The Clinical Effectiveness of the Person-Centred Psychotherapies

360 Pages·2011·3.45 MB·English

by  Windows User

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The Clinical Effectiveness of the
Person-Centred Psychotherapies: The
Impact of the Therapeutic Relationship
By Tony Weston

Thesis submitted in part-fulfilment of the requirements for the award of Doctor (PhD) in
Counselling at the University of East Anglia, School of Lifelong Learning. This copy of the
thesis has been supplied on condition that anyone who consults it is understood to recognise
that its copyright rests with the author and that use of any information derived there from
must be in accordance with current UK Copyright Law. In addition, any quotation or extract
must include full attribution.

Corrections submitted February 2011 – Original Date of Submission 2007
Document word count 109,585 words of which 9,699 words in appendices, thesis word count
99,886 words, which is less than the UEA PhD word limit of 100,00 words.
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Abstract
Background: Person-centred psychotherapies have fared poorly in reviews of „empirically
supported therapies‟, compared with cognitive-behaviour therapy (CBT). Yet there is
evidence of comparable efficacy and effectiveness of person-centred therapies (PCT), of
elements of the therapeutic relationship as defined in PCT as a therapeutic process of change
and an NHS research funding gap (£m CBT >> PCT). The author wondered if PCT was an
effective intervention for a range of different symptoms and about the role of therapeutic
relationships.
Aim: The aim was to measure the clinical effectiveness of PCT as practised in the author‟s
private practice and by colleagues at the University of East Anglia Counselling Service and to
assess the therapeutic relationship as a putative predictor of outcome.
Method: This was primarily an uncontrolled naturalistic experiment; outcome measures were
completed at first therapy session and subsequently, along with a measure of the relationship.
Results: There was evidence that PCT was an effective intervention for clients who
completed subsequent questionnaires who started with symptoms of depression (ES(d) =1.48,
n =111), anxiety (ES(d) =1.15, n=91) and distress (ES(d) =1.80, n=79). These outcomes were
broadly comparable with the literature. Some of the difficulties identified with uncontrolled
naturalistic experiments described in the literature are addressed in the text, further
supporting the validity of these findings. There was no evidence of the role of the therapeutic
relationship (Rogers 1957) as a predictor of outcome for depression (n=92), anxiety (n=75) or
distress (n=54). Further analysis of outlier and influential cases suggested the therapeutic
relationship had an effect on depression outcome, r = .22. Illustrative analysis suggested the
therapeutic relationship could have an effect on outcomes for anxiety in the order of r = .25
and distress r = .29. Non-positive findings may have been due to problems with the protocol
and sample, these are discussed in the text and recommendations for future research made.
Conclusions: PCT warrants further outcome and change process research and inclusion as a
comparator treatment condition in NHS-sponsored trials of CBT.
Declaration of interest: The author was trained and practices as a person-centred
psychotherapist. During the period 19/5/5 – 13/7/6 the author received £8,167.07 from the
University of East Anglia University Counselling Service; this was for sessional counselling
work and included a contribution towards the costs of this research.
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Table of Contents
Abstract ...................................................................................................................................... 2
List of Figures ............................................................................................................................ 7
List of Tables ........................................................................................................................... 11
1. General Introduction ............................................................................................................ 15
1.1 The source of this research ............................................................................................. 16
1.2 Overview of this research. .............................................................................................. 17
2. Person-centred psychotherapies. .......................................................................................... 23
2.1 Early research leading up to the statement of Rogers‟ theories. .................................... 23
2.2 Main statements of Roger‟s theories and Rogers‟ attempts to validate his theories. ..... 37
2.3 Contemporary person-centred psychotherapies. ............................................................ 42
3. Placing this research in the context of the literature ............................................................ 44
3.1 Outcomes literature ........................................................................................................ 45
3.1.1 Overview of outcomes literature ............................................................................. 46
3.1.2 Anxiety outcomes .................................................................................................... 51
3.1.3 Depression outcomes ............................................................................................... 54
3.1.4 Distress outcomes and related commentary on methodologies. .............................. 55
3.1.5 The therapy workforce in the UK and investment in therapy research ................... 58
3.1.6 Outcomes management. ........................................................................................... 59
3.1.7 Concluding comments on outcome research. .......................................................... 61
3.2 Process-outcome research literature ............................................................................... 62
3.2.1 The case against Rogers‟ theory .............................................................................. 64
3.2.2 Abuse of the drug metaphor .................................................................................... 70
3.2.3 Causation approaches .............................................................................................. 75
3.2.4 Common factors ...................................................................................................... 79
3.2.5 Meta-analytic approaches ........................................................................................ 82
3.2.6 Some Recent studies ................................................................................................ 85
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3.2.7 Anti-depressant medication ..................................................................................... 91
3.2.8 Dose effect relationships ......................................................................................... 93
3.2.9 Concluding comments on process-outcome research .............................................. 94
3.3 Research Design. ............................................................................................................ 95
3.3.1 Overview of design issues. .......................................................................................... 95
3.3.2 Measuring outcomes. .................................................................................................. 96
3.3.3 Measuring process-outcome correlations. ................................................................... 98
4. Introduction to this study ................................................................................................... 100
4.1 The need for this research ............................................................................................ 100
4.2 Overview of hypotheses to be tested ............................................................................ 107
4.3 Specific hypotheses to be tested ................................................................................... 109
4.4 Concluding comments on the introduction to the research. ......................................... 111
5. Method ............................................................................................................................... 113
5.1 Participants ................................................................................................................... 114
5.1.1 Clients .................................................................................................................... 114
5.1.2 Therapists............................................................................................................... 120
5.2 Measures....................................................................................................................... 121
5.2.1 Outcome measures ................................................................................................. 121
5.2.2 Process measure ..................................................................................................... 127
5.3 Research protocol ......................................................................................................... 130
5.4 Treatment duration ....................................................................................................... 133
5.5 Resulting sample .......................................................................................................... 136
5.6 Participant flow and demographic characteristics for each sample analysed .............. 138
5.7 Analytical approach...................................................................................................... 140
6. Results ................................................................................................................................ 141
6.1 Outcomes ...................................................................................................................... 141
6.1.1. Depression (BDI-II) outcomes ............................................................................. 142
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6.1.2 Anxiety (BAI) outcomes ....................................................................................... 149
6.1.3 Distress (CORE-OM) outcomes ............................................................................ 155
6.1.4 Personality Disorder Prevalence (PBQ) ................................................................ 162
6.2 Predictor analysis .................................................................................................... 165
6.2.1 Depression (BDI-II) outcome prediction by therapeutic relationship (BLRI) ...... 165
6.2.2 Anxiety (BAI) outcome prediction by therapeutic relationship (BLRI) ............... 167
6.2.3 Distress (CORE-OM) prediction by therapeutic relationship (BLRI)................... 169
7. Further results .................................................................................................................... 171
7.1 Outcomes research: Addressing some of the criticisms of uncontrolled naturalistic
research............................................................................................................................... 171
7.1.1 Missing cases: Depression ..................................................................................... 172
7.1.2 Controlling for other causes of recovery ............................................................... 180
7.1.3 Lack of randomisation to different treatments ...................................................... 219
7.1.4 No evidence that treatments appropriately delivered ............................................ 220
7.2 Process-outcome research. ........................................................................................... 225
7.2.1 The range of client perceptions of the therapeutic relationship tested in this
research. .......................................................................................................................... 225
7.2.2 The depression process-outcome data. .................................................................. 228
7.2.3 The anxiety process-outcome data. ....................................................................... 230
7.2.4 The distress process-outcome data. ....................................................................... 234
7.2.5 The predictive ability of within and between therapist variability. ....................... 238
7.2.6 Possible sources of client „rating tendencies‟ for the therapeutic relationship. ..... 238
8. Discussion .......................................................................................................................... 244
8.1 Summary of findings .................................................................................................... 244
8.1.1 Depression ............................................................................................................. 245
8.1.2 Anxiety .................................................................................................................. 251
8.1.3 Distress .................................................................................................................. 255
8.2 Process-outcome findings ............................................................................................ 259
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8.2.1 Introduction ........................................................................................................... 259
8.2.2 Depression ............................................................................................................. 260
8.2.3 Anxiety .................................................................................................................. 261
8.2.3 Distress .................................................................................................................. 262
8.3 The case for causal inference based on the outcomes and process-outcomes findings.
............................................................................................................................................ 263
8.4 Strengths and weaknesses of this research ................................................................... 268
8.4.1 Questionnaires and related issues .......................................................................... 268
8.4.2 Frequency of measurement and related issues ...................................................... 271
8.4.3 Measurement of the therapeutic relationship and related issues ........................... 274
8.4.4 Sampling – Clients, and related issues .................................................................. 276
8.4.5 Sampling – Therapists, and related issues ............................................................. 277
8.4.6 Methodology and related issues ............................................................................ 278
8.4.7 Analysis and related issues .................................................................................... 280
8.4.8 Summary of strengths and weaknesses ................................................................. 280
8.5 Discussion of results..................................................................................................... 282
8.5.1 Outcomes and related issues .................................................................................. 282
8.5.2 Process-outcome correlations with therapeutic relationship and related issues .... 285
8.5.3 Person-centred theory and related issues ............................................................... 287
8.6 Implications of this research ........................................................................................ 290
9. References .......................................................................................................................... 291
10. Appendices ....................................................................................................................... 320
Appendix 1: Research Ethics Committee submission ....................................................... 320
Appendix 2: Characteristics of sample upon which coefficient alphas were estimated. ... 346
Appendix 3: Participant flow and demographic characteristics for each sample analysed 347
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List of Figures
Figure 1: For University Counselling Service clients, flow diagram of participation at each
stage of research. .................................................................................................................... 116
Figure 2: For Private Practice clients, flow diagram of participation at each stage of research.
................................................................................................................................................ 119
Figure 3: Extract of Barrett-Lennard Relationship Inventory as used in this research: Tick box
format as agreed with Barrett-Lennard. ................................................................................. 128
Figure 4: Research protocol: The six phases of development of the research protocol. ....... 132
Figure 5: Jacobson Plot for Depression (BDI-II) Outcomes. ................................................ 145
Figure 6: Jacobson Plot for Depression (BDI-II) Outcomes using transformed data. ........... 147
Figure 7: Jacobson Plot for Anxiety (BAI) Outcomes........................................................... 152
Figure 8: Jacobson Plot for Anxiety (BAI) Outcomes using transformed data. .................... 154
Figure 9: Jacobson Plot for Distress Outcomes. .................................................................... 158
Figure 10: Example of client PBQ score: Black bars indicate mean z-scores for patients with
diagnosis of each personality disorder whilst this questionnaire was being tested (Beck, et al.,
2001) and grey bars indicate this client‟s score for each personality disorder subscale. ....... 162
Figure 11: Regression of depression (BDI-II) at first and subsequent session for full sample
(n=92): Two outliers with standardised residuals >=3. ......................................................... 166
Figure 12: Regression of anxiety (BAI) at first and subsequent session for full sample (n=75):
Two outliers with standardised residuals >=3. ...................................................................... 168
Figure 13: Regression of anxiety at first and subsequent session for full sample (n= 54): No
outliers with standardised residuals >= 3. .............................................................................. 170
Figure 14: Hypothetical impact of „missing cases‟ on effect size: removal of cases from the
research for reasons given in text (x-axis is descending number of cases left „in the research‟
once these cases are removed and y-axis is mean effect size on an LOCF basis). ................ 178
Figure 15: Scatter plot of transformed BDI-II at first session versus subsequent counselling
session minus score at first session. ....................................................................................... 182
Figure 16: Scatter plot of regression to mean corrected transformed BDI-II at subsequent
session minus first session score versus first session score. .................................................. 183
Figure 17: Scatter plot of treatment period (number of days from first session to subsequent
session) versus improvement in depression (BDI-II) during treatment period: One outlier with
standardised residual >= 3. .................................................................................................... 186
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Figure 18: Estimated marginal means at exploratory session (stage 1) and first session (stage
2) for 36 UCS clients in the „wait and treatment‟ condition and 32 UCS clients in the „wait
only‟ condition: stage (1 = exploratory session, 2 = first session) is x-axis and depression
(BDI-II) score is y-axis. ......................................................................................................... 189
Figure 19: Estimated marginal means at first (stage 1) and subsequent session (stage 2) for 36
UCS clients in the „wait and treatment‟ condition and 75 PP clients in the „treatment only‟
condition: stage (1 = first session, 2 = subsequent session) is x-axis and depression (BDI-II)
score is y-axis. ........................................................................................................................ 189
Figure 20: Box plot of depression (BDI-II) scores at first session (y-axis) for clients with no
subsequent BDI-II measurement (81 clients) and a subsequent BDI-II measurement (124
clients): Clients with a subsequent measurement started therapy with a significantly higher
level of depression p < .001. .................................................................................................. 191
Figure 21: Estimated marginal means at first (stage 1) and subsequent session (stage 2) for 25
clients in the „relevant medication taken‟ condition and 86 clients in the „no relevant
medication taken‟ condition: stage (1 = first session, 2 = subsequent session) is x-axis and
depression (BDI-II) score is y-axis. ....................................................................................... 192
Figure 22: Estimated marginal means at first (stage 1) and subsequent session (stage 2) for 21
clients in the „anti-depressant medication taken‟ condition and 86 clients in the „no relevant
medication taken‟ condition: stage (1 = first session, 2 = subsequent session) is x-axis and
depression (BDI-II) score is y-axis. ....................................................................................... 193
Figure 23: Scatter plot of transformed BAI at first session versus subsequent counselling
session minus score at first session. ....................................................................................... 196
Figure 24: Scatter plot of regression to mean corrected transformed BAI at subsequent
session minus first session score versus first session score. .................................................. 197
Figure 25: Scatter plot of wait period (number of days from exploratory session to first
session) versus improvement in anxiety (BAI) during wait period: A negative improvement
was a worsening in anxiety score........................................................................................... 200
Figure 26: Estimated marginal means at exploratory session (stage 1) and first session (stage
2) for 36 UCS clients in the „wait versus treatment‟ condition and 30 UCS clients in the „wait
only‟ condition: stage (1 = exploratory session, 2 = first session) is x-axis and anxiety (BAI)
score is y-axis. ........................................................................................................................ 203
Figure 27: Estimated marginal means at first (stage 1) and subsequent session (stage 2) for 36
UCS clients in the „wait versus treatment‟ condition and 54 PP clients in the „treatment only‟
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condition: stage (1 = first session, 2 = subsequent session) is x-axis and anxiety (BAI) score
is y-axis. ................................................................................................................................. 204
Figure 28: Box plot of anxiety (BAI) scores at first session (y-axis) for clients with no
subsequent BAI measurement (102 clients) and a subsequent BAI measurement (102 clients):
Clients with a subsequent measurement started therapy with a significantly higher level of
anxiety p < .001. .................................................................................................................... 205
Figure 29: Estimated marginal means at first (stage 1) and subsequent session (stage 2) for 20
clients in the „relevant medication taken‟ condition and 71 clients in the „no relevant
medication taken‟ condition: stage (1 = first session, 2 = subsequent session) is x-axis and
anxiety (BAI) score is y-axis. ................................................................................................ 206
Figure 30: Scatter plot of CORE-OM at first session versus subsequent counselling session
minus score at first session. ................................................................................................... 208
Figure 31: Scatter plot of regression to mean corrected CORE-OM at subsequent session
minus first session score versus first session score. ............................................................... 209
Figure 32: Scatter plot of treatment period (number of days from first session to a subsequent
session) versus improvement in distress (CORE-OM) during treatment period: A positive
improvement in CORE-OM score was a lessening in distress. ............................................. 211
Figure 33: Estimated marginal means at exploratory session (stage 1) and first session (stage
2) for 37 UCS clients in the „wait versus treatment‟ condition and 34 UCS clients in the „wait
only‟ condition: stage (1 = exploratory session, 2 = first session) is x-axis and distress
(CORE-OM) score is y-axis................................................................................................... 215
Figure 34: Estimated marginal means at first (stage 1) and subsequent session (stage 2) for 37
UCS clients in the „wait versus treatment‟ condition and 41 PP clients in the „treatment only‟
condition: stage (1 = first session, 2 = subsequent session) is x-axis and distress (CORE-OM)
score is y-axis. ........................................................................................................................ 216
Figure 35: Box plot of distress (CORE-OM) scores at first session (y-axis) for clients with no
subsequent CORE-OM measurement (66 clients) and a subsequent CORE-OM measurement
(89 clients): Clients with a subsequent measurement started therapy with a non-significant
higher level of distress (p=.054). ........................................................................................... 217
Figure 36: Estimated marginal means at first (stage 1) and subsequent session (stage 2) for 12
clients in the „relevant medication taken‟ condition and 67 clients in the „no relevant
medication taken‟ condition: stage (1 = first session, 2 = subsequent session) is x-axis and
distress (CORE-OM) score is y-axis...................................................................................... 218
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Figure 37: Box plot of BLRI subscale scores for 118 clients who completed the BLRI in this
research. ................................................................................................................................. 221
Figure 38: „Regard‟ BLRI subscale scores: Distribution was significantly different from
normal. ................................................................................................................................... 222
Figure 39: „Empathy‟ BLRI subscale scores: Distribution was significantly different from
normal. ................................................................................................................................... 223
Figure 40: Distribution of BLRI scores for the process-outcome research. .......................... 227
Figure 41: Histrionic personality disorder (PBQ-HI subscale score) as a predictor of client
perception of the therapeutic relationship (BLRI score). ....................................................... 240
Figure 42: Box plot of therapeutic relationship (BLRI) subscale scores. .............................. 241
Figure 43: Origin of clients (Phase of Protocol) and questionnaire completion for clients
completing BDI-II at First Session. ....................................................................................... 349
Figure 44: Origin of clients (Phase of Protocol) and questionnaire completion for clients
completing BAI at First Session. ........................................................................................... 351
Figure 45: Origin of clients (Phase of Protocol) and questionnaire completion for clients
completing CORE-OM at First Session. ................................................................................ 353
Figure 46: Origin of clients (Phase of Protocol) in depression predictor sample: Clients who
completed BDI-II at First Session, BLRI at a subsequent session and BDI-II at a subsequent
session. ................................................................................................................................... 359
Figure 47: Origin of clients (Phase of Protocol) in anxiety predictor sample: Clients who
completed BAI at First Session, BLRI at a subsequent session and BAI at a subsequent
session. ................................................................................................................................... 359
Figure 48: Origin of clients (Phase of Protocol) in distress predictor sample: Clients who
completed CORE-OM at First Session, BLRI at a subsequent session and CORE-OM at a
subsequent session. ................................................................................................................ 360