Counseling 407 Community Counseling

1. Counseling 407Community Counseling • Dr. Jeffrey K. Edwards, LMFT • Office 4054 • Phone 773-442-5541 • Office Hours – Wednesdays 1-4, Thursdays 3-6

2. Counseling 407Community Counseling • Day one – Introduction • Counseling research – Review or new? • Community Counseling - Definitions • Prevention - Models

3. Counseling Knowledge Well known facts that most therapists either overlook, forget, or were never told. Or, why counseling/psychotherapy myths about who is better prevail. Arm yourself with this information and you will be an unstoppable Community/Family Counselor.

4. Counseling Knowledgethis will wake you up. Counseling and or Psychotherapy are comparatively the same thing. They are simply different names for doing the same activities. However, there are many professionals who have been trained to believe that doing psychotherapy is more scientific and rigorous, and should only be provided by certain professions. (For a comprehensive review see Neukrug, 2003)

5. Counseling Knowledgethis will wake you up. Counseling/Psychotherapy works. More than 40 years of outcome studies have demonstrated effectiveness (Hubble, Duncan and Miller, 1999). However, nearly 50% of clients drop out of treatment. There are few predictors of premature dropout, except substance abuse, minority status, and lower education (Prochaska, 1999).

6. Counseling Knowledge Smith et al. (1980) found that at the end of treatment, clients were better off than 80% of a control group that did not have treatment. Two studies showed that about 75% of clients significantly improve after 26 sessions (six months) and that 50% show significant improvement after only 8 to 10 sessions.

7. Counseling Knowledge In fact, the average length of stay in treatment is around 8 to 10 sessions, with a modal number of 1. In a famous research project at Keiser Permenante 80% of those clients who dropped out after one session reported that they had received the help they needed after that one session.

8. Counseling Knowledge Certain types of client problems are more likely to relapse, notably those with substance abuse problems, eating disorders, recurrent depression, and personality disorders (Asay and Lambert, 1999). It seems, however that change is more likely to last, if the client attributes their changes to their own efforts ( Lambert & Bergin, 1994).

9. When therapy succeeds, the convention is to attribute the positive outcome to the therapy or ministrations of the therapist. In contrast, when therapy goes awry, or at least yields disappointing results, it has been customary to place the failure in the client or the client’s personality (Hubble, Duncan, & Miller, 1999).

10. Counseling Knowledge • Counseling/Psychotherapy models all have the same effectiveness, more or less (see comprehensive reviews in Hubble, Duncan and Miller, 1999). • This has been called the Dodo effect, by Luborsky et al. (1975) - from Alice and Wonderland, “Everyone has won and all must have prizes.”

11. Counseling Knowledge If techniques are not that important, then what are the factors that contribute to positive outcome? There are four: • Client Variables (40%); • The Therapeutic relationship (30%); • Expectancy and Placebo Effect (15%); • Technique (15%).

12. Counseling Knowledge

13. Client Variables (40%) • Severity of Symptoms (both psychological and physical); • Motivation; • Psychological mindedness; • Ability to identify a focal problem (Lambert and Anderson, 1996).

14. Client Variables (40%) “a withdrawn, alcoholic client, who is “dragged into therapy’ by his or her spouse, possesses poor motivation for therapy, regards ,mental health professionals with suspicion, harbors hostility toward others, is not nearly as likely to find relief as the client who is eager to discover how he or she has contributed to a failing marriage and expresses determination to make personal changes” (Asay and Lambert, 1999).

15. The Therapeutic Relationship (30%)Spontaneous Improvement “a significant number of people are helped by friends, family, teachers, and clergy who use a variety of supportive and HOPE instilling techniques. Howard et. al (1986) estimated that about 15% of clients experience some improvement before the beginning of treatment” (Asay & Lambert, 1999).

16. The Therapeutic Relationship (30%)Spontaneous Improvementis influenced by • Length of time the problem has been evident; • Underlying personality disorder; • Quality of social support, especially the marital relationship (Andrews & Tennant, 1978; Mann, Jenkins, & Belsey, 1981).

17. The Therapeutic Relationship (30%) The Necessary and sufficient conditions • Accurate Empathy • Positive Regard • Non possessive warmth • Congruence and genuineness. These are client-perceived rather than objective raters’ perceived.

18. The Therapeutic Relationship (30%) It seems that the following components are important to the therapeutic alliance: • Client’s affective relationship with the therapist; • Client’s capacity to work purposefully in therapy; • Therapist’s empathic understanding and involvement; • Client-therapist agreement on goals and tasks of therapy (Gaston, 1990).

19. The Therapeutic Relationship (30%) During a demonstration of “bad” therapy techniques I did at Wheaton College, I demonstrated bad posture, bad eye contact, etc. When done, I asked the class to evaluate, and they were correct in their perceptions of my techniques, however, the “client” saw things differently. She said it was the most profound experience of her life!!

21. Things to think about! The mortal wound of psychotherapy occurred when it made objects-to-be-fixed of the people it was trying to help. Gerald May, M. D. (1990)

22. Counseling Knowledge Since the mid 1980’s there has been an 275% increase of persons who have trained and provide counseling/psychotherapy.

23. The Therapeutic Relationship (30%) In the NIMH Study of Depression Collaborative Research Program (1996), a comparison between psychotherapy and active and placebo pharmacology found that the therapeutic alliance had a significant effect on outcome. So what do you think about that?

24. there are well over 260 models of counseling/psychotherapy, and most people seeking help have only a vague idea of what to expect. • Edwards, J.K. & Heath, A.W. (2006). Unveiling the Mysteries of Psychotherapy: A consumers guide to mental health services. Haworth Press, Inc.

25. Most psychiatric conditions do not have a clear etiology, rather they are defined as either syndromes or patterns of symptoms that include emotion, cognition, perception, and/or behaviors. • Sahler, O.J.Z., & Carr, J.E. (2003) (Eds.). The Behavioral Sciences and Health Care. Hogrefe & Huber, Cambridge, MA.

26. The problem raised by the term “mental” disorders has been much clearer than its solution, and, unfortunately, the term persists in the title of DSM-IV because we have not found an appropriate substitute. A categorical approach to classification works best when all members of a diagnostic class are homogeneous, when there are clear boundaries between classes, and when the different classes are mutually exclusive. Nonetheless, the limitations of the categorical classification system must be recognized. In DSM-IV, there is no assumption that each category of mental disorders is a completely discrete entity with absolute boundaries dividing it from other mental disorders or from no mental disorder. There is also no assumption that all individuals described are having the same mental disorder are alike in all important ways. • American Psychiatric Association, Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, Text Revision Washington DC. APA, (2000). - p. xxx and xxxi

27. In the last fifteen years, HMO’s, insurers, pharmaceutical companies, hospital corporations, physicians, and other segments of the industry contributed $479 million to political campaigns – more than the energy industry ($315 million), commercial banks ($133 million), and big tobacco ($52 million). More telling is how much the health care industry spends on lobbying. It invests more than any other industry except one, according to the nonpartisan Center for Responsive Politics. From 1997 to 2000, the most recent year for which complete data is available, the industry spent $734 million lobbying Congress and the executive branch. • Barlett & Steele, (2004). Critical Condition

28. OK now, what does all this mean to you? • How does this change the way you will practice? • What ideas do you have for changing the way you thought you might work? • What excites you about these concepts?

29. A Community Counseling ModelThe Upstream Model

30. A Model of Community Counseling • This is the story of the Jeffrey’s River – • Once upon a time. There was a river. named Jeffrey. I wonder why?

31. A Model of Community Counseling • One day …someone came floating ..

32. A Model of Community Counseling • down the river, almost drown.

33. A Model of Community Counseling • A good Samaritan saw the drowning person Help!

34. A Model of Community Counseling • helped him out and saved his life. Thanks

35. A Model of Community Counseling • Soon, another person came floating down the river, almost drown. Help!

36. A Model of Community Counseling • and he too, was helped out and had his life saved. Thanks

37. A Model of Community Counseling • soon there were lots and lots of people coming down the river drowning. Help! Help!Help! Please!! Help!

38. A Model of Community Counseling • The Samaritan needed some help. So he asked a friend. Help! Help! Help!Help! Please!!

39. A Model of Community Counseling • And soon there were lots and lots of people helping all those other people coming down the river drowning.

40. A Model of Community Counseling • Soon they were building hospitals, and clinics….

41. A Model of Community Counseling • And then they had supervisors and administrators…

42. A Model of Community Counseling • And they had overseers who told them how much they would pay…called Managed Care.

43. A Model of Community Counseling • And then one very smart person decided to go up stream to see…..

44. A Model of Community Counseling • what or who was causing all those people to fall in the river. It is me. I like to push them into the drink.

45. A Model of Community Counseling • And he told him to stop. So, he did! OK, I will. Hey, stop that!

46. A Model of Community Counseling • And that is how a Preventative Public Health model was born…. You are welcome. Thanks.

47. Community Counseling Components • The community has all the resources needed to provide for it’s members; • Finding out what the community needs, and then what their resources are starts the process.

48. Prevention • Public Health came about from the work of Health Care professionals, like Physicians, Nurses and other professionals, who study epidemiology, and they then find ways to treat groups who have similar problems. • Epidemiology – • 1. a branch of medical science that deals with the incidence, distribution, and control of disease in a population ; • 2 : the sum of the factors controlling the presence or absence of a disease or pathogen .

49. Examples of Epidemiology and Prevention Work • Snow, Edwin Miller– America's first professional city medical health officer he, took on the serious problems with cholera epidemic of 1854 in Providence, in which he investigated about 150 cases. There was no health authority in the city, so he personally undertook action to curb the epidemic. He drew up a report sharply criticizing the city's complete lack of sanitary precautions and recommended measures to deal with the problem.

50. Examples of Epidemiology and Prevention Work • SIDS – 50% reduction of deaths by placing babies on their backs. • SIDS – with Native Americans – did not respond in kind, but further investigation found that many mothers were also binge drinking, and by swaddling the babies in the colder months so they get too hot.