Principles-Based Counselling and Psychotherapy

A Method of Levels approach

Timothy A. Carey, Warren Mansell, Sara Tai

• Publisher: Routledge
• Year: 2015
• ISBN:
  9781317443933
• Edition: 1
• Topic: Psicología
• Subtopic: Psicoterapia

Many current approaches to the treatment of psychological problems focus on specific disorders and techniques that are purported to be effective and distinct. Recent advances in knowledge and theory, however, have called into question this approach. The conceptual framework of transdiagnostic, rather than disorder specific, processes is gaining traction. Alongside this has been the call to focus on evidence-based principles rather than evidence-based practices and techniques. The rationale behind this is that many apparently unique and innovative practices are usually the reflection of common underlying principles. This book describes three foundational principles that are key to understanding both the rise and the resolution of psychological distress.

Principles-Based Counselling and Psychotherapy promotes a Method of Levels (MOL) approach to counselling and psychotherapy. Using clinical examples and vignettes to help practitioners implement a principles-based approach, this book describes three fundamental principles for effective therapeutic practice and their clinical implications. The first chapter of the book provides a rationale for the principles-based approach. The second chapter describes the three principles of control, conflict, and reorganisation and how they relate to each other from within a robust theory of physical and psychological functioning. The remainder of the book covers important aspects of psychological treatment such as the therapeutic relationship, appointment scheduling, and the change process from the application of these three principles.

With important implications for all therapeutic approaches, Principles-Based Counselling and Psychotherapy will be an invaluable resource for psychotherapists, counsellors and clinical psychologists in practice and training. It provides clarity about their role, and a means for providing a resolution to psychological distress and improving the effectiveness of their practice.

1 A principles-based approach to therapy The what and why

DOI: 10.4324/9781315695778-1

By reading this chapter, you will learn:

1. what a principles-based approach is;
2. why a principles-based approach is important; and
3. what the advantages of a principles-based approach are.

Compromised states of mental health are a growing problem in society. National surveys, for example, estimate that as many as one in five people report experiencing symptoms of a mental health disorder in a 12-month period (e.g. Slade, Johnston, Oakley Browne, Andrews, & Whiteford, 2009). The mental health difficulties that people experience are costly to both the individual and society. They are costly to individuals in terms of miserable lives and unfulfilled potential, and they are costly to society in terms of lost productivity and an increasing demand for health services. The significance of mental health troubles is magnified if one considers the interrelatedness of mental health and physical health. Mental health issues are increasingly being recognised as important factors in chronic diseases, terminal illnesses, degenerative conditions, and substance use disorders.

The concept of disease burden is a way of quantifying the impact of disease and injury. The World Health Organization (WHO, 2008) estimates that mental health disorders make up ‘3 of the 10 leading causes of disease burden in low- and middle-income countries, and 4 of the leading 10 in high-income countries’ (p. 46). For women, depression is the leading cause of disease burden in high-, middle-, and low-income countries (WHO, 2008). From a global perspective to national examples: in Australia, mental health disorders are the third most important determinant of burden (Andrews, Sanderson, Slade, & Issakidis, 2000), and they make the largest contribution to health-related nonparticipation rates in the labour force (Whiteford & Groves, 2009), while in Britain the picture is similar, with mental illness reported to account for over one-third of the burden of illness (London School of Economics, 2006). The Improving Access to Psychological Therapies (IAPT) initiative was prompted largely by a report in 2006 by the London School of Economics in which it was stated that mental illness had usurped unemployment as Britain’s largest social problem. In the report, estimates were provided for potential savings to the government by treating people’s mental health problems and thereby returning them to work and reducing the expenditure on incapacity benefits (London School of Economics, 2006).

Given the increasing prevalence of mental health problems, it is not surprising that demand for effective therapies for these problems is increasing. Consequently, there has been an unprecedented and unabated promulgation of new therapeutic options available to counsellors, psychotherapists, psychologists, cognitive behavioural therapists, psychiatrists, mental health nurses, and other mental health clinicians. Although the range of treatment options is expanding, this growth does not necessarily represent progress in terms of increased understanding or enhanced treatment effectiveness. Some research, for example, indicates that many bona fide therapies show equal effectiveness in terms of client outcomes when pooled across studies (e.g. Wampold, 2001). Furthermore, meta-analyses indicate that psychotherapy effect sizes may be declining over time or, at most, staying stable (Collins & Carey, 2015), which is the opposite of what would be expected if substantial progress was being realised in understanding and addressing psychological maladies. Additionally, while it has been estimated that the average person is better off than 80 per cent of untreated people (Asay & Lambert, 1999), this also means that 20 per cent of people who do not receive treatment are better off than 50 per cent of people who do receive treatment (Carey, 2006a). So, while researchers and therapists continue to develop new treatment options for people, we are not necessarily making great strides in enhancing the effectiveness or efficiency of the treatments we offer.

While the effectiveness and efficacy of psychological therapies is often, but not always, clearly demonstrated through various research programmes, a frequently overlooked aspect of therapy effectiveness is efficiency. It is rare to find studies that explicitly investigate the efficiency of psychological therapies, as well as their effectiveness or efficacy. To quantify just how scarce efficiency studies are in the literature, a database search was conducted in June 2014 of two of the most prominent journals in the field with regard to the evaluation of psychological treatments: Journal of Consulting and Clinical Psychology and British Journal of Clinical Psychology. Combining the search term ‘efficien*’ along with the title of the journal yielded a total of 93 articles but, of these, perusal of abstracts indicated that only four articles included an investigation of treatment efficiency as one of the main aims of the study.

We find this lack of empirical attention to treatment efficiency perplexing because we think efficiency should be regarded as a fundamental component of therapy effectiveness. Suppose that two therapies are equally effective in assisting people to resolve their psychological distress as assessed, perhaps, by changes in scores on standardised outcome measures. To achieve this change, however, people use an average of six sessions of Therapy A and an average of 11 sessions of Therapy B. In this situation, we would consider Therapy A to be a more effective treatment than Therapy B because it is more efficient. The difference in people requiring either six sessions (on average) or 11 sessions (on average) to achieve the same state of desired functioning has important implications for both the time it takes to function the way one would like to, and the difference in cost required to provide treatment of an average of either six or 11 sessions.

By including efficiency as an essential component of therapy effectiveness, we are not advocating for ‘quick and dirty’ approaches. Nor are we recommending a purely ‘economic’ attitude with regard to service provision. We believe therapy should be as long as necessary and no longer. We also believe ‘as long as necessary’ will be different for different clients: even clients who are ostensibly experiencing the same kinds of problems. If therapy remains focused on helping clients live the sort of lives they want to live, and if therapists see their role as, ultimately, to help the client get along without the therapist, then, all other things being equal, we do not think clients generally want to be ‘in therapy’ for long periods of time or even indefinitely. Ultimately, we think clients want to be ‘out there’ in the ‘real world’ living a life they value. Efficient therapists, therefore, might have an attitude of, ultimately, making themselves redundant to their clients. These therapists provide only as much therapy as the client requires and they understand that individual clients will determine what ‘only as much’ is. While therapists might be aware of how much improvement is possible for clients, they can never know (except by asking the client) how much improvement is desired by any particular client.

Therapies are needed, therefore, that can flexibly adapt to the various requirements of different clients. Focusing on the application of important principles of therapy rather than the utilisation of a range of specific therapeutic techniques and strategies can provide the required degree of flexibility while maintaining a high standard of effectiveness. To use a trivial example, someone who had a principle of ‘eat a balanced diet’ would be able to function effectively in a much broader range of contexts than someone who lived by the more specific directive of ‘eat meat and three vegetables every day’. By basing one’s practices on the application of foundational principles rather than the accumulation of different methods and activities, therapists will be able to be more helpful to more people more of the time.

Before discussing the way in which fundamental principles can be applied in therapy, it is necessary to explain what we understand a principles-based approach to counselling and psychotherapy to be and to outline why we think this approach is important. It will also be useful to describe some of the advantages of this approach, as well as trying to anticipate some of the difficulties you might encounter as you adopt this approach in your therapeutic practice. We will not be able to predict every possible problem of course, but we will discuss some typical concerns that might resonate with you. After beginning the book by considering what a principles-based approach is and why it is important, throughout the rest of the book we will describe the Method of Levels (MOL; Carey, 2006a, 2008a; Mansell, Carey, & Tai, 2012), which is a therapy based on three fundamental principles related to behaviour, psychological distress, and change.

What is a principles-based approach?

The online dictionary www.dictionary.com offers five explanations for the definition of ‘principle’. Although the explanations are somewhat different, they all have something to do with a rule or a law that guides, or is the basis of, action or conduct. It seems that these rules can be professed or accepted but might also be fundamental or general laws, doctrines, or tenets.

Principles, then, can be accepted rules and norms or fundamental laws and tenets. They seem to be inherently involved in courses of action. Thinking of principles in this way suggests that principles are a ubiquitous and necessary, although sometimes perhaps unstated, aspect of day-to-day functioning. We think of principles as things such as honesty, respect, the laws of physics, or ‘pursue a life worth living’. Sometimes, principles are expressed explicitly, such as ‘Children should be seen and not heard’, and sometimes they are more implicit. ‘Wash your hands after you’ve patted the dog’, for example, indicates a principle of hygiene. Sometimes, principles seem to be used to help achieve other principles. For instance, people might actually vary how tightly they adhere to their principle of honesty because, from time to time, it might be necessary to have a more relaxed approach to honesty in order to maintain respect and closeness (other principles) with a friend.

Principles are certainly involved in the conduct of counselling and psychotherapy. You might be able to remember conversations you have overheard or participated in where principles were discussed in some way. Statements such as ‘It’s a life-long illness’, ‘He’s just not engaged in therapy’, ‘Your fluctuating moods are caused by a chemical imbalance’, ‘She’s only doing it for attention’, ‘The client is the agent of change’, ‘Self-disclosure interferes with the process of therapy’, and ‘If we keep giving her more appointments, we’re just reinforcing her behaviour’ all reflect principles of one kind or another. Significantly, quite independently of the ‘truth’ or accuracy of any of these statements, they will have an important influence on the way therapists who subscribe to them interact with their clients. A therapist, for example, who believes that ‘the client is the agent of change’ will ask questions and introduce activities differently from the way in which a therapist who believes ‘the treatment gets the client better’ will ask questions and structure activities.

Surprisingly, despite the importance of principles to our general conduct and daily work, they seem not to be the focus of inspection when new therapies are being developed. In the field of counselling and psychotherapy, it is much more common to read books, attend workshops, and receive training in various techniques and strategies than it is to engage in professional development identifying and applying important principles. We think techniques and strategies are important but they are not important in and of themselves. The importance of techniques and strategies is in their ability to embody and apply particular principles. In fact, some techniques that appear quite different could well be informed by the same principle. Therapists who encourage their clients to paint or dance and therapists who encourage their clients to journal might all think that it is helpful to encourage the external expression of internal anguish even though the ways they promote this expression vary markedly.

So a principles-based approach to counselling and psychotherapy is one where the spotlight of attention shifts from techniques and strategies used in therapy to the principles underlying these methods. A principles-based approach is more interested in why counsellors and psychotherapists do what they do rather than what they do in any given session with any particular client. Paradoxically, by focusing on the principles underlying the practices of therapy, therapists will be able to be more creative and flexible with the techniques they use. After all, there are many different ways of achieving the same aim. Indeed, some therapists may even feel liberated since they will no longer be confined to particular courses of action by particular therapeutic modalities. Therapists who encourage clients to paint, for example, by recognising that they are actually applying a principle of ‘expression’, might be able to be more flexible and responsive to clients who seem reluctant to draw or paint. It could be that the way clients express themselves is less important than the actual expression occurring in some form. If clients shy away from painting or drawing, therefore, a responsive therapist could encourage clients to find their own best way of expressing those things they find difficult to think about. The challenge from this perspective is not to persuade the client to adopt the favoured activity of the therapist, but rather for the therapist to find the strategy preferred by the client that reflects the principle the therapist thinks is most relevant at that time.

As we discuss the importance of principles, we should qualify this information by explaining that we are not trying to lay down universal truths on stone tablets in this chapter. We are outlining our approach to principles-based psychotherapy and counselling. Other researchers and practitioners may consider principles differently. In 2006, for example, Castonguay and Beutler were the editors of an Oxford University Press publication titled Principles of Therapeutic Change that Work. The book has more than 40 chapter authors and presents the findings of a Joint Presidential Task Force of the Society of Clinical Psychology (Division 12 of the American Psychological Association) and of the North American Society for Psychotherapy Research. Information about the book on www.amazon.com states:

This book transcends particular models of psychotherapy and treatment techniques to define treatments in terms of cross-cutting principles of therapeutic change. It also integrates relationship and participant factors with treatment techniques and procedures, giving special attention to the empirical grounding of multiple contributors to change. The result is a series of over 60 principles for applying treatments to four problem areas: depression, anxiety disorders, personality disorders, and substance abuse disorders.

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Table of contents

• Cover
• Halftitle Page
• Title Page
• Copyright Page
• Contents
• Introduction
• 1 A principles-based approach to therapy: the what and why
• 2 The principles: control, conflict, and reorganisation
• 3 The clinical implications: a summary
• 4 Clarifying roles: both the therapist and the client
• 5 The therapeutic relationship
• 6 Putting clients in charge: client-led appointment scheduling
• 7 Making therapy sessions more therapeutic
• 8 Treat the distress, not the symptoms
• 9 Therapeutic change: expect it at any time
• 10 How it all works in practice
• References
• Index