Robert Kominski, U.S. Census Bureau Diana B. Elliott, U.S. Census Bureau
Robert Elliott University of Strathclyde
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Transcript of Robert Elliott University of Strathclyde
Person-Centered Science: What We Know and How
We Can Learn More about Humanistic/Person-
Centered/Experiential Psychotherapies
Robert ElliottUniversity of Strathclyde
OutlineHistorical IntroductionQuestion 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
PioneerInnovations:
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 situationDanger 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 projectMeta-analysis: analysis of results
Effect size = standardized difference statistic
Creates a common for comparing results
Change E.S. =
m
pre
− m
post
sd
( pooled )
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) Meta-analysis 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) Meta-analysis 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) Meta-analysis 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) Meta-analysis 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) Meta-analysis 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 RCTsBut 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
InventoryMeta-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 = .321. Optimist’s view: 10% is a lot!
One of the best predictors of outcome Maybe even better that therapeutic alliance
Interpretation of r = .322. 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 = .323. 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
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 sessionsSystematic qualitative research is a
relatively recent developmentBut 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 therapiesSelected 5 most frequent helpful and 3
most frequent hindering aspects14 categories of Helpful aspects,
grouped into 4 larger domains
Most Common Helpful Aspects in HPCE therapies1. 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 studyMost 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 outcomeJersak, Magana and Elliott (2000; in
Elliott, 2002)5 studies, mostly Process-Experiential
for depression or trauma
Jersak et al. (2000)
Vitalizing the Self: Internal change4 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 HPCE9 common categoriesAll 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
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 person-centered principles
Even in the same study
2. Follow Person-Centred Research
PrinciplesE.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 = co-researcher; 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 researchFairly easy to see application to qualitative
research, e.g., Clarifying expectations and other researcher pre-
understandings; 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 ResearchAlways put the participant’s needs
ahead of yoursTreating 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
ResearchA 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 qualitativeSingle client or group of clientsStandard questions or individualizedSee 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
ResearchExamine turn-by-turn interaction
between client and therapistQuantitative: client and therapist
process measures (e.g., client experiencing and therapist empathy)
Qualitative: Task analysis or Conversation analysis
e. Complex Change Process Research MethodsCombine genres to develop richer pictureBalance strengths, limitationsExamples:
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 practice-based 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]: pe-eft.blogspot.com