Tag Archives: psychotherapy

Relationship’s role in therapy?

How important is it to get the right kind of counseling/therapy modality? How important is it to get the right person?

These questions plague both researchers and the people looking to get better. Why do some clients get better and others do not? Why do some therapists have a better success rate and others do not? Does the kind of therapy matter?

Well, as you can imagine, the answer is, “it depends.”

Yes, diagnosis and assessment do matter. If your child begins to struggle with bed-wetting after having been continent, you need to know what the problem is and what to do about it.

But, consider this: various studies make overlapping comments as to what really is going on when people get better

  • One researcher suggests that some 85+% of the reason for change are factors pertaining to the client and what is called “extratherapy” factors (social support, physical health, etc. )
  • Another places the portion the therapist plays in the 13% or so

Confusing? Consider this stark fact presented at a recent conference I attended

Patients receiving placebos from the top (best?) 1/3 psychiatrists fared better than patients who received actual medications from the bottom 1/3 psychiatrists. This was cited from the following study: Kim, D., Wampold, B. E., & Bolt, D. M. (2006). Therapist effects in psychotherapy: A random-effects modeling of the National Institute of Mental Health Treatment of Depression Collaborative Research Program data. Psychotherapy Research, 16(2), 161-172.

So, when you are looking for a therapist or psychiatrist, you may want to know if he/she studied at Harvard or a degree mill. But, you may be better served to by one who listens to you, doesn’t fall asleep, and is able to collaborate with you to find a solution that works for you.

The moral of the story? Better to have a good psychiatrist with no meds than a poor one with a gunnysack full of pills.

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Filed under counseling, counseling science, counseling skills, Uncategorized

When theory, technique and person combine…

Am trying to write an academic journal article on clinical applications of Christian Psychology. Heady…I know. Too heady for me I think. However, in my study I ran across these quotes from

Leitner, L.M. (2007). Theory, Technique, and Person: Technical Integration in Experiential Constructivist Psychotherapy. Journal of Psychotherapy Integration, 17, 33-49.

From his abstract:

From an experiential constructivist position, the distinction between the therapist as a person, the therapist’s theory of psychotherapy, and techniques used within the therapy room is, in some ways, forced and arbitrary.

He starts out this article, after the abstract with,

“Becoming a psychotherapist is not about assembling a bag of tricks and learning the formula for matching tricks (i.e., techniques) with problems. What you do as a therapist emerges from who you are in the therapy room. And, when an intervention comes from who you are, it is no longer a technique.”

SO, it stands to reason that we ought to view therapists in their sessions in order to see what kind of people they are. We therapists often think in terms of theory to practice. But practice probably reveals a truer picture of our theory.


Filed under christian counseling, christian psychology, counseling, counseling science, counseling skills, teaching counseling

Improving Case Conceptualization?

For my counselor readers: What books or other helps have you encountered that improved your ability to conceptualize cases?

When we teach counseling skills we do the following (we do more than this but this is the general trajectory):

  1. Build basic helping/counseling skills (if you can’t connect with a person and build a trusting relationship, any knowledge you might have will be useless!)
  2. Expose students to a wide variety of problems (so they can understand and describe common problems in living or common pathologies–even if they are not sure of the causes of these problems)
  3. Explore human growth and development from a descriptive and biblical viewpoint (this at the same time as #2 so that they learn about common problems  and sufferings as well as what healthy and Godward lives look like in a fallen world)
  4. Teach case conceptualization (marrying client information (e.g., background info, presenting problems, attempts to solve the problems, etc.) with theoretical understanding of the person/problem/desired outcome.
  5. Build intervention repertoire during fieldwork.

#4 is the hardest, especially in a generalist program that doesn’t spend a great deal of time on theoretical models (we teach models as part of every course and our model of Christian psychology (biblical anthropology along with process oriented model) isn’t as defined as the old models (e.g., Rogers, Freud, etc.).

If you were teaching counseling to practicum students who needed help with conceptualizing cases, what resources would you turn to?


Filed under biblical counseling, christian counseling, christian psychology, counseling, counseling science, counseling skills, Psychology, teaching counseling

Practicum Monday: Premature Termination in Counseling

Today in Practicum class we discuss matters around ending treatment or counseling relationships with our counselees. The one that causes interns most consternation is the premature termination by clients after only one session. The trainee is left to wonder why. “Did I fail to connect? Did I say something to offend them? What did I do wrong? Did they figure out I don’t know what I’m doing?” Usually, they report feeling like a failure. Here’s a secret: even experienced therapists feel this at times as well.

Well, let’s start with the murky data. Brogan, Prochaska & Prochaska (v. 36 (1999) of Psychotherapy: Theory, Research, Practice & Training, 105-113) report that various studies reveal a premature termination after just one session stands somewhere between 20 and 57%. Some 30-60% drop out before the counselor thinks they should. And a meta-analytic study (of 125 studies) reports a premature dropout rate of 47%. Even though our research in this area is still weak (we don’t really know what factors to use to report premature dropout), the numbers are pretty high.

So, why do people stop counseling before they should? Why do our clients not return? We really don’t know as much as we would like. We do know that individuals in certain demographics are more likely (lower SES, lower education, minority status) to drop out. But even here, we don’t really know why. Is it client-counselor mismatch? Lack of understanding of the process of counseling? Lack of hope?

We do know that several factors do NOT seem to relate to premature termination (therapy mode, setting, and ages of clients).

While our research is still cloudy, it makes sense to consider the combination of client factors (motivation for personal growth, ability to have insight), environmental factors (financial status, family support or detraction, cultural support), and counselor factors (capacity to empathize and connect with the client’s perceptions, diagnostic and listening skills).

Trainees can ask these questions in their postmortems:

1. Did we share an understanding of the type and severity of the problems?
2. Did I give evidence that I understand their experience (beyond saying so)?
3. Did I give some evidence of the path forward and hope for the future without overselling it?
4. Did I acknowledge potential pit-falls, hopelessness, fear?
5. Was my client the “customer” or was someone else demanding it (e.g. parent)?   


Filed under counseling, counseling science, Psychology, teaching counseling

Note-taking in sessions?

Counselors have vastly differing styles of counseling. Some choose to be directive, others are remain passive even when the client wants them to give advice. We are different because of our varying theories and personalities. But I always assumed that most counselors do not take notes during sessions unless needing to record very specific details (say taking a family genogram or collecting details for a psychological report). But after having conversations in several different locations I learn that many write during the session. They write down key client phrases and other things that they wish to come back to and explore at a later date.

I’m curious about your experiences–either as a counselor or counselee. Was there note-taking going on during the session and was it helpful (for both)? Did it cause problems?

I don’t take notes in session so that I can stay engaged in good dialogue with my clientele. I don’t want to miss subtle details and I don’t want to break up the work by taking a note. It seems to me that if I take a note during the session, the client waits for me to do so and then they move out of an experience to only describing an experience–and so distance themselves from their feelings and thus any insight or intervention is also distant.

What do you think?


Filed under christian counseling, christian psychology, counseling, counseling skills

Science Monday: Therapist characteristics that may lead to greater treatment success

Today in Psychopathology class we will be studying the anxiety disorders. In preparing for the class, I happened on an 2001 article by Huppert, Bufka, Barlow, Gorman, Shear, & Woods in the Journal of Consulting and Clinical Psychology (v. 69, pp747-755). FYI, David Barlow is a well-known anxiety researcher in the Boston area.

These authors researched how various therapist characteristics influence outcome in CBT for anxiety disorders.  While CBT has been found to be effective in treating anxiety, does it matter much what therapist you get?

What therapist characteristics were not found to be all that meaningful to outcome? Gender, age, and theoretical orientation did not seem to make any difference. The fact that theoretical orientation didn’t make much difference is quite interesting. This suggests that expertise in CBT may not matter as much as one might think. Anybody with a manual and a willingness to follow it can do it well enough–maybe.  

So what counselor characteristics do increase successful outcome for anxiety treatment? Experience. The more experienced therapists had clients who had less anxiety after treatment. Experience (number of years as a therapist) matters quite a bit. The authors did not find that experienced therapists were more apt to follow the treatment protocol as there were no differences between experienced and inexperienced therapists as far how they did in following the protocol.

So, what does experience mean? We’re not really sure but it probably has something to do with therapist flexibility while continuing to adhere to the treatment protocol. Those who followed the protocol but were more rigid may have communicated that rigidity to their patients and missed key interpersonal processes. This study didn’t explore this issue but I surmise that is part of the issue.

One funny finding was that more experienced therapists suffered the same drop-out rate as did the more inexperienced therapists. And yet, those who stayed in treatment had much lower anxiety when they were seen by the experienced therapists. So, just because you go to an experienced therapist, don’t assume that everything will go well. No, you have to want to be there and be willing to do the hard work. Also, you just may not click with the counselor.

Most of us counselors want to be skilled and have cool techniques. But once again we find that relationships matter more than technique.

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Filed under Anxiety, counseling, counseling science