What Works in Psychotherapy & Counselling A Presentation by Courtenay Young – UKCP Psychotherapist and NHS Counsellor University of Strathclyde Counselling

What Works in Psychotherapy & What Works in Psychotherapy & CounsellingCounselling

A Presentation by Courtenay Young – UKCP Psychotherapist and NHS CounsellorUniversity of Strathclyde Counselling Placement Presentation: 05-Aug 2015

What Works in Psychotherapy & What Works in Psychotherapy & CounsellingCounselling

And – to a lesser extent - what doesn’t!

What Works in Psychotherapy & Counselling

What this presentation isn’tisn’t about ……

• It isn’t about any particular method or modality being better: see the “Dodo Bird” verdict – i.e. all therapies are equally effective, as they all produce equally effective outcomes; 1

• It isn’t about developing a good therapeutic relationship – you should have already been told about this, and be practicing it, and discussing it with your supervisor, and getting “client feedback” etc. – whatever your method or modality happens to be;

• It isn’t about ‘artificial’ distinctions between … psychotherapy, counselling, coaching, psychological therapy (IAPT), guided self-help, etc.;

• And it isn’t about randomized controlled trials, empirically supported therapies, evidence-based practice, effect-sizes, risk-factors, etc. 2, 3

Continued over


What this presentation also isn’t about ……

• It also isn’t about professional competencies or national occupational standards – which is what every one of you is supposed to be able to do; 4, 5

• It isn’t about one’s views about ‘mental illness’, the ‘medical model’, etc. vs. the more humanistic view, client-centred, or context-based, practice;

• It has nothing at all to do with ethics and professional behaviour – which is about how you ought to be working – or how you ought not to be working;

• It has also nothing to do with UKCP or BACP or COSCA or APA or EAP … and all their Ethical Principles and Codes of Practice, etc.

• And it isn’t about what I do – because what works for me with this person, probably won’t work for you with that person (and v.v. /u.s.w).So … … … …


What this Presentation therefore is about is: … …• The Common Factors Theory 6

• STAB – Some ‘Therapists’ Are Better than others: Some ‘Treatments’ are Better (for some things);

• The Four Magic Words;• WOOPS• The Great Divide -> CPRN• Critical Psychotherapy & Counselling• Real Therapy & ‘The Big Issues’• And …

(hopefully) some good ideas from you!

The Common Factors Theory advantages, disadvantages and developments

• Meta-Analysis: 7

– Meta-analysis is safer than single study – but not necessarily more reliable

– A meta-analysis is a snapshot in time – it can be outdated as soon as it is published

– Don’t take an outcome literally – look carefully, as it may no be what it appears

– Not all studies belong together – again be careful

– Missing studies and missing data can torpedo a meta-analysis

– Forest Plots & the confidence interval

– Strength of evidence varies from outcome to outcome

– Data choice and statistical techniques can change a result

– All meta-analyses are not the same: systematic reviews; cumulative, network, prospective

– Absence of evidence is not evidence of absence … most of the timemost of the time


• Meta-Analysis:

• Scott Miller: “What Works in Psychotherapy?”• Scott Miller 8 also wrote: “Why Most Therapists are Average (and How We Can Improve)” a; “Escape from

Babel” (with Mark Hubble & Barry Duncan) b; and “When I’m good, I’m very good, but when I’m bad, I’m better: A new mantra for psychotherapists” (with Barry Duncan) c.

• Miller has also found that the therapist is the main determining factor, not the treatment model. This means that therapists can learn, grow and be more effective with their clients by systematically monitoring therapy outcomes. This can be done by: Knowing your base-line (Step 1); Inviting all sorts of feedback (inc. negative) (Step 2) and asking the simple question that so often seems too difficult for therapists to ask: "How is this working for you?”; Deliberate Practice with measurement (Step 3). i.e. Create a good stable base, and then use ‘Deep Contextual Knowledge’ to develop from there.

• Common Factors are thus a way of studying the effects of psychotherapy, but not a way of actually implementing it.

• “The difference between the best and the rest is what they do before they meet a client and after they’ve met them, not what they’re doing when they’re with them.”

• Darryl Chow’s research indicates that … within the first eight years of practice, therapists with the best outcomes spend approximately more than seven times the number of hours on study and contemplation, than the bottom two-thirds of clinicians engaged in these kinds of activities.


• Meta-Analysis:

• Scott Miller: “What Works in Psychotherapy?”

• “The Heart & Soul of Change” – Hubble, Duncan & Miller 9, 10

[They] have created a new and enriched volume that presents the most recent research on what works in therapeutic practice, a thorough analysis of this research, and practical guidance on how a therapist can truly "deliver what works in therapy." This volume examines the common factors underlying effective psychotherapy and brings the psychotherapist and the client–therapist relationship back into focus as key determinants of psychotherapy outcome.The second edition of The Heart and Soul of Change also demonstrates also demonstrates the power of systematic client feedback to improve effectiveness and the power of systematic client feedback to improve effectiveness and efficiency efficiency and legitimize psychotherapy services to third party payers. In this way, psychotherapy is implemented one person at a time, based In this way, psychotherapy is implemented one person at a time, based on that unique individual's perceptions of the progress and fit of the on that unique individual's perceptions of the progress and fit of the therapy and therapist.therapy and therapist.


• Meta-Analysis:


• “The Heart & Soul of Change” – Hubble, Duncan & Miller

• A Common Factors Approach to Psychotherapy Training: 11, 12

– Common Categories in 50 authors: client characteristics (26%); therapist qualities (24%); change processes (41%); treatment structure according to theory (8%); and therapeutic relationship (56%). Grencavage & Norcross (1990) 13

– Common Categories: therapeutic contract; interventions; relationship bond; states of self-relatedness; and realization. Orlinsky & Howard (1986, 1987) 14


• Meta-Analysis:


• “The Heart & Soul of Change” – Hubble, Duncan & Miller

• A Common Factors Approach to Psychotherapy

• Empirically Validated Therapy v. The Recovery Model 15

– Common Factors account for more of the variance than specific techniques

– The EVT model suggests that some therapies work better than others for some conditions: e.g. CBT for anxiety disorders

– The Recovery Model is more theoretical, philosophical and more systemic: a ‘stage’ model of change; also respecting the consumer’s choice.

STAB - Some Therapists Are Better• The “effective” therapist has a sophisticated set of interpersonal The “effective” therapist has a sophisticated set of interpersonal

skills including: verbal fluency; interpersonal perception; affective skills including: verbal fluency; interpersonal perception; affective modulation and expressiveness; warmth and acceptance; empathy; modulation and expressiveness; warmth and acceptance; empathy; focus on the other.focus on the other.

• Clients of “effective therapists” feel understood, trust the therapist, Clients of “effective therapists” feel understood, trust the therapist, and believe the therapist can help him or her. and believe the therapist can help him or her.

• The therapist creates these conditions in the first moments of the The therapist creates these conditions in the first moments of the interaction through verbal and importantly non-verbal behavior. In interaction through verbal and importantly non-verbal behavior. In the initial contacts, clients are very sensitive to cues of acceptance, the initial contacts, clients are very sensitive to cues of acceptance, understanding, and expertise. understanding, and expertise.

• Although these conditions are necessary throughout therapy, they Although these conditions are necessary throughout therapy, they are most critical in the initial interaction to ensure engagement in are most critical in the initial interaction to ensure engagement in the therapeutic process. the therapeutic process. 16

STAB - Some Therapists Are Better

• ““Effective Therapists” are able to form a working alliance with Effective Therapists” are able to form a working alliance with a broad range of clients.a broad range of clients.

• ““Effective Therapists” provide an acceptable explanation for Effective Therapists” provide an acceptable explanation for the client’s distress.the client’s distress.

• The “effective therapist” provides a treatment plan The “effective therapist” provides a treatment plan – that is consistent with the above explanation.

• The “effective therapist” is influential, persuasive and The “effective therapist” is influential, persuasive and convincing.convincing.

• The “effective therapist” continually monitors the client’s The “effective therapist” continually monitors the client’s progress in an authentic way. progress in an authentic way.

STAB - Some Therapists Are Better• The “effective therapist is flexible The “effective therapist is flexible and will adjust therapy if

resistance to the treatment is apparent or if the client is not making adequate progress..

• The “effective therapist” does not avoid difficult material in The “effective therapist” does not avoid difficult material in therapy and uses such difficulties therapeutically.therapy and uses such difficulties therapeutically.

• The “effective therapist” communicates hope and optimism.The “effective therapist” communicates hope and optimism.

• Effective therapists are aware of the client’s characteristics Effective therapists are aware of the client’s characteristics and context. [and context. [Characteristics = culture, race, ethnicity, spirituality, sexual orientation, age, physical health, motivation: Context = available resources, family & support networks, vocational status, cultural milieu and concurrent support services.]

STAB - Some Therapists Are Better

• The Effective Therapist is aware of his or her own The Effective Therapist is aware of his or her own psychological process psychological process and does not interject his or her own material into the therapy process unless such actions are deliberate and therapeutic.

• The Effective Therapist is aware of the best research evidence The Effective Therapist is aware of the best research evidence available available that relates to the client’s condition: re treatment, problems, social context, biological & psychological bases.

• The Effective Therapist seeks to improve continually – The Effective Therapist seeks to improve continually – achieving expected or more than expected progress with his or her clients and who is continually improving. . 16

STAB - Some Treatments Are Better

• STAB -STAB - Some Treatments Are Better than others - for some things – and for some people

• There is NO one-size-fits-all !!! There is NO one-size-fits-all !!! e.g. for depression – for some people, anti-depressants are a life-saver; for others, an anathema; and for others (about 60%), a combination of SSRI and counselling actually works best.

• Ditto – GAD, IBS, etc. Ditto – GAD, IBS, etc. 17 Then there is the “placebo effect”.

• Ditto – CBT, DBT, IPT, FFT, PCC, SAD, AAT, Ditto – CBT, DBT, IPT, FFT, PCC, SAD, AAT, 18

• ““A Guide to Treatments that Work” – A Guide to Treatments that Work” – Nathan & Gorman. .

The Four Magic Words!

What – Works – For – Me!What – Works – For – Me!

• Client Empowerment 19, 20, 21

• The Power of Choice 22, 23

• Self-Help Orientation & Techniques 24

=> Proactive Client-Centered ‘coaching’ – “Is there anything wrong with that?”

“The Great Divide”• The “Great DivideGreat Divide” is what exists between practitioners and

researchers 25

• Clinical Practitioners Research Networks (CPRN) Clinical Practitioners Research Networks (CPRN) – allows practitioners to become involved in ‘realistic’ research networks. 26,

27

• CORECORE Outcome Research Network 28

• SPR – Society for Psychotherapy ResearchSPR – Society for Psychotherapy Research 29

• BACPBACP – Counselling & Psychotherapy Research Journal; Case Study research in counselling & psychotherapy; Essential Research Findings in Counselling & Psychotherapy “The Facts Are Friendly”; Treatment of Choice in psychotherapy & counselling: evidence-based clinical practice guidelines. 30

WOOP-ing along successfully!

Wish – Outcome – Obstacle – Plan• Used to be called MCII (Mental Contrasting with Implementation Intentions) and is

very well-researched. This involved Cognitive Changes, Motivational Changes, and Response to negative feedback.

• Mental Contrasting was combined with “Implementation Intentions”. People taught ‘Implementation Intentions’ do much better than ‘information-only’

• Boosts motivation, goal-setting and goal achievement

• WOOP is both time- & cost-effective to teach and can be applied to issues from any life domain (interpersonal, academic, professional, health). It can be used for goals that are small, large, short-term and long-term.

• Health professionals trying to help people make effective changes should know about the ‘psychological technology’ of WOOP. 31

Critical Psychotherapy & Counselling

Craig Newnes: (editor of the Journal of Critical Psychology, Counselling & Psychotherapy (formerly “Changes”) writes:

“I believe that unhappiness is a form of heresy and most of the misery for which people seek help is only amenable to alleviation through changes in their material lives.”

What role therefore has psychotherapy & counselling in this?

Do We Need A Critical Psychotherapy?

In June 2015, at the Anna Freud Centre in London, there was a one-day conference ‘event.’ 32 Speakers from different countries and different theoretical perspectives addressed questions about the provision of talking therapies in contemporary society, and how therapeutic practice is affected – or not.

They addressed various questions like:


In June 2015, at the Anna Freud Centre in London, there was a one-day conference ‘event.’ Speakers from different countries and different theoretical perspectives addressed questions about the provision of talking therapies in contemporary society, and how therapeutic practice is affected – or not.


• Is it important for psychotherapy & counselling to be 'critical’, socially engaged, and/or even political?


In June 2015, at the Anna Freud Centre in London, there was a one-day conference ‘event.’ Speakers from different countries and different theoretical perspectives addressed questions about the provision of talking therapies in contemporary society, and how therapeutic practice is affected – or not.



• Do psychotherapists & counsellors do a disservice to their clients by not challenging present professional parameters?


In June 2015, at the Anna Freud Centre in London there was an ‘event’! Speakers from different theoretical perspectives addressed questions about the provision of talking therapies in contemporary society, and how therapeutic practice is affected.




• Do psychotherapy & counselling trainings actually discourage critical thought and free-thinking, or are they just churning out ‘clones’?







• Do present professional parameters promote an other-worldly sense of psychotherapy and the patient/client’s ‘inner world’?







• Do present professional parameters promote an other-worldly sense of psychotherapy and the patient/client’s ‘inner world’?

• What models of 'mental illness' and (especially) 'mental health' are appropriate for psychotherapy in the 21st century?


I personally would have liked to attend this – especially Session 2 – What can we learn from Critical Psychology and Critical Psychiatry? ; and Session 4 – Users’ and Educators’ Perspectives.

Session 2:

Ian Parker: Toward critical psychotherapy and counselling: what can we learn from critical psychology (and political economy)?

Hugh Middleton: The Medical Model: What is it, where did it come from and how long has it got?

Session 4:

Tom Cotton: “Personal vs medical meanings in breakdown, treatment and recovery from schizophrenia.”

Jay Watts: “Systemic means to subversive ends: maintaining the therapeutic space as a unique encounter”.


Another (2014) conference, The Limbus Critical Psychotherapy Conference: – “Challenging Cognitive Behavioural Therapies: The Overselling of CBT’s evidence-base” has a post-conference website 33 with download-able papers like:

Shedler (2010). The Efficacy of Psychodynamic Psychotherapy

Longmore & Worrell (2007). Do we need to challenge thoughts in Cognitive Behavioural Therapy?

Adams (2008). Naughty not N.I.C.E.: Implications for therapy and services.

Ferraro (2015). Torture, Psychology & the Neoliberal State.

Henrich, Heine, Norenzayan (2008). The Weirdest People in the World.

Richardson (1997). Fields of play. Constructing an academic life.

Greenhalgh (2014). Evidence based medicine: a movement in crisis?

Samuels & Veale (2007). Improving Access to Psychological Therapies: For and Against.

Westen, Novotny, Thompson-Brenner (2004). The Empirical Status of Empirically Supported Psychotherapies: Assumptions, Findings, and Reporting in Controlled Clinical Trials.

What is Real Therapy?And what doesn’t work, or isn’t working, or isn’t being

addressed?

Clare Slaney (of PCSR) 34 recently posted a discussion on this topic on Linked-In (15-July, 2015). She sees a threat to “real therapy” coming from:

• ‘initiatives’ like IAPT; and recently IAPT ‘therapists’ being placed in Job Centres;• the volunteering system for trainees and the ‘intern’ system for new graduates; • state regulation for psychotherapy & counselling; • professional association ‘ducking the issues’ of diversity and equality issues; • the irrelevance of therapy to the impact of austerity on communities and individuals

and the blind-spot of the psychological damage these policies incur; • innovative (quick fix?) therapies that question traditional ideas of expertise and

containment; • bullying, harassment and intimidation in training and service organisations; etc.

These she calls “The Big Issues” – and there is a seminar / conference on 26-Sept in London, “Addressing the crisis in psychotherapy and counselling” with Nick Totton.

How We Can Improve• 25% of least helpful therapists produced effect sizes of 0.2 35

• 25% of the most helpful therapists produced effect sizes of 0.9Imagine the possibilities of improved service effectiveness if the least helpful Imagine the possibilities of improved service effectiveness if the least helpful

can become much better.can become much better.• Objective and supportive feedback on our actual practice (routine Objective and supportive feedback on our actual practice (routine

outcome monitoring) is absolutely necessary => practice-based evidenceoutcome monitoring) is absolutely necessary => practice-based evidence 36

• Use of CORE, OQ and/or PCOMS and engaging patients with these Use of CORE, OQ and/or PCOMS and engaging patients with these “Clinical Support Tools”“Clinical Support Tools”

• Cutting down number of ‘unnecessary’ sessions –i.e. 6-8 sessions is often Cutting down number of ‘unnecessary’ sessions –i.e. 6-8 sessions is often at the point of peak improvement. at the point of peak improvement. 37

• Try also to reduce drop-out rates (c. 25-35%)Try also to reduce drop-out rates (c. 25-35%) 38; don’t interpret it; focus on ; don’t interpret it; focus on the seemingly ‘inaccurate’, confusing or anxiety-provoking bits;the seemingly ‘inaccurate’, confusing or anxiety-provoking bits; 39

Why Therapy Works• If you are interested in the neuro-science perspective, then Louis

Cozolino’s latest book (to be pub., Nov. 9, 2015) , “Why Therapy Works: Using our minds to change our brains” might also be worth reading:

“The story of why psychotherapy works begins with the brain. We must understand how it evolved to learn, unlearn, and relearn. We have to understand the power of human relationships to regulate anxiety and stimulate learning, and that the way we interact with the world physically, emotionally, psychologically, and spiritually has been woven into our social brains.

Finally, we must understand the role of stories and our ability to edit our own stories to change the patterns of our lives for the better.”

W.W. Norton & Co.

What Doesn’t Work?• ‘‘Normal’ one-to-one counsellingNormal’ one-to-one counselling & psychotherapy does & psychotherapy does notnot work very well for:work very well for:

– People with a severe mental condition that affects their ability to make relationships, concentrate and attend regularly. Examples include: severe depression, psychotic illness, personality disorders, etc.

– People who are currently engaged in self-destructive behaviour, prolonged substance abuse, alcohol abuse, eating disorders, etc.

– People with severe mental disabilities or learning disorders

– People with a history of violence, or with severe post-traumatic stress disorder

– People with a poor understanding of the therapist’s language

– People from a very different culture

These people usually do much better working within a specialized team approach, or in residential setting, or with specialist facilities, or working with a therapist with specialized training – and then counselling and psychotherapy can be appropriate.

It is therefore very important to know – and work within – one’s personal & It is therefore very important to know – and work within – one’s personal & professional limitations.professional limitations.

What Else Doesn’t Work?• Sticking too rigidly to the method that you have been taught: this is – no doubt – a

very good basis for your future work, but it probably (almost certainly) isn’t enough, or suitable in every situation.

• Not … : … keeping proper notes and records; … getting enough supervision; … obtaining enough CPD; … doing additional reading; … attending conferences; … writing papers; … engaging with other peer professionals; etc.

• Your Needs getting in the way: your regular hours, holiday times, frequency of sessions, fee structure, etc. all need to be a bit flexible; you are dealing with people.

• Counter-transference: if something in the client work “triggers” your ‘stuff’, you need to take care of it separately; beware counter-transference – it can sneak up on you and bite; etc.

• Attitudes … of pride or superiority; thinking you know better; thinking you can ‘help’ or ‘save’ this person; that your ‘way’ (method, style) is good, better, best; that because you have been trained, qualified, accredited, that that is it; etc. and so forth – beware “hubris”; you could do worse than remember Socrates. 40

What Also Doesn’t Work?• Working with clients in areas that we are not familiar with: e.g. (possibly) trans-

gender issues; trans-cultural issues; etc.

• Working with clients from backgrounds that were are not familiar with: social & cultural differences; ethnic differences; prisoners; refugee & asylum seekers; etc.

• Trying to be “helpful” – because this is possibly more your agenda than the client’s – and it often doesn’t work anyway. 41

• Not doing a ‘risk assessment’ – especially if there is a ‘red light’. 54

• Not reading books like:

– “The Mirror Crack’d - When Good Enough Therapy Goes Wrong and other cautionary tales for humanistic practitioners.” Kerns 55

– “The Gift of Therapy: An Open Letter to a New Generation of Therapists and Their Patients” - Yalom 56

What Also Doesn’t Work?• Not being aware of any possible adverse effects: AdEPT –> Supporting Safe

Therapy 50, 51, 52

• Ignoring / overlooking a client’s needs or vulnerabilities: you can sometimes do harm by not responding properly.

• Reasons why someone in therapy might not get better: 53

1. Being the wrong therapist for the client2. Not identifying clear goals3. Are our interventions accessible to the patient / client4. Is there something about the patient / client we don’t like5. Are we being patient enough with the patient / client6. The patient has: … a fear of judgment; … a fear of rejection; … a fear of assuming

greater responsibility; … or a fear of intimacy (However, these last 5 points tend to put some of the onus for the failure on the (However, these last 5 points tend to put some of the onus for the failure on the

patient and are therefore dubious.)patient and are therefore dubious.)

What We Don’t Know?The range of what we think and doIs limited by what we fail to notice

And because we fail to noticeThat we fail to notice

There is little we can doTo change

Until we noticeHow failing to notice

Shapes our thoughts and deeds. R.D. Laing

So What Does Work?

• The therapist is The therapist is onlyonly there to facilitate the client’s process there to facilitate the client’s process – the “midwife approach”.– Follow Follow theirtheir Process – in Process – in ItsIts own time – let own time – let ItIt “unfold” or “emerge” “unfold” or “emerge”

– If you think you “know” – you probably don’tIf you think you “know” – you probably don’t

– Don’t Assume Anything – Ever: be ready to be Surprised!Don’t Assume Anything – Ever: be ready to be Surprised!

– Hope for the Best; Prepare for the WorstHope for the Best; Prepare for the Worst

– No Action is (usually) better than Wrong ActionNo Action is (usually) better than Wrong Action

– Keep it Sweet and SimpleKeep it Sweet and Simple

– Respect, Respect, Respect – and then some more RespectRespect, Respect, Respect – and then some more Respect

– When All Else Fails – PrayerWhen All Else Fails – Prayer

And Now For Your Ideas, Experiences or Findings About ‘What Works’ …

• …

• …

• …

• …

• …

• …

• …

• …

• …

• …

Please send these to me at: [email protected]

mailto:[email protected]

Notes & ReferencesNote 1: ReferencesRosenzweig, Saul (1936). "Some implicit common factors in diverse methods of psychotherapy". American Journal of Orthopsychiatry 6 (3): 412–15.Bentall, Richard P. (2009). Doctoring the mind: Is our current treatment of mental illness really any good?. New York: New York University Press.Luborsky, L. (1999). "The researcher's own therapeutic allegiances: a 'wild card' in comparisons of treatment efficacy". Clinical Psychology: Science and Practice 6: 49–62.Luborsky, L.; Rosenthal, R.; Diguer, L.; Andrusyna, T.P.; Berman, J.S.; Levitt, JT; Seligman, D.A.; Krause, E.D. (2002), "The dodo bird verdict is alive and well–mostly", Clinical Psychology: Science and Practice 9: 2–12.Luborsky, L; Singer, B; Luborsky, L (1975), "Is it true that 'everyone has won and all must have prizes?'", Archives of General Psychiatry 32: 995–1008.Wampold, Bruce E (2001), The great psychotherapy debate: models, methods, and findings, Mahwah, NJ: L. Erlbaum.Barlow, D.H. (2010), "The dodo bird– again– and again", The Behavior Therapist 33: 15–16.

Note 2:Nathan, P.E. & Gorman, J.M. (Eds.) (2007). A Guide to Treatments that Work (3rd Ed.) Oxford: Oxford University Press. “… [this book] offers detailed evaluative reviews of current research on treatments for disorders for which empirically supported interventions have been developed.” These include: Pharmacological and non-pharmacological ‘treatments’ for Attention Deficit / Hyperactivity Disorder; Psycho-social Treatments for Conduct Disorder; Treatments for Dementia; Pharmacological and Psycho-social Treatments for Substance Use Disorders; Pharmacological and Psycho-social Treatments for Schizophrenia; Pharmacological and Psycho-social Treatments for Uni-polar Disorder, Major Depression & Bipolar Disorder; Pharmacological and Psycho-social Treatments for Panic Disorders, Generalized Anxiety Disorder, Phobias & Social Anxiety Disorder; Cognitive Behavioral and Pharmacological Treatments for Obsessive-Compulsive Disorder; Pharmacological and Psycho-social Treatments for Post-Traumatic Stress Disorder; Psychotherapy & Pharmacology for Sexual Dysfunctions; Treatments for Pathological Gambling and Other Impulse Control Disorders, Eating Disorders, Insomnia & Restless Legs Syndrome; Psychological and Pharmacological Treatments for Personality Disorders; and Combination Pharmacotherapy and Psychotherapy for the Treatment of Major Depressive and Anxiety Disorders.

Note 3: Many of these ‘controls’ are ‘supposed’ to ensure that we “do no harm”! i.e. If psychotherapy is powerful enough to do good, it may be powerful enough to do harm: See: Dimidjian, S. & Hollon, D.S. (2010). "How would we know if psychotherapy were harmful?". American Psychologist 65: 34–49. Young, C. (2014). “The possible harmful side-effects of psychotherapy.” International Journal of Psychotherapy, Vol. 18, No. 2, 63-82.Castonguay, G.L., Boswell, F.J., Constantino, J.M., Goldfried, R.M. & Hill, E.C. (2010). "Training implications of harmful effects of psychological treatments". American Psychologist 65: 34–49.

Note 4:National Occupational Standards: https://tools.skillsforhealth.org.uk/competence_search/ and type in “psychological therapies”Professional Competencies: EAP Project to Develop the professional Competencies of a European Psychotherapist: http://www.psychotherapy-competency.eu/

Note 5: The regulation of psychotherapy and counsellors; BACP 2008-2009; (Mind, 2009)

Note 6: ReferencesWampold, Bruce E (2001), The great psychotherapy debate: models, methods, and findings, Mahwah, NJ: L. Erlbaum.Horvath, A.O. & Bedi, R.P. (2002). "The alliance.” In: J.C. Norcross, Psychotherapy relationships that work: therapist contributions and responsiveness to patients, (pp. 37–70). New York: Oxford University Press.Martin, D.J.., Garske, J.P., Davis, M.K. (2000). Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review, Journal of Consulting and Clinical Psychology: 438–50.Grencavage, L.M. & Norcross, J.C. (1990).” Where are the commonalities among the therapeutic common factors?” Professional Psychology: Research and Practice 21 (5): 372–378.Tracey, T.J.G. (2003), "Concept mapping of therapeutic common factors", Psychotherapy Research 13 (4): 401–13

Notes & ReferencesNote 8:Scott Miller: Pupil of Mike Lambert: Solution Focused Therapy -> Common Factors Theory –> International Center for Clinical Excellence & Institute for the Study of Therapeutic Changea https://www.psychotherapy.net/interview/scott-miller-interviewb http://www.psychotherapy.net/video/scott-miller-psychotherapy-effectivenessc https://www.psychotherapy.net/article/therapy-effectivenessNote 9: Duncan, B.E., Miller, S.D., Wampold, B.E. & Huddle, M.A. (2009). The Heart & Soul of Change: Delivering what works in therapy (2nd Ed.) Washington, DC: American Psychology Association.Note 10: Duncan, B.E. (Ed.) (2014). On Becoming a Better Therapist (2nd Ed.) Washington, DC: American Psychology Association.Note 11: Castonguay, L.G. (2000). A Common Factors Approach to Psychotherapy Training. Journal of Psychotherapy Integration, Vol. 10, No 3, pp. 263-282. Note 12: Stricker, G. & Gold, J.R. (Eds.) (1993). Comprehensive Handbook of Psychotherapy Integration. New York: Springer.Note 13: Grencavage, L.M. & Norcross, J.C. (1990). What are the Commonalities among Therapeutic Common Factors. Professional Psychology: Research & Practice, Vol. 21, No. 5, pp. 372-378.Note 14: Orlinsky, D.E. & Howard, K.I. (1986). Process and Outcome in Psychotherapy. In: S.L. Garfield & A.E. Bergin (Eds.), Handbook of Psychotherapy & Behavior Change (3rd ed., pp. 283-330). New York: Wiley.Orlinsky, D.E. & Howard, K.I. (1987). A generic model of psychotherapy. Journal of Integrative & Eclectic Psychotherapy, 6, pp. 6-26.Note 15:Reisner, A.D. (2005). The Common Factors, Empirically Validated Treatments, and Recovery Models of Therapeutic Change. The Psychological Record, Vol. 55, pp. 377-399.Note 16: https://www.apa.org/education/ce/effective-therapists.pdf

Notes & ReferencesNote 17: GAD - Generalized Anxiety Disorder; IBS - Irritable Bowel SyndromeNote 18: CBT - Cognitive Behaviour Therapy (Beck) for depression, anxiety, bipolar, eating disorders and schizophrenia ; DBT - Dialectical Behaviour Therapy (Marsha Linehan) for suicide & self-harm, also borderline personality disorder; IPT - Interpersonal Therapy (Klerman & Weissman) for depression, dysthemia; FFT - Family-focussed Therapy (Miklowitz & Goldstein) for bipolar disorder; PCC - Person-Centered Counselling (Maslow); SAD - Seasonal Affective Disorder (Light Therapy); AAT - Animal-assisted Therapy; etc. Ref: http://www.nimh.nih.gov/health/topics/psychotherapies/index.shtmlNote 19: McWhirter, E.H. (2011). Empowerment in Counselling. Journal of Counselling & Development, Vol. 69, No. 3, pp. 222-227.Note 20: Pickett, S. (2014). Promoting Empowerment in Clinical Practice. http://www.carlatbehavioralhealth.com/free_articles/promoting-empowerment-clinical-practice-free-articleNote 21: Stosny, S. (2012). Validation and Empowerment: The necessary balance for self-help. https://www.psychologytoday.com/blog/anger-in-the-age-entitlement/201208/validation-and-empowermentNote 22: Prochaska, J.O. & Norcross, J.C. (2013). Systems of Psychotherapy: A Trans-theoretical Analysis. Cengage Learning.Note 23: http://www.padraigomorain.com/concise-guide-to-choice-theoryreality-therapy.htmlNote 24: Young, C. (2010). Help Yourself Towards Mental Health. London: Karnac Books.McLeod, J. & McLeod, J. (2012). Counselling Skills: A practical guide for counsellors and helping professionals. Milton Keynes, UK: Open University Press.Proctor, G. (2002). The Dynamics of Power in Counselling & Psychotherapy. Ross-on-Wye: PCCS Books.Note 25:Stiefel, I., Renner, P. & Riordan, D. (2014). Evidence Based: Crossing the Great Divide between Research and Clinical Practice. http://www.researchgate.net/publication/264736541_Evidence_Based_Crossing_the_Great_Divide_Between_Research_and_Clinical_Practice?ev=auth_pubNote 26:Leung, O. & Bartunek, J.M. (2012). Enabling Evidence Based Management: Bridging the Gap between Academics and Practitioners. http://www.cebma.org/wp-content/uploads/Leung-Bartunek-Enabling-EBMgt.pdfNote 27: http://www.crn.nihr.ac.uk/mentalhealth/

http://www.nimh.nih.gov/health/topics/psychotherapies/index.shtml

Notes & ReferencesNote 28:Mellor Clark, D. et al. (2007). Resourcing a CORE Network to develop a National Research Database to help enhance psychological therapy and counselling service provision.Note 29: SPR – Society for Psychotherapy Research – http://www.psychotherapyresearch.org/Note 30:http://bacp.co.uk/research/publications/index.php Note 31:Oettingen, G., Kappes, H.B. Guttenberg, K.B. & Gollwitzer, P.M. (2015). “Rethinking positive thinking: Inside the new science of motivation.” Note 32: www.freud.org.uk/events/75929/do-we-need-a-critical-psychotherapy/Note 33:http://www.limbus.org.uk/cbt/papers.htmlNote 34: PCSR – Psychotherapists and Counsellors for Social Responsibility: Locating Psychotherapy & Counselling in a Socio-Political Context: pcsr-uk.ning.comhttps://www.linkedin.com/grp/post/2154299-6026820190442975236Note 35: Green, H., Barkham, M., Kellet, S. & Saxon, D. (2014). Therapist effects and IAPT Psychological Wellbeing Practitioners (PWPs): A multilevel modelling and mixed methods analysis. Behaviour Research and Therapy, Vol. 63, pp. 43-54. Note 36: Drapeau, M. (2012). The Value of Progress Tracking in Psychotherapy. Integrating Science and Practice: 10 Tools for Progress Monitoring in Psychotherapy. www.ordrepsy.qc.ca/en Note 37: Lambert, M.J., Harmon, C., Slade, K., Whipple, J.L., & Hawkins, E.J. (2005). Providing feedback to psychotherapists on their patients' progress: Clinical results and practice suggestions. Journal of Clinical Psychology, 61, 165–174.Note 38: Wierzbicki M, Pekarik G. A meta-analysis of psychotherapy dropout. Professional Psychology: Research and Practice 1993; 24, pp 190–195. - See more at: http://www.therapytoday.net/article/show/4259/the-researcher-drop-outs-arent-just-a-statistic/#sthash.NtQxQN93.dpufNote 39: Rousmaniere, T. (2012). Preventing Psychotherapy Dropouts with Client Feedback. https://www.psychotherapy.net/article/psychotherapy-dropoutsNote 40: “The only true wisdom is in knowing that you know nothing.” “The unexamined life is not worth living.”“There is only one good, knowledge, and one evil, ignorance.”“I cannot teach anybody anything, I can only make them think.”“Wonder is the beginning of wisdom.”“Education is a kindling of the flame, not a filling of the vessel.”

https://www.psychotherapy.net/article/psychotherapy-dropouts

Notes & ReferencesNote 41: Patrick Casement (2014). Some hazards in being helpful in psychotherapy. Psychotherapy Section Review, No. 53, pp. 15-25.Note 42: Lawrence Stevens: The Case against Psychotherapy. http://www.antipsychiatry.org/psychoth.htmNote 43:Masson, J. (1968). Against Therapy. London: Atheneum.Note 44:Coleman, L. (1984). The Reign of Error. Beacon Press.Note 45: Wood, G. (1986). The Myth of Neurosis. Harper & RowNote 46:Eysenck, H.J. (1960). Behavior Therapy and the Neuroses. London: Pergamon Press.Note 47:Eysenck, H.J. (1983). The Effectiveness of Psychotherapy: The Specter at the Feast. The Behavioral and Brain Sciences, Vol. 6, p. 290.Note 48:Kilpatrick, W.K. (1985). The Emperor's New Clothes: The Naked Truth About the New Psychology. Crossway Books.Note 49:Aftel, M. & Lakoff, R. (1985). When Talk Is Not Cheap, Or How To Find the Right Therapist When You Don't Know Where To Begin. Warner Books. “Since so-called psychotherapy is a form of education, not therapy, you need not a doctor or therapist but a person who is qualified to educate in the area of living in which you are having difficulty. The place to look for someone to talk to is where you are likely to find someone who has this knowledge. Someone whose claim to expertise is a "professional" psychotherapy training program rarely if ever is the person who can best advise you.”Note 50:University of Sheffield: https://www.sheffield.ac.uk/news/nr/preventing-adverse-effects-of-psychological-therapies-1.376074 => Supporting Safe Therapy: http://www.supportingsafetherapy.org/Note 51:Young, C. (2014). The Possible Harmful ‘Side-Effects’ of Psychotherapy. International Journal of Psychotherapy, Vol. 18, No. 3, pp. 633-82.Note 52:Barllow, D.H. (2010). Negative Effects from Psychological Treatments. American Psychologist, Vol. 65, No. 1, pp. 13-20. Available: http://coping.us/images/Barlow_2010_Neg_effects_of_EBP.pdfNote 53:http://psychcentral.com/blog/archives/2011/03/16/10-reasons-why-someone-in-therapy-may-not-be-getting-better/Note 54:http://www.bacp.co.uk/ethical_framework/good_standard.phphttp://www.lifeforce-centre.co.uk/downloads/level4_yr2/session11/suicidal_client.pdfhttp://www.therapytoday.net/article/show/1016/personal-safety-do-counsellors-care/Note 55:Kearns A. (Ed.). (2007). The Mirror Crack’d: When good enough therapy goes wrong and other cautionary tales for humanistic practitioners. London: Karnac Books.Note 56:Yalom, I. (2003). The Gift of Therapy: An open letter to a new generation of therapists and their patients: Reflections on Being a Therapist. London: Piatkus.

Other Resources• Lowenthal, D. (2013). The unfortunate need for critical psychotherapy and

counselling. European Journal of Psychotherapy & Counselling, Vol. 15, No 1, 1-4.

• Lowenthal, D. (2015). Critical Psychotherapy, Psychoanalysis and Counselling. London: Palgrave Macmillan.

• Feltham, C. (2010). Critical Thinking in Counselling & Psychotherapy. London: Sage.

as well as …

• Dr. James Hawkins - goodmedicine.org.uk

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Young, C. (2015). What Works in Psychotherapy & Counselling. Strathclyde University, Counselling Course Presentation: 05-Aug, 2015.

© Courtenay Young, UKCP Registered Psychotherapist; NHS Counsellor; COSCA Supervisor• Editor: International Journal of Psychotherapy; • Author of “Help Yourself Towards Mental Health” (2010, Karnac); “First Contacts with

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What Works in Psychotherapy & Counselling A Presentation by Courtenay Young – UKCP Psychotherapist and NHS Counsellor University of Strathclyde Counselling