Research in Psychotherapy and Counselling

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Ladislav Timulak

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    Dedication

    Dedicated to my parents and Katka, Adam, Dominika and Natalia

    Acknowledgements

    This text is based on the book Současny výzkum psychoterapie (Timulak, 2005), which was written in Slovak and then translated into Czech. The text of this book was first translated by me and my friends and colleagues, Matus Biescad, Julia Halamova, Sona Chamrazova and Jana Hanulova. I would like to thank them for this contribution. The translation was then edited, revised and updated by me. Helpful comments from the reviewers of the book (Mick Cooper, Georgia Lepper, Robert Elliott and John McLeod) were then incorporated, as well as the suggestions of Alice Oven, editor at Sage. I would like to acknowledge their contribution as well. The whole text was then language edited by Beth Humphries and then thoroughly copy-edited by Sarah Bury for whose help I am thankful. I would like to thank Dr David Hevey for help with the Glossary. I would also like to acknowledge the support of my wife Katka Timulakova and to my mum for all the help she provided to both of us, which allowed me to focus on this work.

    The work was also supported by following grants: the Trinity College Benefaction Fund and the Provost's Academic Development Fund and grant VEGA 1/4520/07.

  • Conclusion

    This book is not the definitive text on psychotherapy and counselling research. Many areas are not covered in detail and are merely mentioned to the reader. Some aspects of research are emphasized more than others. Since I wrote the Slovak version of this text (in autumn 2004) several books on psychotherapy and counselling research have been published (e.g. Dallos & Vetere, 2005; Lebow, 2006; Lepper & Riding, 2006) that complement the good introduction Doing Counselling Research by John McLeod (1994, 2003).

    In this book, I wanted to focus on the field in its entirety and discuss some examples of what good studies focus on and what they can bring to the reader or potential future researcher. I wanted the book to be simple, so that it can be followed by the reader who has a basic understanding of research methodology. I hope this text will not only present the field of psychotherapy and counselling research, but will also stimulate interest in using research literature to inform one's practice. Psychotherapy research will certainly play a more and more important role in the future development of professions that use psychotherapy and/or counselling. It is difficult to imagine a therapist of the future who would not describe his or her own practice as research-informed.

    I hope that this book will also stimulate some interest in conducting new research on psychotherapy and counselling. I hope it will be used in training programmes as a tool for informing students' choice of which area of research they could contribute to through their dissertations and research projects. I also hope the book may stimulate an interest among practising therapists in examining their local problems by conducting practitioners' research (McLeod, 1999). Many methodological approaches presented in this book are very valuable for that.

    I also hope that the book will provide an overview for practising therapists and trainees that will make them more informed consumers of research findings. Sometimes research evidence is used ‘politically’, when evidence that supports particular practices is embraced while evidence that would speak against them or that would support different approaches goes unnoticed. This is probably often unintentional, since – as in other human activities – people can feel very passionate about the things that are close to them (and spending several years in mastering a specific therapeutic approach makes such an approach very important).

    Sometimes evidence is incorporated into the language used to describe psychological therapies and so it can happen that some approaches, such as cognitive or behavioural or their combinations, are thought of as synonymous with evidence-based therapy and others, such as humanistic or psychodynamic therapy, as its opposite. Certainly cognitive and behavioural approaches are to be commended for their scientific rigour and the emphasis they place on conducting RCTs and experimental case studies, but as many examples used throughout the book have shown, other approaches are being studied from different angles too.

    Furthermore, it may happen for some reason that certain therapeutic procedures are considered to be empirically supported because of a study or series of studies conducted on them. However, a closer look sometimes shows that the actual study that is being cited produced quite different results than recommendations based on it claim. An example would be the TDCRP study on depression that has been used as an example throughout the book. Though the interpretations of this study often lead to many controversies (e.g. Craighead et al., 2007) quite often it is cited as an example of the effectiveness of brief cognitive and interpersonal therapy, while the original authors (Shea et al., 1992), after conducting a follow-up examination of the results of this project, concluded that because of the modest results from the longer-term perspective, brief cognitive or interpersonal therapy may not be optimal for depressed patients (this is not to say that the same applies to medication, the usage of which is now recommended for a significantly prolonged time). Despite that finding, the recommended length of these therapies is still short (see National Collaborating Centre for Mental Health & National Institute for Clinical Excellence guidelines for depression, 2007). It seems that some research studies are becoming part of a psychotherapy culture and their actual results are getting lost beneath layers of different arguments that were made on the basis of them.

    Anyway, the main message that this book has tried to convey is that research in psychotherapy and counselling is broad and its different strands are trying to answer different, but altogether mutually complementary issues of whether therapy (or rather, a specific therapeutic procedure) works and how it works. My intent here has been to present the diversity of psychotherapy research and the importance of its different components as my experience has been that some practising therapists are unaware of different types of research and are cognizant only of RCTs because they are politically influential; on the other hand, some practising therapists, preferring ‘soft data’, are often aware only of qualitative studies and thus ignore the rich potential of other research approaches. I hope that this book will persuade proponents of both camps that their approaches can be more embracing.

    Glossary

    • Adherence measures – measures used for evaluating whether the therapist follows a prescribed manual or theoretical principles of delivered therapy.
    • Analysis of covariance – analysis of difference between groups that statistically controls for confounding or interfering variables.
    • APA – American Psychological Association; the biggest psychological society in the USA.
    • Aptitude treatment interaction – research design looking at the interaction of particular client characteristics and a specific form of treatment.
    • Bona fide therapy – therapy conducted by the therapist who considers it to be therapeutic.
    • Cohen'sd – an index expressing the magnitude of effect size for differences between two groups (e.g. treatment vs. control).
    • Composite outcome – the outcome averaged across several measures.
    • Construct – a term used in psychological research depicting the phenomenon studied (e.g. depression); often explained by its definition.
    • Construct validity – can have two meanings: in regard to construct validity of an instrument, it reveals how well the instrument correlates with other instruments measuring similar constructs (convergent validity) and whether or not it correlates with dissimilar and independent constructs (divergent validity); in terms of research design, construct validity talks about how well the investigated construct is measured – usually by utilizing several instruments measuring the same or similar constructs.
    • Descriptive studies – research designs that do not use experimental manipulation but observe a phenomenon (or the relationship of independent and dependent variables) in its natural course.
    • Dodo bird verdict – alludes to the bird Dodo in Alice in Wonderland. The Dodo said, ‘All have won and all must have prizes’. It is a mataphor used in psychotherapy research to point to the fact that different therapies are approximately equally effective. The phrase was first used by Rosenzweig in the 1930s.
    • Dose-effect research – a type of outcome research that examines the relationship between the number of therapy sessions and outcome.
    • DSM-IVDiagnostic and Statistical Manual of the American Psychiatric Association, 4th edition; contains descriptions, diagnostic and differential diagnostic features of all psychiatric disorders. It also provides information on prevalence and the typical course of illness.
    • Dysfunctional population (sample) – clinical population; usually scores obtained on psychological instruments by patients seeking psychological or psychiatric treatment.
    • Effect size – in the context of measuring psychotherapy outcome it is usually a numerical expression of the difference between the means of two or more compared groups as measured by an outcome measure. See also Colen's d
    • Empirically supported (validated) treatments – psychological therapies considered by the APA Society of Clinical Psychology as having empirical evidence of their effectiveness.
    • Error of measurement – an index expressing the magnitude of variance from true score in a measurement.
    • Experiment-wise error – in cases when several significance tests are conducted (e.g. measuring outcome on several measures) there is an increased chance to detect change even though it may be just an artefact of the fact that several tests were conducted (the chance of obtaining significance is inflated with repeated testing). As we usually accept a 5% chance of error in research, if we run more tests, there is an increased likelihood that such an error may occur.
    • Experimental case study – a case study that uses experimental manipulation and control.
    • Experimental designs – research designs utilizing experimental manipulation with an independent variable (in psychotherapy research it is psychotherapy) and experimental control to establish a causal link between an independent variable (psychotherapy) and the dependent variable (the client's state after therapy).
    • Expert rated scales – psychometrically sound rating scales used by trained observers for assessing verbal or non-verbal behaviour in therapy.
    • External validity – an aspect of research design addressing the generalizability of findings (the match between research and real-life conditions).
    • Factor analysis – a statistical technique used to explain variability in responses to items in terms of variation in hypothetical variables (factors) that are believed to be responsible for the responses.
    • Functional population (sample) – non-clinical population; data gathered from healthy participants.
    • Hierarchical linear modelling – statistical analysis looking at the explanation of variance in a dependent variable on more hierarchical levels. An extension of multiple regression, it is used with data structured hierarchically i.e. data in which subgroupings (e.g. therapists, hospitals, regions) exist within the data.
    • Independent variable – a variable influencing the dependent variable in research designs; in experimental designs this variable is manipulated by the researcher so that its impact can be causally interpreted.
    • Interfering variable – a variable that may have an influence on the observed dependent variable; it needs to be controlled for so that the link between the manipulated independent (therapy) and the dependent (clients' state) variable can be established. An example could be the variable of therapist quality when we want to assess a specific set of techniques such as CBT techniques.
    • Internal validity – an aspect of experimental design capturing the strength of causal interpretation of the relationship between the independent and the dependent variable.
    • Intraclass correlation – reliability coefficient assessing the agreement between two or more experts using interval scales (see also expert rated scales).
    • Logistic regression – statistical analysis in which a dichotomous dependent variable (e.g. readmitted to hospital vs. not readmitted) is predicted by one or more variables. The results are presented in the form of odds ratios (e.g. those with a history of deliberate self-harm are five times more likely to be readmitted than those with no history of deliberate self-harm).
    • Mediator – a variable explaining how the independent variable has the effect on the dependent variable.
    • Meta-analysis – a quantitative tool allowing a quantitative overview of findings across several studies by converting findings of individual studies to a common metric (usually effect size).
    • MMPI – Minnesota Multiphasic Personality Inventory- one of the most commonly used personality inventories; it assesses psychopathological features across several domains.
    • Moderator – a variable that influences the effects of the independent variable on the dependent variable.
    • Naturalistic studies – in the context of psychotherapy and counselling research, these are studies that look at the therapy intervention as it occurs in everyday practice.
    • Non-participative methods – methods used in process research employing trained raters for the evaluation of session material.
    • Normal distribution (Gaussian distribution) – a distribution of the variable values that has a symmetrical bell-curve shape and is defined by the mean and the variance parameters. The normal distribution of the variable is usually an assumption for conducting parametrical tests (e.g. t-test, F-test).
    • Normative data – data gathered from referential samples (e.g. non-clinical population; clinical population) often following normal distribution. They can be used for benchmarking.
    • Participative methods – the methods used in process research in which the clients and the therapists are used as raters of a studied aspect of therapeutic process.
    • Patient-focused research – research developed by Michael Lambert and his colleagues that focuses on the establishment of normative curves of positive progress in therapy in reference to which it is possible to benchmark an individual client.
    • Phase model of change – a theoretical model based on empirical findings developed by Ken Howard and his colleagues; the model predicts that therapeutic change first occurs in the domain of subjective well-being, then in psychopathological symptoms and then in broader social and interpersonal functioning.
    • Predictor – a variable predicting scores on the dependent variable.
    • Preferential trials – quasi-experimental designs assessing the outcome of therapy that take into account the client's choice of a specific treatment.
    • Probit analysis – Similar to logistic regression, it is a statistical method analysing the relationship of levels of dose of an independent variable (e.g. number of therapeutic sessions attended) and a dichotomous outcome (e.g. readmitted or not readmitted to hospital).
    • Quasi-experimental designs – research designs with limitations in the experimental manipulation that weaken the interpretation of a causal link between the independent variable (therapy) and the dependent variable (clients' state after therapy).
    • Randomized control trial – an experimental design using (1) randomization when allocating participants to compared groups and (2) a sophisticated experimental control ruling out other influences than studied psychotherapy intervention.
    • Reactivity – respondents' response not to the measure they are filling in but to the context of using that measure; for example, if the therapist administers an instrument, the client may be aware that the therapist will see the responses and therefore provides answers depending on how he or she wants to appear in the therapists' eyes.
    • Regression analysis – a correlational data analysis technique looking at the relationship between several independent variables (and, if necessary, their combinations) and the dependent variable.
    • Regression equation – an equation based on correlations among variables that allows prediction of scores on a dependent variable based on the scores obtained on the independent variable(s).
    • Regression line – a line depicting the linear relationship between the dependent variable and the independent variable(s).
    • Reliability – the consistency of measurement of a specific psychometric instrument.
    • Reliable Change Index – an index delineating the size of pre-post change that would be considered reliable, not random.
    • Remission – recovery from the disorder.
    • Residual scores – a deviation of observed scores from the predictions made on the basis of the regression equation in regression analysis.
    • RosenzweigseeDodo bird verdict
    • Sensitivity to change – an aspect of a measurement instrument that indicates whether the instrument is likely to capture changes if they occur.
    • Single-case experiments – experimental research designs focused on a limited number of participants using them as their own controls for experimental manipulation. The causal link between an independent variable (therapy) and a dependent variable (client's state after therapy) may be well controlled and therefore safely interpreted; however, there are limits to the generalizibility of findings.
    • SPR – International Society for Psychotherapy Research; an international body for psychotherapy researchers.
    • Standard deviation – a parameter of variability that, together with the mean, describes the distribution of data.
    • Statistical conclusion validity – an aspect of research design that considers whether statistical analyses are properly used and interpreted.
    • Statistical power – an index that expresses the probability with which the statistical test detects the difference between the experimental and the control group, if a difference exists.
    • Survival analysis – a statistical technique modelling of the time needed for an event to occur (in psychotherapy research, often recovery).
    • Type I error – a probability that we claim that a statistically significant difference exists between the compared groups while in reality it does not exist.
    • Variable – an assessed construct in a specific study or studies; the term ‘variable’ indicates that the observed values of the construct in a specific study vary.

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