PRRC-IADP 2008, Japan. PreCongress Workshop
Best practices in psychotherapy, coaching and counseling
Introduction
Coaching is a work-oriented learning process by means of dialogue with a (helping) professional (E. de Haan, 2007).
What coaches, counselors and psychotherapists have in common is that they use dialogue to facilitate change. There are differences in approach but they do have a lot in common. In fact, they are more alike than they are different. There is more to bind them then to divide them.
In the field of psychotherapy, there has been extensive research in effect, outcome and process of using dialogue for change. Psychotherapists, coaches and counselors (professionals) can benefit greatly from those research results. It can help them to work shorter, more effectively and with more pleasure.
The heart of psychotherapy
In 1999, Mark Hubble, Barry Duncan & Scott Miller published The heart and soul of change: What works in therapy. In this book on modern, result-oriented forms of psychotherapy they list what psychotherapists actually do. The following list is the result:
▪Ask questions
▪Listen, summarize, reflect
▪Comfort
▪Confront
▪Give information
▪Give explanation (interpretations, reformulations, clarifications)
▪Make suggestions
▪Self-disclosure: tell something about your own experiences in relation to the topic at hand
▪Give tasks/assignments for during or outside the session
In my training courses for coaches, I often present this list and ask the coaches to check which actions they regularly employ as coaches. The answers are more or less always the same. Almost everyone does almost everything on the list and they do so almost every session.
Coaching and psychotherapy therefore have important things in common. Of course, coaches are not psychotherapists and a psychotherapist is not a coach. However, the similarities outweigh the differences. There is an overlap in goals (change behavior) and in the tools (elements of dialogue). In fact all helping professionals, coaches, counselors and psychotherapists try to achieve more or less the same goals with more or less the same means.
The biggest differences may be in the area of expertise and the transfer thereof. Coaching is a young profession, whereas psychotherapy has been in existence for more then a hundred years. For coaching there are few good, practical teaching books, while the list of publications on psychotherapy is endless. There is little known yet about the effectiveness of coaching while the effect of psychotherapy has been the subject of many studies for more than fifty years.
For coaches and other professionals it can be very useful to acquaint themselves with the gist of outcome and process research of psychotherapy. This research can answer questions like:
▪Does psychotherapy work? Is it possible to help people change their behavior, solve problems in living, decrease complaints?
▪How does psychotherapy work?
▪What works best? With which problems, complaints or goals?
▪How long should a treatment continue?
In this article I will present the answers to these questions. It is my goal to offer professionals points of view, methods and techniques to help them to help others more effectively.
Critical factors of success for behavioral change: lessons of fifty years of scientific research into the process and outcome of psychotherapy
In 1952, the renowned English behavioral psychologist Hans Eysenck put the cat among the psychotherapeutic pigeons with the statement that psychotherapy did not work. His research showed that clients after treatment were in the same state as the untreated control group. His confrontational conclusion raised much debate among psychotherapists. Several research projects were started to prove Eysenck wrong. As early as 1960, it transpired that psychotherapy was indeed effective. In proportion, even very effective. Roughly, it can be said that people in psychotherapy are better off in eighty percent of the cases. Of people who are untreated, only twenty percent improves significantly. Eysenck was therefore wrong. Still, he has done the psychotherapeutic profession much good. It was his provocative statement that triggered many studies on the outcome of psychotherapy. These are in short the main fruits of that research.
1Psychotherapy works, it is very effective, it has lasting positive effects. But it works not for everybody, all the time.2The many different systems of psychotherapy are all equally effective. But not equally efficient
3Personal characteristics of the therapist is far more important than the technique or method she uses.
4Some therapists are consistently more successful than others.
5These therapists belief strongly in what they are doing, they are more competent, curious open, and flexible.
6Competence is not necessarily enhanced by training and experience. The positive result of training and experience of professionals has not (yet) been proven by research.
7Positive changes in the first few sessions of the therapy predict overall success.
8Another early predictor for the success of the treatment is the quality of the working alliance, as experienced by the client.
9Therapy is usually short therapy. Long-term therapy gives only slightly better results.
10Client hope, trust and positive expectations are very important for outcome
11Methods and techniques are of minor importance
What do these results mean for the helping professions and: how can professional benefit from them?
‘All change is self change. Psychotherapy is actually professionally supported self change.’ (Prochaska)
The client holds the key….
A most conspicuous finding of the effect research is that not everything that changes during therapy changes through therapy.[1] When psychotherapy has effect and people change, that change should be attributed to extra-therapeutic and client factors for the biggest part. Effects, therefore, that the client achieves independently and that occur outside the context of therapy and that are completely separate from the therapy. Effects that might also have occurred without therapy. Client factors have to do with the client’s psychological resources: resilience, talents, intelligence, or with stamina and determination. Also social support often is the key to change, just as positive life events can be, such as an inheritance, a job promotion or requited love.[2] An example from practice:
I am coaching a thirty-five-year old process manager for problems with the balance between work and private life and with work-related stress. An important disappointment in her life was that she was childless against her will. She met every criterion for being a “workaholic”. Coaching did not yet change that very much. She kept falling back into old habits of pushing herself, taking work home, neglecting her social life, and so on. Until she got pregnant. The way she handled her work changed in a matter of weeks. She suddenly had eye for other aspects of life, beside work. Within a short period of time, she managed to give work a much healthier place in her life. Her stress-related complaints decreased and the coaching could be successfully ended not long after that.
Of the changes during therapy the contribution of client- and extra-therapeutic factors turns out to be a whopping 87%.[3] The remaining 13 percent is change through therapy. The variance in the effects of psychotherapy is attributed for an estimated 43% to the competence of the therapist and her belief in her methods. To an estimated 28% to the quality of the working alliance between therapist and client – as experienced by the client. Therapeutic change is for an estimated 21% attributed to the clients hope of recovery, belief in therapy and the expectation of recovery. The therapeutic method, and the techniques derived there from, cause a mere 8% of the therapeutic changes.
(in kader)
Change during therapy:
13% through treatment
87% through client- en extra-therapeutic factors
Change through treatment:
43% through therapist factors
28% through therapeutic alliance
21% through placebo factors
8% through methods and techniques
(einde kader)
The importance of client factors in the process of change is supported by the fact that many people seem to overcome difficult problems on their own. Take for instance the percentage of smokers in the United States that has declined from fifty percent to twenty-five percent over the last decades. Of about thirty million quitters ninety-five percent quit on their own! This is independent behavioral change of a habit that is hard to kick. Other research shows that cognitive behavioral therapy with a computer program instead of a therapist generally works remarkably well, just as the use of self-help books and psycho-education. The behavioral change accomplished with these methods does not involve a therapist.[4] In the process of change that does involve a therapist, the client’s participation turns out to be a most important factor. How involved is the client? How cooperative? Does the client have a collaborative attitude or is he dependent or defensive during therapy?[5]
The challenge for therapists and coaches
You can easily see the major importance of extra-therapeutic and client factors as a major disappointment. Yet, there is no reason to just throw in the towel as psychotherapist (or other professional)! . The challenge is: what can you do as a helper to let the client factors and extra-therapeutic forces work for your client and make sure these factors have an optimal effect on the process of change.? The answer is: by expecting change, stimulating change and rewarding change.
Stimulate
Very often, clients have already achieved a fair amount of change between calling to make a first appointment and the first session itself. Solution-oriented psychotherapists call this pre-session change. Some of them try to bring about this pre-session change by suggesting an assignment on the telephone when making the first appointment. For instance:
I would like to ask you, until our first appointment, to pay attention to what happens in your life and at your work that you would like to see continued? What are the positive things that you want to keep happening? In this way you will help me understand your goals and what it is you want to accomplish in our conversations.[6]
The effect of this assignment is often that the client’s attention is diverted away from the negative for which he seeks help to the positive. The professional can then tap into this by searching with the client for ways to enhance the positive. Enhancing the positive is often far more productive then changing the negative.
Expect
As a professional, you can also increase the effect of client factors by being change-oriented from the very beginning of the intervention. Seek out ‘any change at all’ in your client’s story – not just change through therapy – and pay attention to it. Name the change. Emphasize the change. Bring it out and put it in the spotlight. Compliment your client for it happening. Attribute the change to your client when opportune.
Reward
Reinforce and underline everything the client does that contributes to change. You do this mainly by giving compliments for what the client has tried and for what he has already accomplished and achieved. Say nice things about it. Try to place yourself in the frame of mind of your client as much as possible and try to speak his language.[7]
How long does therapy take ?In the United States, there has been extensive research to answer the question as to how long successful therapy should last. Conclusion: successful therapy is often short therapy. It seems that the law of diminishing returns applies: at the start of treatment, during the first 3 to 5 sessions, most of the results are achieved. If there are results, these will usually become apparent during the first three sessions. When there is no visible result after five sessions, it is unlikely that there will be any. When there is little or no result after eight sessions, it is best to cease the treatment.
What is the client’s desire to change does the client have?
In all of this, it is very important to connect to the client’s desire to change. Therapists are usually very change-oriented and they often assume that a client with a complaint also has a wish to change. But this is not always the case.
Research shows that the drop-out percentage for psychotherapy is around fifty percent. So, half of the people that seek help, withdraw from the treatment prematurely, often after one or a few sessions. Researchers analyzed this phenomenon. They learned that dropouts felt in a way pressured by professionals to make changes they are not (yet) ready for.
In coaching for work related issues respecting the client’s goal for change is even more pressing because often there is a third party involved (employer, manager) who has a desire for change for the client. Frequently, this third party wants something else than the client, or something the client does not want at all. The coach should be certain that he is connecting to the goal of the client.
‘There should be a match...’ – On the importance of good work relationship
As mentioned, most of what changes during psychotherapy is connected to client and extra-therapeutic factors. Of change through therapy more than a quart can be attributed to the quality of the cooperation between client and therapist as experienced by the client, also called ‘work relationship’ or ‘therapeutic alliance’. For the sake of brevity we here use the term ‘alliance’.
It is obvious that also in coaching also the quality of the cooperation between client and coach plays an important role in achieving results. What can a professional do to influence the alliance in a positive way?
Build an emotional bond
For the establishment and reinforcement of the alliance it helps to:
▪Create a climate of safety and trust by expressing your commitment to the client.
▪Listen actively and with attention.
▪Express understanding and respect of the client.
▪Compliment the client on what he has said or done that was useful or effective.
▪For clients it is usually important to be liked by the professional. When you like your client let it show or say so.
Be aware that the first few sessions are your window of opportunity to bring about the alliance. The first session is crucial and by the third conversation the alliance should already be what you want it to be. After the fifth session there is generally not much change for the better in the work relationship.A helping relationship is further determined by the degree in which the client experiences the professional as ‘genuine’ and ‘congruent’. The term congruent comprises aspects such as being yourself, being open and transparent, not playing a role. It can mean that the professional tells something about himself or shares personal experiences (self-disclosure). And also that she has opinions, gives feedback about the client’s behavior and answers to the client’s direct questions. Congruent responses are honest; they convey that the professional is a human being with preferences and dislikes, opinions and beliefs. They take on the form of I-messages: ‘I think’, ‘It is my opinion that’, ‘I experience that like this’.
Finally, you can also reinforce the alliance by empathy. Empathy is the ability to see the world through the eyes of your client. Empathy is more cognitive than emotional: it is more about thinking like your client than ‘feeling with’ your client. Moreover, it is not just crawling in the skin of your client but also in the skin of the relationship. It is to understand what the alliance means to the client and how he feels and thinks about it.[8]
What you should not do
Just as there are things that contribute to the reinforcement of the alliance, research shows there is behavior best not displayed for a good cooperation. Below are the four most important no-no’s:
▪Avoid starting out the intervention with a ‘take charge’ attitude. With an approach that is too active and direct you take away too much initiative from your client. Don’t lead, follow. Don’t tell, ask.
▪Avoid remarks or an attitude that can be perceived as ‘cold’ by your clients.
▪If ever you want to confront your client, don’t do it in the beginning of the relationship. First build cooperation and trust. It is much easier to hear ‘the truth’ from somebody you like and trust.
▪Be careful with behaviour that might suggest irritation or annoyance, especially during the first session. [9]
Personal qualities of ‘master therapists’
Research has taught us that the therapist’s personal characteristics are far more important for the effect of the intervention than the method or technique that is used. How a therapist is is more important than what he does. It is of course of major importance which personal qualities play a part in this. Studying therapists that are considered ‘the cream of the crop’ produced the following results:[10]