What is their opinion of our alliance? What do they expect to achieve from counseling? How do they measure progress? What is important to them? How much did they go through to wind up in my office today? (they made it!)
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Treatment Effects (13%)

Therapist (6-9%) Some things cannot be taught (personality, likeableness) And some can! (flexibility, timing, phrasing, warmth/empathy, nonjudgmental, presentation as healer) Practical Tools Genuineness, presence Describe a nightmare counselor!

Whats your name, again??

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Treatment Effects (13%)

The Alliance (5-7%) Alliance is 7x more predictive of outcomes than techniques (Duncan et al., 2004) The only factor that seems to differentiate therapists (Baldwin et al., 2007; Anker et al., 2009) Practical Tools Influence and persuasion
Reciprocity, commitment Connection/relatedness Immediacy increases engagement

Recruit feedback about the alliance

Repairing alliance ruptures

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Treatment Effects (13%)

The alliance is not just a container for the real ingredient
Yalom (2002): allow the patient to matter to you. Listening, understanding, validating
(the LUV triangle; Echterling, Presbury, & McKee, 2005)

When considering confronting the client: What is the cost to the relationship?
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Treatment Effects (13%) Allegiance/Expectancy

(4% +) What is this?
The belief in the intervention by the counselor (allegiance) The expectancy of change by the client - AKA Placebo Effect
Drug trials and placebos Clients perception strongly influences outcome

Practical Tools The first session = crucial Average # of sessions per client = ? Your belief in your services has a direct effect on the client

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Treatment Effects (13%)

Model/Technique (1%) Model = Theory Technique = Intervention E.g.,
Gestalt / empty chair CBT / cognitive restructuring Psychodynamic / transference

Practical Tools Remember, the belief (allegiance/expectancy) in the model/technique is more powerful than the actual intervention itself Clients will resist explanations that are not compatible with their attitudes/values

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REVIEW: TOWARD AN EVIDENCE-BASED PHILOSOPHY OF CHANGE

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The client, as primary agent of change, directs treatment. The counselor listens, empathizes, and validates the clients experience. The counselor s central tasks are to
form a collaborative alliance with the client be responsive to the clients culture, value and preferences assess the clients expectancy of change occurring support the clients goals and beliefs about change provide the client with choices and options about treatment foster the clients autonomous decision-making seek out areas of resilience and strength demonstrate allegiance and belief in the chosen myth and ritual of intervention www.thomfield.com

References
Anker, M., Duncan, B., & Sparks, J. (2009). Using client feedback to improve couples therapy outcomes: A randomized clinical trial in a naturalistic setting. Journal of Consulting and Clinical Psychology, 77, 693-705. Baldwin, S. A., Wampold, B. E., & Imel, Z. E. (2007). Untangling the alliance-outcome correlation: Exploring the relative importance of therapist and patient variability in the alliance. Journal of Consulting and Clinical Psychology, 75, 842-852. Conners, G. J., Carroll, K. M., DiClemente, C. C., Longabaugh, R., & Donovan, D. (1997). The therapeutic alliance and its relationship to alcoholism treatment participation and outcome. Journal of Consulting and Clinical Psychology, 65, 588-598. Duncan, B. L., Miller, S. D., & Sparks, J. A. (2004). The heroic client: A revolutionary way to improve effectiveness through client-directed, outcome-informed therapy (Rev. ed.). San Francisco: Jossey-Bass.www.thomfield.com

References
Duncan, B. (2010). On becoming a better therapist. Washington, DC: American Psychological Association. Echterling, L. G., Presbury, J. H., & McKee, J. E. (2005). Crisis intervention: Promoting resilience and resolution in troubled times. Upper Saddle River, NJ: Pearson. Frank, J. D., & Frank, J. B. (1991). Persuasion and healing: A comparative study of psychotherapy. Baltimore, MD: Johns Hopkins Press. Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd Ed.). New York, NY: Guilford. Prochaska, J. O., & DiClemente, C. C. (1982). Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research, and Practice, 19, 276-288. Robinson, L. A., Berman, J. S., & Neimeyer, R. A. (1990). Psychotherapy for the treatment of depression: A comprehensive review of controlled outcome research. Psychological Bulletin, 108, 30-49.
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References
Rosenzweig, S. (1936). Some implicit common factors in diverse methods of psychotherapy. American Journal of Orthopsychiatry, 6, 412-415. Shapiro, D. A., & Shapiro, D. (1982). Meta-analysis of comparative therapy outcome research: A critical appraisal. Behavioural Psychotherapy, 10, 4-25. Wampold, B. E., Minami, T., Baskin, T. W., & Tierney, S. C. (2002). A meta-(re)analysis of the effects of cognitive therapy versus other therapies for depression. Journal of Affective Disorders, 68, 159-165. Wampold, B. E., Mondin, G. W., Moody, M., Stich, F., Benson, K., & Ahn, H. (1997). A meta-analysis of outcome studies comparing bona fide psychotherapies: Empirically, all must have prizes. Psychological Bulletin, 122, 203-215. Yalom, I. D. (2002). The gift of therapy. New York, NY: Harper Collins.
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