Evidence Based Counselling & Psychotherapy for the 21st Century Practitioner

Psychotherapy is perhaps the most known and identifiable with one of the field’s originators Sigmond Freud who is often accredited as being the inventor of the talking cure. However, it was many decades after psychoanalysis was first used by Freud that robust research and evidence was applied to psychotherapy, and its findings used to support practice in various contexts. While psychoanalysis is still practiced, the field has moved on and includes many hundreds if not thousands of approaches to healing. What has not improved, in general, is the between school rivalry regarding the efficacy and effectiveness of the different approaches. While it is now accepted that in general terms all approaches are about equally effective, certain research is often provided with more legitimacy than others. Mainly, the randomised control trial (RCT) is considered the gold standard in research terms, especially when it comes to establishing the efficacy and effectiveness of different psychotherapies. Empirically supported treatments (ESTs) are in prime position to take advantage of these political decisions, and this chapter will introduce the reader to these debates.

In the last chapter, I introduced the reader to the concept of empirically supported treatments and some of the research methods of providing evidence for the effectiveness of these interventions. Unfortunately, the field seems to place much importance on the techniques and methods used by the practitioner, when the reality is that there are a vast amount of components and variables that contribute to change in effective psychotherapy. In this chapter, I move beyond the idea of the treatment method and explore the idea of evidence based practice (EBP) in its entirety. The reader will be provided with a description of EBP as a tripartite model. While it is beyond the current chapter to delve in depth into each aspect of EBP, the chapter does act as an excellent introduction providing the practitioner with key learnings to build on.

In the previous chapters, we have explored some of the key debates around empirically supported treatments, and I have introduced the reader to the concept of evidence based practice as a tripartite model that speaks to a much wider understanding of therapy research and practice. In this chapter, I introduce the concept of the common factors and some of the research that supports the idea that in general all therapy approaches tend to be as effective as each other, indeed, a summary of this research going back as far as 1936 is highlighted. The common factor proposition rests on the premise that there are far more commonalities across diverse therapy methods, than differences, and that it is these trans-theoretical constructs that are responsible for the lion’s share of outcomes. After briefly reviewing some of the literature, several common factor models are presented for the reader to consider.

In the previous chapter, I introduced the reader to the ideas and research of the common factors. The common factors are varied and have demonstrated to have small to large effect sizes depending on what variable is being examined. In this chapter, I categorise four more evidence based relationship variables which tend to be more task orientated and aligned to the therapeutic alliance. Indeed, the therapeutic alliance, goals and collaboration, alliance rupture–repair, and feedback-informed care are four trans-theoretical factors that can contribute greatly to outcomes. At the same time, when poorly established they can and do impact negatively on client outcomes. This is not an exhaustive overview of the literature, rather each variable is briefly discussed, the evidence supporting the effectiveness is highlighted, and Top Tips are provided to assist the development of the practitioner.

In the previous chapter, the reader was introduced to four relational common factor variables that impact upon therapy outcomes. In this chapter, I continue the exploration of common factor variables by establishing the research evidence base for another two factors: treatment credibility (TC) and outcome expectancy (OE). The evidence for each individual variable is detailed and Top Tips for each is provided to support both seasoned and beginning practitioners to improve engagement and outcomes. The chapter distinguishes between each of the variables presented, while also acknowledging some overlap and how they complement each other. As with the previous chapter, I have considered these factors together for similar reasons, that is, they are closely aligned and learning about these variables together will help the reader think about how to leverage them in practice.

In the previous chapter, we explored in a broad sense, the idea of various types of expectancy related to processes involved in the delivery of treatment, and the desire of the client for treatment approaches and other important preferences. In this chapter, I discuss four more variables that we can consider to align to the theme of inner experiences, of the practitioner, with a lesser focus on the client. The relationship between outcomes and emotional expression of the client and practitioner, and outcomes related to the practitioner’s counter-transference (CT), self-disclosure (TSD), and use of immediacy (Im) are discussed. As with previous chapter, definitions are provided, the research base is explored, and Top Tips for each variable are outlined for the developing and seasoned practitioner.

The last chapter examined evidence based relationships from the perspective of emotional expression and the inner experience of the practitioner in relation to the client. In this chapter, I am introducing the first of a number of variables situated in evidence based relationships. Empathy, congruence, unconditional positive regard, and the real relationship will be discussed. I have chosen to categorise these four variables together due to their significant overlap and interaction with each other in terms of practice and research. This chapter does not attempt to provide an exhaustive description of each factor. Rather, I provide a very brief overview of the variable, provide an analysis of the research behind each, and highlight Top Tips that can guide the practitioner in their development.

Thus far, I have introduced the reader to evidence based practice in a broad sense, and evidence based relationships across important variables. In this chapter, I further build on this by extending the need for evidence based responsiveness as applied to client factors. While the practitioner brings themselves and their bag of tools to the therapy encounter, the client brings not just their presenting problem, but their characteristic way of thinking about their problems and how they manage distress and change. Therefore, the supportive practitioner will be best served to understand how these client factors manifest for each individual that they work with. The purpose of this chapter then, is to discuss coping style, reactant level, stage of change, attachment style, and client preferences, within the context of the practitioner being responsive to these factors as they impact on therapy outcomes.

In this chapter, Ravind Jeawon and I discuss the ideas around being responsive to diversity in an evidence based manner. Although this chapter belongs within the evidence based responsiveness section discussed in the previous chapter, we both considered it essential to provide a whole chapter on its theory and application, as it is an integral area often overlooked in clinical training and provided a curtesy overview during ongoing professional development and clinical supervision. The multicultural literature uses different terminology to refer to the practice of responsiveness, we discuss these ideas and the evidence base for them, while introducing the reader to other processes and theories which will help developing practitioners make sense of what can be a vastly complex area of clinical work. Several adapted, real life case examples are drawn from Ravind’s clinical experience to encourage reflection and provide insight into these processes.

The use of data in the twenty-first century to improve expert decision-making has radically transformed what it means to be an expert in multiple fields, including behavioural healthcare. This chapter summarises the impact on information technology on the field, including use of digital platforms to enable video therapy and online cognitive behavioural therapy programmes. The chapter is intended for practitioners seeking information on how to be a twenty-first century expert, where years of education and experience matter less compared to evidence of performance in the form of solid outcome data. Key to the use of outcome data is expertise in how to use questionnaires in therapy and how to interpret results, both at the individual client level as well as overall results across multiple clients. A twenty-first century expert measures are not simply to measure outcomes but to improve results over time. Failure to incorporate the use of data into routine practice ignores an evidence based practice with decades of evidence as to its effectiveness, potentially resulting in suboptimal care.

Deliberate practice (DP) is an innovative training method for improving psychotherapy skills acquisition and expertise in the twenty-first century. I introduce the reader to the principles and processes of DP and the rationale for its use. The concept of DP is not new, indeed it is used to support the improvement of performance in diverse areas, from sport to music. However, its application to psychotherapy is still in its infancy. Firstly, I provide the rationale for including DP as a method of therapist training based on research that illustrates that many of the current criteria that we use to identify expertise have little to no added impact on client outcomes. Additionally, some of the limitations of current traditional training regimes are outlined, along with the emerging evidence base for DP as a training method that can help improve the acquisition of therapeutic skills and expertise.

Supervision is considered the signature pedagogy and after direct client practice it is rated as the number one learning and development method by practitioners. However, as we set out in this chapter, the relationship between supervision and client outcomes is not a strong one. Drawing on the use of routine outcome data, we demonstrate how clinical supervision can be improved when both practitioner and supervisor demonstrate an attitude of humility and a willingness to learn from the data they collect. Using these data to enhance supervision by improving client outcomes and to inform deliberate practice (DP) is the hall mark of the effective twenty-first century practitioner and supervisor.

The application of therapeutic theory to routine psychotherapy practice is a complex area, and needs to be done by a competent and well-trained practitioner. The case study is recognised as a valid method to illustrate the processes of therapy and how theoretical knowledge can be applied to practice scenarios to bring about change. This simulated case study illustrates the application of therapeutic variables based on evidence based relationships and responsiveness. A therapist and client-simulated case illustrate these applications, and an accompanying narrative elucidates the role these play in the therapeutic encounter. Finally, the chapter describes how some of the issues identified in the case study as practitioner deficiencies can be used to inform a deliberate practice (DP) training regime supported by supervision and the use of data. In doing so, this chapter builds on the previous chapters in this book and provides a picture of how the twenty-first century practitioner and supervisor can use data to better inform their individual, and collective work, with the ultimate aim of improving expertise in order to increase client outcomes.