Transcript Person-Centered Science - Strathprints

Person-Centered Science:
What We Know and How We
Can Learn More about
Humanistic/PersonCentered/Experiential
Psychotherapies
Robert Elliott
University of Strathclyde
Outline
Historical Introduction
Question 1: What have we learned from
existing quantitative research on
Humanistic/Person-Centred/Experiential
therapies?
Question 2: What have we learned from
existing qualitative research on
Humanistic/Person-Centred/Experiential
therapies?
Question 3: How can we learn more?
Context: Carl Rogers as
Psychotherapy Research Pioneer
Innovations:
Use of voice recording technology
Psychotherapy process research
Controlled outcome research
Modern process-outcome research
Humanistic Therapy in Eclipse
Rogers gave up scientific research
when he moved to La Jolla
Lack of research 1965 - 1990 hurt
scientific & academic standing of
humanistic therapy
Led to humanistic therapies being
marginalized
Humanistic Therapy Revival
Since 1990:
Rise of qualitative research
Re-engagement in quantitative research
Newer therapies (e.g., Focusing-oriented,
Process-Experiential/Emotion-Focused
Therapy, Pre-therapy)
Available outcome research has tripled
Current situation
Danger of split between:
Practitioners and training schools: reject
quantitative research in favor of qualitative
research
Small cadre of academic researchers:
doing quantitative outcome research in
order to gain official recognition
Question 1a: What Does Positivist
Outcome Research Tell Us?
Humanistic/Person-Centred/Experiential
(HPCE) meta-analysis project
Meta-analysis: analysis of results
Effect size = standardized difference
statistic
m m
 Change E.S.
 pre post
sd
(pooled
)
Creates a common for comparing results
The HPCE Meta-Analysis
Project
1st Generation: Greenberg, Elliott & Lietaer,
1994 (n= 36 studies) ….
5th Generation: Elliott & Freire (2008):
Supported by a grant from the British Association
for the Person-Centred Approach
180+ studies
200+ samples of clients
>13,000 clients
60 controlled studies (vs. no therapy or waitlist)
110 comparative studies (vs. HPCE therapies)
Elliott & Freire (2008) Metaanalysis Preliminary Results
1. HPCE therapies associated with large
pre-post client change
Effect size: 1.03 sd [standard deviation units]
 = a very large effect
2. Clients’ large posttherapy gains are
maintained over early & late follow-ups
Post: .95sd => early follow-up: 1.08sd => late
follow-up (12+ months): 1.14
Elliott & Freire (2008) Metaanalysis Preliminary Results
3. Clients in HPCE therapies show
large gains relative to untreated
clients
Effect size: .81 sd = a large effect size
 Proves therapy causes client change.
Elliott & Freire (2008) Metaanalysis Preliminary Results
4. HPCE therapies in general are
clinically and statistically equivalent
when compared to other treatments
(combining CBT and other therapies)
Effect size: .01 sd
= no difference in amount of change
Held true even when we only considered
randomized (“gold standard”) studies
Elliott & Freire (2008) Metaanalysis Results
5. Comparison to Cognitive-Behavior
Therapy (CBT):
HPCE therapies as a group slightly
but trivially less effective than CBT:
Effect size: -.18 sd
=trivially worse (a small effect)
But…
Elliott & Freire (2008) Metaanalysis Results
6. Researcher theoretical allegiance
effects strongly predict comparative
ES:
Correlation between comparative ES and
theoretical allegiance of researcher: -.52
CBT-oriented researchers => worse effects for
HPCE
 Small negative effect for HPCE therapies
vs. CBT disappears after statistically
controlling for researcher allegiance
Where does researcher
allegiance effect come from?
Big differences in how different HPCE therapies
do in comparison to CBT
Type HPCE Therapy
N
Comparative ES
Nondirective/
supportive
37
-.36 (=worse)
Person-centred
22
-.09 (=equivalent)
Emotion-Focused
6
+.60 (=better)
Other experiential
10
-.14 (=equivalent)
What is “Nondirective/
Supportive” Therapy?
Nondirective/supportive:
 87% studies carried out by CBT Researchers
(40/46 in total sample)
 65% explicitly labelled as “controls” (30/46)
 52% involve non bona fide therapies (24/46)
 76% of researchers are North American (35/46)
 61% involve depressed or anxious clients (28/46)
The Moral of this Story:
We don’t have to be afraid of
quantitative research or RCTs
But if we let others define our reality, we
are going to be in trouble.
Therefore, we need to do our own
outcome research… including RCTs
Question 1b: What does Quantitative
Process-Outcome Research Tell Us?
Process-outcome research predicts outcome
from in-therapy process measures, e.g.,
therapist empathy
Best-known process variable is Therapeutic
Alliance
Most common measure: Working Alliance
Inventory
Meta-analyses show that alliance predicts
outcome: e.g., Horvath & Bedi, 2002; n = 90
studies: mean r = .21
Process-Outcome Research
on Therapist Empathy
 Therapist empathy is one of the
strongest predictors of outcome
 Bohart et al. (2002) meta-analysis
 47 studies: mean r = .32
Accounts for about 10% of the variance in
outcome
Interpretation of r = .32
1. Optimist’s view: 10% is a lot!
One of the best predictors of outcome
Maybe even better that therapeutic alliance
Interpretation of r = .32
2. Pessimist’s view: The glass is 90%
empty!
 Rogers’ “necessary & sufficient” predicts
perfect correlation (r = 1.0)
 r = .32 decisively refutes Rogers’
hypothesis
Interpretation of r = .32
3. Optimist’s rebuttal: 10% is almost 100% of
what we can reasonably expect from the real
world
Client individual differences in problem severity
and resources predict most of outcome
Measurement error
Restriction of range (not enough unempathic
therapists!)
Other stuff
Interpretation of r = .32
4. Pessimist’s plea: I still want the other
90%…
Question 2: What does
Qualitative Research Tell
Us?
Rogers’ Process Equation was based
on proto-qualitative research:
Years of careful observation of productive
and unproductive therapy sessions
Systematic qualitative research is a
relatively recent development
But mature enough now to allow a few
small qualitative meta-analyses
1. Helpful and Hindering
Factors
Greenberg et al. (1994)
Reviewed 14 studies of HPCE therapies
Selected 5 most frequent helpful and 3
most frequent hindering aspects
14 categories of Helpful aspects,
grouped into 4 larger domains
Most Common Helpful
Aspects in HPCE therapies
1. Positive Relational Environment (7 out of
14 data sets; e.g., empathy) =>
2. Client's Therapeutic Work (13 sets)
Most common : Self-Disclosure, Involvement =>
3. Therapist Facilitation of Client's Work (6
sets; e.g., fostering exploration) =>
4. Client Changes or Impacts (12 sets)
Most common: Understanding/ Insight,
Awareness/Experiencing
Most Common Hindering
Aspects
Much less common; difficult to study
Most common: Intrusiveness/
Pressure
Even in person-centered therapy
Also present:
 Confusion/Distraction (derailing the
client's process)
 Insufficient Therapist Direction
2. Client Post-therapy
Changes
Qualitative outcome
Jersak, Magana and Elliott (2000; in
Elliott, 2002)
5 studies, mostly Process-Experiential
for depression or trauma
Jersak et al. (2000)
Vitalizing the Self: Internal change
4 subprocesses:
Leaving Distress Behind =>
Increased Contact with Emotional Self =>
Improved Self-esteem =>
Increased Sense of Personal
Power/Coping/Self-control
 Describe the first phase of a metaphorical
journey
Jersak et al. (2000)
Changes in the Self’s Relationships to
Others/World:
3 subprocesses:
Defining Self with Others/Asserting
Independence
Engaging with Others,
Experiencing the World More/Mobilizing Self to
Act in the World
 Describe the outward phase of the client’s
journey
3. Effects of significant
therapy events
Timulak (2007)
7 studies, most HPCE
9 common categories
All 7 studies:
Awareness/Insight/Self-Awareness
Reassurance/Support/Safety
More than half the studies:
Behavior Change/Problem Solution
Exploring Feelings/Emotional Experiencing
Feeling Understood.
Implication: Qualitative
Studies of HPCE
May be possible to integrate these 3
types of research into a model of HPCE
change process
Framework:
Helpful (hindering) aspects =>
Immediate effects (significant events)
=>
Qualitative outcome
Question 3: How Can We
Learn More?
1. Be Methodologically
Pluralist
Most sensible course of action:
To encourage both kinds of research
Render politically expedient quantitative
data to the government and professional
bodies (“Caesar”)
Simulaneously carry out qualitative
research that completely honors personcentered principles
Even in the same study
2. Follow Person-Centred
Research Principles
E.g., Mearns & McLeod (1984)
(1) Empathy. Understand, from the inside, the
research participant’s (client or therapist) lived
experiencing
(2) Unconditional Positive Regard. Accept/prize
the research participant’s experiencing,
(3) Genuineness. Be an authentic/equal partner
with the research participant: participant = coresearcher; researcher = a fellow human being.
(4) Flexibility. Creatively and flexibly adapt
research methods to the research topic and
questions at hand
Applying Person-centred
principles to different types of
research
Fairly easy to see application to qualitative
research, e.g.,
Clarifying expectations and other researcher preunderstandings;
Negotiating nature of participation with informant
in a transparent, collaborative manner;
Carrying out data collection in a careful, intentional
manner, including helping informant stay focused
and clarifying their meanings; etc.
Person-Centred Principles
Apply Equally to Quantitative
Research
Always put the participant’s needs
ahead of yours
Treating participants disrespectfully and
inconsistently leads to resentment and
sloppy, invalid data
A questionnaire is a form of relationship
Person-Centred Principles Apply
Equally to Quantitative Research
A research participant will feel misunderstood
and uncared for by a confusing questionnaire
layout or an overly hot or noisy research room
An ill-prepared research packet or an anxious
interviewer can betray a lack of genuine
commitment by the researcher
All of our criticisms of quantitative research are
really criticisms of bad research, of any kind
3. Focus on Change
Process Research
Much current research on HPCE
therapies does not focus on how
change occurs
Needed as complement to outcome
research & improve therapy
Select from different genres of change
process research
a. Important preliminary: Basic
outcome research
What are the effects of HPCE therapies with
specific client populations?
Can be quantitative or qualitative
Single client or group of clients
Standard questions or individualized
See Elliott & Zucconi (2006) for suggestions
to implement in practice and training settings
Necessary starting point for Change Process
research
b. Process-Outcome
Research
Quantitative genre: Measure process
(e.g., empathy) => predict outcome
HPCE’s not studied enough with this
approach:
Only 6 out of 47 studies in Bohart et al.
(2002) empathy-outcome meta-analysis
were HPCE therapies
Highly appropriate to naturalistic
samples
c. Helpful Factors Research
Qualitative genre:
Interview (e.g., Change Interview)
Helpful Aspects of Therapy (HAT) Form
Analyze with variety of methods, e.g.,
Grounded Theory, discourse analysis
d. Micro-analytic Sequential
Process Research
Examine turn-by-turn interaction
between client and therapist
Quantitative: client and therapist
process measures (e.g., client
experiencing and therapist empathy)
Qualitative: Task analysis or
Conversation analysis
e. Complex Change Process
Research Methods
Combine genres to develop richer picture
Balance strengths, limitations
Examples:
Assimilation Model (Stiles et al., 1990)
Task Analysis (Rice & Greenberg, 1984)
Comprehensive Process Analysis (Elliott, 1989)
Hermeneutic Single Case Efficacy Design (Elliott,
2002)
4. Get Involved!
Elliott & Zucconi (2006): International
Project on Psychotherapy and
Psychotherapy Training (IPEPPT)
The project is to stimulate practicebased research, especial in training
centres
Have developed a set of sample
research protocols to choose form
Further Suggestions (Elliott &
Zucconi, 2006)
(1) Contribute to dialogues on how to measure
therapy and training outcomes within HPCE
therapies
(2) Set an example for students and colleagues by
carrying out simple research procedures with your
own clients and in your own training setting
(3) Help to develop specialized research protocols
for particular client populations (e.g., people
living with schizophrenia)
Further Suggestions (Elliott &
Zucconi, 2006)
(4) Contribute to method research aimed at
improving existing quantitative and qualitative
instruments
(5) Take part in more formal collaborations with
similarly-inclined training centers to generate data
for shared research
Robert Elliott: [email protected]
Blog: pe-eft.blogspot.com