Counsellors Column: What does the evidence say about “best practice” for Counsellors working with clients? A response to the ACC Clinical Pathway.

 By Steve Taylor

In 2006, Massey University, funded by the Accident Compensation Corporation (ACC), began an extensive multi-disciplinary review of the available evidence as current literature and practice pertained to working with victims of sexual abuse. The independently peer-reviewed publication, entitled “Sexual Abuse and Mental Injury: Practice Guidelines for Aotearoa New Zealand” (2008), conducted a Transdisciplinary investigation of both service receipt and provision, utilising both quantitative and qualitative research methodologies with both consumers and consumer treatment providers.

Of initial  interest to me ( in my own work towards completing a Masters Thesis on Counselling Outcome Research) was a Consumer Focus Group (Woolley, Mortimer, 2006) that identified within the research source document as to what was both helpful and hindering to the Counselling process for this client group.

The summary of factors that ACC service consumers considered helpful included:

  • “Being believed and listened to non-judgementally and carefully by a counsellor who is interested in me as a person”
  • “Being reassured the abuse was not my fault and that things will get better over the course of therapy”
  • “Making sure the counselling moves at a pace which feels comfortable for me, and that the counsellor ensures that I have enough time to feel calm and safe before the end of the session sessions.”
  • “Helping to make links between things that happened in the past (experiences of abuse) and the effects on my life now”
  • “Setting goals with the counsellor about what is important to work on, and in what order, and getting feedback from the counsellor about how I am doing.”
  • “Having homework tasks to do between sessions”
  • “Knowing the counsellor is well trained, confident, and knows this area well”
  • “Feeling confident that my counsellor “knows the system” and what I am entitled to and can guide me about my rights, including how to access free counselling through ACC to deal with my issues of sexual abuse”
  • “Finding a counsellor who “suits me”, either because they are warm, empathic and competent, or because they share some characteristics with me (e.g. from the same culture, speak the same language, have some similar interests)”
  • “Having the counselling in a place which feels comfortable, private and safe”

A summary of things that ACC consumers considered hindering included:

  • “Feeling judged by the counsellor for my actions, my sexual orientation, or any other aspect of my life”
  • “Being touched by the counsellor (although some clients said they appreciated some safe touch such as a hand on their back when they were distressed)”
  • “Not feeling in control of the process”
  • “The counsellor “just listening” and not providing any guidance”
  • “The counsellor seeming to use “ideas from a manual”, or their latest training, rather than tailoring the counselling to my individual needs”
  • “Counsellors who have their own abuse history which they haven’t dealt with properly – leading them to talk about their own abuse story instead of listening to mine”
  • “Counsellors who cannot cope with hearing awful stories, making me feel I have to start looking after them, when it should be the other way around”
  • “Having to pay a surcharge that makes it financially difficult for me to continue with the counselling”
  • “Not being able to find a counsellor that fits with my specific needs (e.g. a Maori counsellor) who is ACC accredited”

In 2008, the colloquially termed “Massey Guidelines” were published, and parts of this research was ostensibly adopted and molded by ACC for the agencies new “Clinical Pathways” procedure, a process that met with some significant resistance and controversy by various interest groups (including the Massey University Researchers) right up to and beyond the new ACC Clinical Pathway being adopted by ACC in October 2009.

Among a raft of concerns raised by a number of professional associations was the new requirement that ACC Sensitive Claim clients applying for ACC funding for counselling now had to be clinically assessed for the purpose of prescribing a formal mental health diagnosis.

The negative ramifications of this decision was compounded by the fact that only certain specialists were permitted by ACC to carry out the clinical assessment, namely psychologists, psychiatrists, and latterly, some specifically qualified psychotherapists.

However, the apparent “specialist” focus of the ACC Clinical Pathway seems  at odds with over 70 years of Counselling Outcome Research evidence regarding what constitutes effective therapeutic outcome (see later), and also seems to contradict the above feedback gleaned from a Focus Group with direct experience of receiving counselling for sexual abuse trauma. Indeed, it seems as if the majority of focus group participants above nominated what might be termed effacious “common factors” as being helpful, such common factors contained within a trusting therapeutic relationship, regardless of the presenting problem, and regardless of interventionist specialty.

A brief history of the literature:

There is a plethora of literature that affirms the effacious value of the client-counsellor therapeutic relationship, client-counsellor collaboration, and client-counsellor therapeutic progress.

Norcross, J. (cited in Duncan, Miller, Wampold, Hubble, 2010, p. 115) states that at least 100 studies researching counselling and psychotherapy client perspectives of treatment intervention regularly cite “therapeutic relationship” as a key factor of effective treatment outcome.

 Orlinsky, Ronnestad, and Willutzki, (2003) found over 1000 research findings that demonstrated that a positive alliance between a therapist and client was one of the best positive predictors of client counselling outcome.

According to Orlinsky, (cited in Duncan et al, 2010) the earliest recorded studies of systematic empirical research on counselling and psychotherapy began in the 1940’s (Muench, 1947).

Orlinsky (cited in Duncan et al, 2010) appraises the historical research literature in the field, and concluded that, despite a growing interest in the field by researchers since this time (e.g. Eysenck, 1952; Luborsky, 1969), it was the collation of meta-analysis studies (e.g. Smith, Glass, and Miller, 1980) and the publication of the Handbook of Psychotherapy and Behaviour Change (Garfield and Bergin, 1978, 1986), that began to provide a more credible platform of field research from previous years.

Resistance by practicing clinicians to research findings seemed a common theme from the outset of research in this field, as it appeared that clinicians desired the research to validate their existing practice (Orlinsky, cited in Duncan et al,  2010).When this outcome did not eventuate, many clinicians simply viewed the research as irrelevant to their practice, and promptly ignored the research results, despite cumulative research findings strongly suggesting that psychotherapy was not only effacious, but that certain specific positive intervention factors were beginning to emerge in the literature (Orlinsky & Howard, 1986).  These ‘common factors” were colloquially referred to by researchers as “the Dodo Bird Verdict” – a fuller description of this term is forthcoming

In the 1990’s, researchers began to attempt to address the divide between clinical practice and research (Aveline and Shapiro, 1995, Talley, Strupp, and Butler, 1994), and in 1999, clinicians were able to access a reservoir of research information that could positively influence their applied practice with clients (Hubble, Duncan, and Miller, 1999, 2010).

Between 1999 and 2010, a number of “common factors” have been regularly discussed in the research literature relating to positive psychotherapeutic outcome for clients, with some of these common factors having been identified in other literature as early as the 1930’s (Rosenzweig, 1936).

The “Dodo Bird” verdict or the “Common Factors” hypothesis:

Rosenzweig (1936) coined a metaphoric term called “the dodo bird verdict” to describe the large influence of common factors that contributed to positive psychotherapeutic change for clients, over and above model or method-specific interventions with clients.

In Lewis Carrols Alice’s Adventures in Wonderland (1865), at a certain point in the story, a number of characters become wet. In order to dry themselves off, the Dodo bird decided to issue a competition. Everyone was to run around the lake until they were dry. Nobody cared to measure how far each person had run, nor how long. When they asked the Dodo who had won, he thought long and hard and then said “Everybody has won and all must have prizes.”

In a meta-analysis study conducted by Luborsky (2002), the effect size for specific models of intervention was found to contribute only 20% of the variance relating to positive client psychotherapeutic change, thus ostensibly confirming Rosenzweig’s metaphor.

Attempts to “roast” the Dodo Bird, or support for “Model Factors” hypothesis:

The dodo bird verdict has not however escaped challenge from an opposing research camp, namely supporters of “evidence validated therapies” or “evidence supported therapies”.

Chambless (2002) states that: “there is much evidence that specific therapies are helpful to specific people in specific situations with specific problems”. Chambless argues that the significance of the figure of 20% in the Luborsky (2002) study is “an artifact of grouping problems and therapies in a non-meaningful way”.

Carroll and Onken (2005) argue that in the behavioral therapy discipline: “greater methodological rigor, with emphasis upon treatment specificity, has led to the development of a range of empirically validated therapies”.

Higgins, Delaney, Budney, Bickel, Hughes and Foerg (1991) champion Contingency Management as an evidence-based treatment across wide client populations and settings, with Lussier, Heil, Mongeon, Badger, and Higgins (2006) and Dutra, Stathopoulou, Shawnee, Basden, Levro, Powers, and Otto (2008) illustrating consistent positive effect sizes.

Carroll and Rounsaville (2010) adamantly defend the premise that evidence validated therapies improve client outcomes when compared to “treatment as usual” in an alcohol and drug addiction setting, and illuminate their belief and concern that most treatment centre settings do not adhere to the construct of evidence validated therapies. The authors cite two studies, the first (Santa Ana, Martino, Ball, Nich, and Carroll 2008) that deemed the detection of therapist intentionality around a specific model of treatment as to be “almost undetectable”, while the second (Martino, Ball, Nich, Frankfortor, and Carroll, 2009) found that “clinician initiated discourse that was unrelated to the patients problems (i.e. “chat’) was seen much more frequently than evidence validated therapies”.

Carroll et al (2010) also highlights the specific positive effects upon clients of defined treatment models such as Behavioral Family Therapy, Cognitive Behavioral Therapy, and Pharmacotherapy, while raising other important considerations in terms of client intervention, including the timing and level of intervention with a client, client motivation to change, therapist competence within a specific model of practice, and the role of computer assisted client interventions that perhaps rely less on therapeutic alliance, and more on the construct and content of the computer software and / or online course.

Beutler (2002, p. 30) is emphatic that the dodo bird verdict is extinct:

“The complexity of determining the presence of specific effects has been underestimated and, more importantly, the evidence of specific effects in treatments has been largely ignored by those who adopt a dodo bird’s perspective”.

Johnson (2003, p. 363) defends Emotionally Focused Therapy (EMT), citing four studies to support the claim that the dodo bird verdict is dead (2003, p. 367). 

Much of the defence of the “Model Factors” hypothesis is rallied from the fields of behavioural therapy, cognitive behavioural therapy, and pharmacotherapy, with service providers attempting to place perhaps more emphasis on randomised controlled trials as evidence for efficacy than may be wholly legitimate – a discussion on this point is considered in the next section.

Is it the dodo Bird, or is it the ground that the Dodo Bird is standing on?

Budd and Hughes (2009) attempt to address the divide between the opposing camps of “common factors” verses “model factors” by reviewing thirty years of psychotherapeutic meta-analytic studies, contrasting “common factors” and “model factors” outcomes.

Adopting a “theory of science” perspective, the authors conclude that the methodology of randomised controlled trials as a tool to measure psychotherapeutic outcomes is inappropriate, owing to the assumptions inherent in the methodology.   According to the authors, treating “diagnosis” or type of therapy” as independent variables is impossible to accurately measure, because the construct validity of the diagnosis cannot be agreed on, and the therapeutic delivery of the type of treatment cannot be controlled by the researchers. All the methodology will then find is non-specific effects of covariates, such as those (for example) of therapist allegiance – and thus the dodo bird verdict is cited as a consequence of the research method, and that these non-specific effects are critical features of psychological therapy.

Dingfelder (2004) reminds researchers of the “null hypothesis” outcome, whereby a piece of outcome research may discover the difference between the means of two groups does not exceed what would be expected by chance. The author considers as to whether much unpublished research material is a result of a null hypothesis being found, and if such studies are unpublished, whether or not clinicians are observing a level research based playing field in terms of considering all of the outcome evidence (published and un-published) available.

Christoph (1997) argues that despite the strength of a previous 114 study meta-analysis study on psychotherapeutic outcome research (Wampold, Mondin, Moody, Stich, Benson, Hyun Nee, 1997), some limitations within the meta-analytic framework (e.g. the inclusion of follow up assessments relating to possible client relapse post-treatment, and the use of under-graduates within the sample group) “may have biased the results against finding differences between treatments”. Notably, Christoph is a psychodynamic psychotherapist defending the objections of predominantly behaviorally-orientated critics of the Dodo bird verdict.

Strauss (2001) simply accepts the existence of the “two worlds” of psychotherapy outcome research working side by side, commenting that a “specificity paradox” may be identified within client presentations alongside “general principles” evidenced by “psychological disorders developing their own dynamics”.

Orlinsky (cited in Duncan et al, 2010) also notes that that the divide between “common factors” and “specific factors” (e.g. therapist procedures or model application and techniques) has been more recently merged to encompass “therapeutic factors” as a working paradigm for current and future outcome research.

It would thus appear that that the divide between the two hypotheses (common factors verses model factors) is in the process of being extinguished by researchers within the Counselling Outcome Research field of study, and merged into a more inclusive hypothesis, namely “therapeutic factors” that contribute to positive client efficacy.

 What do clients say about what “works” in therapy?

Paulson, Truscott, and Stuart (1999) reviewed 14 years of previous research pertaining to how clients perceived they had been assisted by the Counselling process. Much of this previous research had been conducted with ‘pseudo-clients”, and the use of researchers, as opposed to participants, sorting and clustering the data. The study identified 80 factors of the counselling process that study clients nominated as being helpful.

Rating values assigned to each factor (1-5) – the higher the rating value the more important the factor was to a client in terms of being helped. Rating values that scored highly in this study included:

  • “Affordable” (4.61)
  • “My counsellor listened to me” (4.56)
  • “My counsellor was non-judgemental” (4.50)
  • “Speaking to someone who is neutral” (4.44)

Key counselling factors identified in the study as being most helpful to a client included counsellor style, relationship roles, positive working relationship, affordability, client self-disclosure, and the client change processes that occurred for a client: nomination of a  model of intervention for these clients as being an influential factor in positive outcome was conspicuously absent in this feedback list.

A New Zealand Families Commission Research study (2008) worked to identify the type and nature of “informal support”, “semi-formal support”, “formal support”, “barriers to informal, semi-formal, and formal support”, and “experiences of support” for couples experiencing difficulty in their relationships with one another.

The study found that participants did not as a rule discuss their relationship issues with counsellors, but rather with families, friends, GP’s nurses, school teachers, church ministers, or community elders, indicating that informal and semi-formal support was preferred by participants over a formal support option such as counselling.

The study also found that the three key outcomes a study participant was seeking when asking for assistance were:

  • A listening ear.
  • Some practical advice.
  • A practical intervention

In a follow up to their 1999 study, Paulson, Everall, and Stuart, J. (2001) conducted a further contrasting study to increase understanding of what counselling clients perceived as hindering experiences in their counselling process.

This study strongly illustrated that “Negative Counsellor Behaviours” had the strongest hindrance factor for clients, recording the highest average cluster rating of 3.66 for client hindrance for the study (1 = not at all hindering; 5 = extremely hindering).

The top 10% n= 8 of the total aspects recorded (n = 80) related directly to this cluster. “Insufficient counsellor direction” ranked 9th, and “Lack of counsellor responsiveness” ranks 10th – 12th in terms of hindrance for clients to the counselling process.

Manthei, (2006) found that clients in crisis talked first to friends and families, followed by trusted professionals, prior to seeking a formal counselling intervention, findings in apparent concert with the previously mentioned New Zealand Families Commission study (2008).

Notably, the Manthei study (2006) is one of only four published New Zealand-based counselling outcome studies available, all written by the same author.

Interestingly then, “model factors” are most often not nominated by clients as being effacious, although this may be because many clients of counselling may not have either a language or an understanding to articulate what might constitute the construct of a counselling “model” in their treatment. This trend may also relate to the type and content of feedback counsellors may secure from their clients when asking for outcome efficacy feedback.

What does the literature say about “therapist factors” influencing client outcomes?

Kervick (2009) synthesised 30 publications from 1951–2008 (publications that include peer reviewed journal articles, clinical texts, and meta-analysis outcome studies) that illustrated key “therapeutic factors” that positively contributed towards effacious client outcomes. The following studies were highlighted in this synthesis.

In Wampold (2001), talk therapy as an intervention was found to be four times as effective as no treatment, and two times as effective as placebo, with 50% of clients experiencing positive change after 7-9 sessions and 50% of clients experiencing a full recovery from presenting symptoms after 7-9 sessions.

Okiishi, Lambert, Nielsen, and Ogles (2003) found that a significant variation existed between counselling client’s rate of improvement and this variation has little to do with a counsellor’s theory orientation, or the level and / or type of training undertaken by the counsellor.

Wampold (2001), Wampold and Messer (2002), Wampold and Brown (2005), and Beutler (2004) cited in Blow, Davis, and Sprenkle, (2007) found that “Therapist factors” were highlighted in a growing body of research as holding a greater importance than “Model factors” in predicting as to whether a specific psychotherapeutic outcome for a client would be successful, with “Therapist factors” being up to nine times as potent as model or technique factors (Wampold, 2001).

Kervick (2009) also discusses the possibility that future therapist training may develop into a trans-theoretical, model-independent approach to learning, “regardless of a specific therapeutic model or tradition”, and identifies a body of existing literature that may be synthesised under a collective heading entitled “Psychotherapy effectiveness literature” including existential psychotherapy (Whitaker, 1975), neo-object-relations therapy (Masterson, 1988), (Scharff & Scharff, 1987), self psychology (Kohut, 1971), interpersonal theory (Sullivan, 1953), Bowen theory (Bowen, 1978),  interpersonal psychotherapy (Weissman, Markowitz, & Klerman, 2000), and client-directed outcomes informed therapy (Duncan, Miller, & Sparks, 2004).

Sexton, Ridley (2004), found that race, gender, age, cultural background, professional identity (e.g. counselling vs. psychology vs. social work) and even professional experience (defined as years of practice) was unrelated to counseling outcome (or at least overrated in the therapeutic relationship).  Matching of clients and counselors on these dimensions (e.g. client and counselor of same race working together) did not result in increased efficacy.

In both a local and international context, as a clinician I have observed a growing emphasis on a range of social service agencies developing population, identity, or culture -specific counselling and psychotherapeutic interventions for clients. Heavily defended discipline boundaries between psychology, counselling, psychotherapy, mental health, and social work are also known to exist in the respective fields of endeavor. It would seem from the above literature that much of this effort is contrary to the outcome research evidence, and may be being driven instead by ideology and popular opinion, as opposed to identifying what therapeutic factors actually contribute to effacious client outcomes.

In his synthesis, Kervick (2009) expanded on his hypotheses about “what works in therapy” and constructed a metaphorical prototype of the “super shrink” to identify evidence – supported findings of effacious therapist factors that contributed to positive client outcomes.

Kervick identified that “super shrinks” have a counter-cultural attitude (Hubble, Duncan, Miller, 2007) Whitaker (1975); adjust what they are doing when clients tell them it is not helpful or could be done better; are expert at soliciting feedback, especially early in the process, which sets them apart from less effective therapists (Duncan, Miller, Sparks, 2004); match therapeutic directiveness to level of resistance (more resistance requiring less directiveness and vice versa (Norcross & Hill, 2004); are experts at repairing inevitable alliance ruptures (Norcross & Hill, 2004); assess motivation for change early and are able to skillfully design their approach based on that readiness for change (Prochaska & DiClemente, 1992); are highly skilled at eliciting and reinforcing client “change talk” especially at the end of sessions (Amrhein, Miller, Yahne, Palmer, Fulcher, 2003); are perceived by their clients to have congruence between their personalities and their office settings (Levitt, Butler, Hill, 2006); employ client-informed and well-managed flexible structure to the therapy that includes relevant and well-managed goal setting (Levitt, Butler, Hill, 2006); are realistic optimists that believe people are resilient and can change. They offer their clients hope without losing empathic attunement (Schneider, 2001).

Kervick (2009) summaries that successful talk therapists are “genuine people with strong character who exude something difficult to define that breeds trust and confidence” qualities grounded in the existential / humanistic psychotherapeutic tradition (Whitaker, 1975), (Rogers, 1951); have a natural “curious personality that enjoys learning about the experiences of others”; are able to stay grounded in themselves while working “flexibly within the therapeutic relationship”, with a similar therapist factor being identified in an earlier study relating to identifying the personal narrative of the therapist as an influence upon what clients found helpful in psychotherapy (Levitt, Butler, Hill, 2006); constantly monitor the status of the therapeutic alliance (be that intuitively or overtly), so as to address any negative impacts that may have occurred during the counseling process in recognition that therapeutic alliance disruption is a significant trigger for a client reporting a negative experience in therapy, and / or terminating therapy prematurely (Wampold, 2001); are able to cognitively and accurately interpret a relational client interpretation that resonates emotionally with the client, communicating empathy in the process, with his positive therapist factor finding also recorded in earlier literature (Sullivan, 1953), (Kohut, 1971), (Weissman et al, 2000); initially score lower client satisfaction ratings with clients early on in the counseling process, for reasons that the research has not as yet identified, yet are able to facilitate a stronger therapeutic alliance with clients over time (Hubble, Duncan, & Miller, 2007).

Kervick (2009) offers a hypothesis that the reason for this latter finding could be that the therapist sets the tone for honesty for the client within the therapeutic alliance by being honest with the client early on in the process, “at times boldly so”, which may negatively influence early client satisfaction rating scales of the therapist; posits that the significance of the timing of a therapeutic intervention as a therapist factor could be better highlighted through more thorough clinical supervision methods e.g. video recordings of sessions to assist inexperienced therapists better recognize when their timing was in need of some improvement; are able to successfully repair ruptures in the therapeutic alliance, and foster a more bonded working relationship with a client as therapy progresses (Norcross, Hill, 2004), (Masterson, 1988), (Stiles, Glick, Osatuke, Hardy, Shapiro, Agnew-Davies, Rees, Barkham, 2004); are able to create a safe client environment whilst being relaxed, direct, in control, but not controlling, creating an environment of sound therapeutic containment (Kervick, 2009) – this therapist factor finding is also highlighted in earlier literature (Scharff & Scharff, 1987; Gladwell, 2008); are aware of extra-therapeutic factors that influence positive client outcomes, and work with clients to positively summon a clients’ appropriate energy to work with these factors (Kervick, 2009); and finally, successful talk therapists are able to act as a positive influence for change, whilst retaining sufficient humility to realise that their role is merely acting a as a facilitator to change, not an author of change.

In the context of working with clients suffering from sexual abuse, Dr Scott Miller, a founder of the International Centre for Clinical Excellence recently addressed the  issue of effacious therapeutic factors when an ICCE  listserve subscriber asked Dr Miller about working with sexual abuse clients, particularly if they are quite young. Dr Miller’s response:

 “From a client directed outcome informed (CDOI) perspective, the type of problem does not have any necessary or absolute influence on what happens between the client and therapist. With sexual abuse or any other problem, the client’s preferences about the problem and how it may be addressed are paramount. So I would be very interested in the child’s take on things and his or her ideas as well as any adults’ perspectives.  Job one would be creating a strong alliance context that engages the clients and their resources in the work. That said, specialized knowledge and possible directions arising from the sexual abuse literature may (or may not) be relevant. Any plan constructed/negotiated by the client and I would have to pass the taste test (the proof of the pudding is in the taste); i.e., show a change on the Outcome Rating Scale (ORS).

In this way, CDOI services (this is the definition) contain no fixed techniques or causal theories regarding the concerns that bring people to treatment. Any interaction can be client-directed and outcome-informed when the consumer’s voice is privileged, social justice is embraced, recovery is expected, and helpers purposefully form partnerships to: (1) enhance the factors across theories that account for success—especially the heart and soul of change; (2) use client’s ideas and preferences (theories) to guide choice of technique and model; and (3) inform the work with reliable and valid measures of the consumer’s experience of the alliance and outcome.

This doesn’t exclude a more specialized approach or therapist expertise but rather embraces the possibility that other alternatives may arise from the process. The bottom line is that theory does not trump client preference; on the other hand, a particular theory or viewpoint may be just the ticket. In other words, theory (including abuse theory) only has value in the particular assumptive world of the participants—the client and therapist—and that theory need not be “true” across clients; rather, any theory needs only to be valid with this client in my office now. This of course injects a high level of uncertainty to the process. Here is how I write about in “On Becoming”:

We long for the structured, the scripted, the predictable, the manualized, the sure fire way to conduct a session—maybe not even to sequester success, but at times, just to get through it, staring eye to eye with a person experiencing significant distress. Who can blame us? But uncertainty and complexity are endemic to the work as they are of life, and therefore are important to embrace for therapist development. You want uncertainty to always be lingering.

Why? As frightening as it feels, uncertainty is the place of unlimited possibilities for change. It is this indeterminacy that gives therapy its texture and infuses it with the excitement of discovery. This allows for the “heretofore unsaid,” the “aha moments,” and all the spontaneous ideas, connections, conclusions, plans, insights, resolves, and new identities that emerge when you put two people together in a room and call it psychotherapy. This doesn’t mean, of course, that it’s all fireworks (just watch an entire session rather than edited video clips), it just means that your tolerance for uncertainty creates the space for new directions and insights to occur to both the client and you. Perhaps, helping at its very best sets the context for these unique discoveries”

Again, “model factors” or “specificity of intervention type” do not feature prominently in this summary, lending an increasing, almost Bayesian probability credence to the “common factors” hypothesis being a significant contributor to the newly emerging “therapeutic factors” construct being developed within the Outcomes Research field.

I am hopeful that the Accident Compensation Corporation Sensitive Claims Unit considers the weight of the above summary, and be encouraged to more meaningfully align practice-based evidence research with practical client application.

Kind Regards,
Steve Taylor (MNZCCA, DAPAANZ) | B. Couns., B. Alc. D.S. | Cert. Clinical Supervision | Cert. Supervisory Management
Director 24-7 Ltd

Counselling | Supervision | Mediation | Training
Level 2, 300 Gt Sth Rd, Greenlane | PO Box 24-700, Royal Oak 1345, Auckland, New Zealand
Ph: (021) 259-2506 | Email: |


Accident Compensation Corporation (2008). “Sexual Abuse and Mental Injury: Practice Guidelines for Aotearoa New Zealand” Palmerston North, Massey University School of Psychology.

Amrhein, P.C., Miller, W.R., Yahne, C.E., Palmer, M., Fulcher, L., (2003). Client commitment language during motivational interviewing predicts drug use outcomes. Journal of Consulting and Clinical Psychology, 71 (5) 862-878.

Aveline, M., Shapiro, D.A. (1995). Research foundations for psychotherapy practice. Chichester, England. Wiley.

Beutler, L.E. (2002). The Dodo bird is extinct. Clinical Psychology: Science & Practice 9 30-34.

Beutler, L. E., Malik, M. L., Alimohamed, S., Harwood, T. M., Talebi, H., Noble, S., et al. (2004). Therapist variables. In M. J. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (pp. 227–306). New York: Wiley.

Blow, A., Davis, S., Sprenkle, D. (2007). Is who delivers the treatment more important than the treatment itself? The role of the therapist in common factors. Journal of Marital and Family Therapy, 33, 298-317.

Bowen, M. (1978). Family Therapy in Clinical Practice. New York: Aronson.

Budd, R., Hughes, I. (2009). The Dodo Bird verdict – controversial, inevitable, and important: a commentary on 30 years of meta-analysis. Clinical Psychology and Psychotherapy 16, 510-522.

Carroll, K.M., Onken, L.S. (2005). Behavioural therapies for drug abuse. American Journal of Psychiatry 162, 1452-60.

Carroll, K.M., Rounsaville, B.J. (2010). Perhaps it is the dodo bird verdict that should be extinct. Society for the Study of Addiction 105, 14-21.

Chambless, D. (2002). “Beware the Dodo Bird: the dangers of overgeneralization”. Clinical Psychology: Science and Practice 9: 13–16.

Christoph, P.C. (1997). Limitations of the Dodo Bird Verdict and the Role of Clinical Trials in Psychotherapy Research: comment on Wampold et al (1997). Psychological Bulletin 122, 3, 216-220.

Dingfelder, S.F. (2004).  The significance of null.  Monitor on Psychology, 24-25.

Duncan, B. L., Miller. S. D., Sparks, J. (2004). The Heroic Client: A revolutionary way to improve effectiveness through client directed outcome informed therapy (revised Ed.). San Francisco: Jossey-Bass.

Duncan, B.L., Miller, S.D., Wampold. B.E., Hubble, M.A. (Eds.) (2010). The Heart and Soul of Change (2nd Ed). Delivering what works in therapy. Washington D.C. American Psychological Association.

Dutra, L., Stathopoulou, G., Shawnee, L., Basden, M., Leyro, T., Powers, M., Otto, M. (2008), A meta-analytic review of Psychosocial Interventions for Substance Use Disorders. American Journal of Psychiatry 165: 179-187.

Eysenck, H.J. (1952). The effects of psychotherapy: an evaluation. Journal of Consulting Psychology, 16, 319-324.

Families Commission. (2008). Reaching Out: Who New Zealanders turn to for Relationship Support. Wellington, NZ: Author.

Garfield, S.L., Bergin, A.E. (Eds.) (1978, 1986). Handbook of psychotherapy and behaviour change (2nd & 3rd Eds.). New York. Wiley.

Gladwell, M. (2008). Outliers. New York: Hachette Book Group.

Higgins, S.T., Delaney D.D., Budney, A.J., Bickel, W.K., Hughes, J.R., Foerg, F. (1991). A behavioural approach to achieving initial cocaine abstinence. American Journal of Psychiatry 148, 1218-24.

Hubble, M.A., Duncan, B.L., Miller, S.D. (Eds.). (1999). The Heart and Soul of Change. What works in therapy. Washington D.C: American Psychological Association.

Johnson, S.M. (2003). The revolution in couple therapy: A practitioner-scientist perspective. Journal of Marital and Family Therapy,29, 365-384.

Hubble, M., Duncan, B., & Miller, S. (2007). Supershrinks: What’s the secret of their success? Psychotherapy Networker, Nov/Dec 31 (6).

Kervick, K. (2009). Interpersonal Wisdom: The capacities and characteristics of the best talk therapists. New Therapist 63, 8-16. South Africa: Author.

Kohut, H. (1971). The Analysis of the Self. New York: International Universities Press.

Levitt, H., Butler, M., Hill, T. (2006). What clients find helpful in psychotherapy: Developing principles for facilitating moment-to-moment change. Journal of Counseling Psychology, 53 (3) 314-324.

Luborsky, L. (1969). Critical evaluation of Strupp and Bergin. Research cannot yet influence clinical practice. International Journal of Psychiatry, 7, 135-140.

Lussier, J., Heil, S., Mongeon, J., Badger, G., Higgins, S. (2006). A meta-analysis of voucher-based reinforcement therapy for substance use disorders. Addiction 101 (2), 192-203.

Manthei, R. J. (2006). Clients talk about their experience of seeking counselling. British Journal of Guidance & Counselling, 34(4), 519-538.

Martino, S., Ball, S., Nich, C., Frankfortor, T., Carroll, K. (2009). Correspondence of Motivational Enhancement Treatment Integrity Ratings among therapists, supervisors, and observers. Psychotherapy Research, 19, (2), 181-193.

Masterson, J. F. (1988). The search for the real self: Unmasking the personality disorders of our age. New York: The Free Press.

Muench, G.A. (1947). An evaluation of non-directive therapy by means of the Rorschach and other tests. Applied Psychological Monographs, 13, 1-163.

Norcross, J., Hill, C. (2004). In “Empirically supported therapy relationships” The Clinical Psychologist, 57 – a publication of the Society of Clinical Psychology, Division12, APA.

Okiishi, J., Lambert, M., Neilsen, S., and Ogles, B. (2003). Waiting for Supershrink: an empirical analysis of therapist effects. Journal of Clinical Psychology and Psychotherapy, 10 (6) 361-373.

Orlinsky, D.E., Howard, K.I. (1986). Process and outcome in psychotherapy. In S.L. Garfield and A.E. Bergin (Eds.), Handbook of psychotherapy and behaviour change (3rd ed., pp. 311-381). New York: Wiley.

Orlinsky, D.E., Ronnestad, M.H., Willutzki, U. (2003). Fifty years of process-outcome research: Continuity and change. In M.J. Lambert (Ed).,Bergin and Garfields handbook of psychotherapy and behaviour change (5th ed., pp. 307-390). New York: Wiley.

Paulson, B. L., Truscott, D., & Stuart, J. (1999). Clients’ Perceptions of Helpful Experiences in Counseling. Journal of Counseling Psychology, 46(3), 317-324.

Paulson, B. L., Everall, R. D. & Stuart, J. (2001). Client perceptions of hindering experiences in counselling. Counselling and Psychotherapy Research: Linking research with practice, 1(1), 53-61.

Prochaska, J. O. and DiClemente, C. C. (1992). Stages of change in the modification of problem behaviors. Newbury Park, CA: Sage Publishers.

Rogers, C. (1951). Client-Centered Therapy: London: Constable.

Rosenzweig, S. (1936). “Some implicit common factors in diverse methods of psychotherapy”. American Journal of Orthopsychiatry 6: 412–415.

Santa Ana, E., Martino, S., Ball, S.A., Nich, C., Carroll, K.M. (2008). What is usual about “treatment as usual”: audio-taped ratings of standard treatment in the Clinical Trials network. Journal of Substance Abuse Treatment 35, 369 – 79.

Scharff, D. E., Scharff, J. S. (1987). Object Relations Family Therapy. Northvale, NJ: Aronson.

Schneider, S. (2001). Realistic Optimism. American Psychologist, 56, (3) 250-263.

Sexton, T. L., Ridley, C. R. (2004). Implications of a moderated common factors approach: Does it move the field forward? Journal of Marital and Family Therapy, 30, 159–163.

Stiles, W. B., Glick, M. J., Osatuke, K., Hardy, G. E., Shapiro, D. A. Agnew-Davis, R., Rees, A., Barkham, M. (2004). Patterns of alliance disruption and the rupture-repair hypothesis: Are productive relationships U-shaped or V-Shaped? Journal of Counseling Psychology, 51 (1) 81-92.

Smith, M.L., Glass, G.V., Miller, T.I. (1980). The benefits of psychotherapy. Baltimore: John Hopkins University Press.

Strauss, B. (2001). Farewell to the dodo-bird: specific versus general psychotherapy from the perspective of psychotherapy research. Allgemeine Arzliche Gesellschaft fur Psychotherpie: Thieme Publishing Group.

Sullivan, H. S. (1953). The interpersonal theory of psychiatry. New York: Norton.

Talley. P.F., Strupp, H.H., Butler, S.F. (Eds.). (1994). Psychotherapy research and practice; bridging the gap. New York: Basic Books.

Wampold, B.E., Mondin, G.W., Moody, M., Stich, F., Benson, K., Hyun Nee, A. (1997). A meta-analysis of outcome studies comparing bona-fide psychotherapies: Empirically, “all must have prizes”. Psychological Bulletin, 122, 203 – 215.

Wampold, B. (2001). The Great Psychotherapy Debate. New Jersey: Erlbaum Associates.

Wampold, B., Messer, S. (2002). Let’s face facts: Common factors are more potent than specific therapy ingredients. Clinical Psychology: Science and Practice. 9 (1) 21-25.

Wampold, B., Brown, G. (2005). Estimating variability in outcomes attributable to therapists: A naturalistic study of outcomes in managed care. Journal of Consulting and Clinical Psychology, 73, 914-923.

Weissman M. M., Markowitz J. C., Klerman G. L. (2000). Comprehensive Guide to Interpersonal Psychotherapy. Basic Books: New York, NY.

Whitaker, C. (1975) Psychotherapy of the Absurd: With a Special Emphasis on the Psychotherapy of Aggression. Family Process, 14 (1) 1–16.

Woolley, C., Mortimer, R. (2006). Consumer focus group and key informant interviews: Pilot report (Raranga Whatumanawa Technical Report 3). Palmerston North. Massey University, School of Psychology.

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