Below are summaries of three important areas of research for counselors to consider.
1. The Limits of “Clinical Judgment”
Many educators often use Socratic questioning methods to nudge students towards providing a rationale for their statements that goes beyond opinion or to clariy their position on an issue. In essence, Socratic questioning is a way of asking, in various wordings, “What is the evidence to support your position?”, or “What are your assumptions?”, or “What is a counter-argument?”. I have to say that this questioningcan sometimes be annoying and frustrating for students. I have certainly had experiences in which I stated an opinion and was challenged by someone to back it up. While frustrating, in the world of counseling we do need to step beyond our assumptions and biases to provide a justification that taps into some deeper rationale or evidence. This is an essential element of a scholar-practitioner approach. With this in mind, consider some different ‘ways of knowing’. Essentially these are ways that humans come to know something or develop particular beliefs. There are different models of ways of knowing and I have pulled 5 major ones according to McBride (2013) and also from Cooper (2012). Here are some ways of knowing to consider:
- Authority – This is basically the idea that some things are accepted to be truth because a person of authority said it was so (Cooper, 2012). For instance, one could argue that many of Freud’s initial theories were accepted as truths because he was a person of authority.
- Intuition – Common sense or what we personally feel to be truth (McBride, 2013).
- Tradition (or tenacity) – A belief or idea that has been passed down as truth and is thus accepted because it has been believed to be true in the past (Cooper, 2012).
- Deduction (or rational analysis) – This utilizing logical reasoning to determine truths and cause-effect (McBride, 2013).
- Scientific Method – Observation, experimentation, efforts to reduce bias, replication (Cooper, 2012).
All of these approaches can potentially have merit. Socratic Questioning is a method to encourage folks, in critical dialogue, not only to consider the justification for their position but also what way of knowing their position is rooted in and whether or not there is conflicting evidence from other Ways of Knowing. One reason it is important that counselors, and critical consumers of information in society, consider Ways of Knowing is that humans are very susceptible to cognitive biases and these have implications for how we behave. While there are many types of cognitive biases, in very general terms cognitive biases may be considered to involve distortion of rational judgment or evaluation due to subjectivity (e.g., likes, dislikes, opinions, etc.). A specific example of how this can play out in the counseling realm is demonstrated in a study by Hannan et al. (2005). The researchers in this case asked counselors in an outpatient clinic to determine, using “clinical judgment”, which clients were at risk of dropping-out of counseling services and were likely to experience a negative outcome during a given time period. At the same time, actuarial data (i.e., a measure of client outcomes) was being collected on clients at the clinic. The results indicated that clinicians using “clinical judgment” accurately predicted 1 out of 40 clients that deteriorated and were at-risk of drop out. The actuarial data accurately predicted 36 out of the 40 clients that were at-risk of dropping out.
The above mentioned finding speaks to the tendency for counselors to gravitate towards self-assessment bias and this is not a stand-alone finding. Indeed, many other studies, including a study by Walfish, McAlister, O’Donnell, and Lambert (2012) have demonstrated that mental health professionals often overestimate their effectiveness and underestimate their treatment failures with clients. Thus, we must consider our “ways of knowing” in a broader sense of research, but also in a specific sense regarding our evaluations about our clients and their progress. Clinical judgment, while useful, is also often inaccurate when it comes to client outcomes so mental health professionals need alternate ways to check their “knowing”.
2. The Dodo Bird and Putting Theories in Perspective
Since the times of Freud, Jung, and Adler there has been ongoing debate about which theoretical orientation is superior. In fact, in some circles that debate still rages today.
Well, the idea of superior therapies has slowly been whittled away by research. The good news is that since counseling outcome research began to boom in the mid-1970s we have learned, year after year, that counseling and psychotherapy is very effective and consistently yields a large effect size (Smith & Glass, 1977; Miller, Hubble, Chow, & Seidel, 2013). However, the difference in effectiveness between one theory of counseling and another is typically not statistically significant when compared in controlled research. This notion was dubbed the Dodo Bird Verdict (Luborsky, Singer, & Luborsky, 1975). You may recall that in Alice in Wonderland that the Dodo Bird declared that “All have won and all deserve prizes”. This reference to the Dodo Bird in counseling dates all the way back to 1936 with a fellow by the name of Saul Rosenzweig who stated that different psychotherapy approaches achieve roughly equivalent outcomes (Rosenzweig, 1936). This finding has been replicated many times over in randomized controlled trials since then. For instance, outcome researchers Bruce Wampold and Zac Imel (2015) conducted a massive meta-analysis of over 300 studies and found that there was no significant difference in client outcomes across treatment approaches.
Putting Theories in Perspective
An additional factor from research that we know is important for a good outcome for clients seeking counseling is that their counselor believes in the theory they use. This is referred to as “allegiance effects” (Wampold & Imel, 2015). Why do I mention this? Well, it is important that you have a theory or theories that resonate for you and that you are competent to deliver counseling in accord with that theoretical orientation. However, it is also important to keep in mind “your theory” isn’t THE best but it may be the best FOR you as a counselor. As mentioned, argument over which theory is inherently the BEST is somewhat of a dead-end. However, when counselors believe that their theoretical approach can be helpful, they are competent in this theory, and they deliver it in a way that fits with the client’s preferences, positive counseling outcomes are enhanced (Miller et al., 2013). Counselors do need a theoretical framework to provide structure and foundation to their work. However, they also need to be able to modify, adjust, and tailor that approach to the client in front of them.
The Authentic Chameleon
We have moved into an era in which more clinicians identify as somewhat integrative as opposed to past eras of ideological purity (Norcross, Karpiak, & Lister, 2005). With this in mind, it makes sense to look to a forerunner in intergrative (or eclectic as he called it) approaches to counseling. Arnold Lazarus (2006) expressed many important points about integration and one is technical eclecticism. This simply refers to selecting techniques based on what clinical wisdom and research indicate are likely the best method, intervention, or style for the individual client. However, there is a very important consideration here. Lazarus warned that choosing from various treatment techniques in a capricious, temperamental manner or without sufficient training is what he referred to as syncretism (Lazarus, 2006). The latter is highly undesirable and potentially unethical. The bottom line is that it makes sense for clinicians to match their style and methods with that of the client, so long as they are trained and competent in the method and are engaged in supervision and professional consultation around the use of those methods.
In addition to intentionally and competently selecting different interventions, Lazarus (2006) also placed emphasis on the counselor adapting his or her style to the client. He termed this authentic chameleon. In essence, this refers to adapting one’s interpersonal style to fit the client and this may include domains such as the level of formality/informality, degree of personal disclosure, level of directiveness, and degree of supportiveness to name a few. On a personal note, I generally tend to be soft in my vocal tone and gentle in my demeanor as a counselor, however, working with some “tough” and matter-of-fact clients lead me to use a different, firmer interpersonal style in some cases. Thus, our style needs to be somewhat adaptable to the client in an authentic manner.
Over 40 year of research has demonstrated that there is little to no difference in counseling treatment outcomes when comparing one bona-fide treatment approach to another (Miller et al., 2013). However, two factors that contribute tremendously to the outcome in counseling are the client’s view of the therapeutic alliance and the counselor’s competence and belief in the theoretical model they use (Miller et al., 2013). Thus, counselors need to pursue training in theoretical models that resonate with them and learn how to adapt their style and the models they use to fit with client preferences and needs. One of other consistent finding is that there is significant variation in client outcomes across different counselors (Miller et al., 2013). In other words, some counselors have better client outcomes than others regardless of their theoretical orientation. Engaging in deliberate counseling practice, learning to use a theory (or integrate a few theories) competently, and engaging in ongoing evaluation of the alliance we have with clients is a way for counselors to improve their outcomes (Miller et al., 2013).
3. Clients Have to Get Worse Before They Get Better
This is a notion that I first heard when I started graduate school in 2000 and it is a belief that is commonplace in mental health circles. As with most absolutist statements, there is often much more detail that needs to be considered. With in this in mind, consider what
the data indicate? Michael Lambert is one of the foremost researchers on psychotherapy outcomes and in his 2013 review he found that about 5-10% of adults in psychotherapy deteriorate (i.e., get worse or show increased symptom severity) and about 14-24% of youth deteriorate in treatment. Moreover, numerous researchers have found that deterioration early in treatment (i.e., clients who get worse in the beginning stages of therapy) places those clients at high risk for a negative outcome in treatment and at high risk for dropping out of therapy (Hanson et al., 2002; Howard et al., 1986; Lambert, 2007; Lutz et al., 2014). In short, deterioration or increased distress during the early stages of treatment does not, on balance, translate into a high likelihood that the client will improve in therapy but, more accurately, it predicts the opposite.
This of course does not mean that some individual clients will not indeed have the experience of things getting worse before they get better. However, that is generally not the case. The notion that “clients have to get worse before they get better” is, according to lots of evidence, an exception to the rule rather than the rule itself. So what can counselors do? The belief that clients have to get worse before they get better can work to the detriment of clients in some cases. Think about it for a moment. This belief can lead to a counselor just continuing with the status quo when the client outcome data may indicate that treatment needs to be changed in some way to meet the client’s needs. An empirically supported way to avoid this pitfall of clinical judgment is to systematically monitor outcome using a validated outcome measure. For example, the Outcome Questionnaire and the Outcome Rating Scale both have been studied extensively and can be used to effectively identify clients who are not progressing in counseling as expected. With the OQ and ORS there are warning systems built into the process that alert the counselor to the level of risk of a negative outcome for the client or of client dropout. These tools, in conjunction with clinical judgment that is not committed to the “clients have to get worse before they get better” mantra, can help counselors be more responsive to clients that are experiencing a worsening of symptoms during counseling.