1. Person-Centered Science: What We Know and How We Can Learn More about Humanistic/Person- Centered/Experiential Psychotherapies Robert Elliott University of Strathclyde

2. Outline  Historical Introduction  Question 1: What have we learned from existing quantitative research on Humanistic/Person-Centred/Experiential therapies?  Question 2: What have we learned from existing qualitative research on Humanistic/Person-Centred/Experiential therapies?  Question 3: How can we learn more?

3. Context: Carl Rogers as Psychotherapy Research Pioneer  Innovations:  Use of voice recording technology  Psychotherapy process research  Controlled outcome research  Modern process-outcome research

4. Humanistic Therapy in Eclipse  Rogers gave up scientific research when he moved to La Jolla  Lack of research 1965 - 1990 hurt scientific & academic standing of humanistic therapy  Led to humanistic therapies being marginalized

5. Humanistic Therapy Revival  Since 1990:  Rise of qualitative research  Re-engagement in quantitative research  Newer therapies (e.g., Focusing-oriented, Process-Experiential/Emotion-Focused Therapy, Pre-therapy)  Available outcome research has tripled

6. Current situation  Danger of split between:  Practitioners and training schools: reject quantitative research in favor of qualitative research  Small cadre of academic researchers: doing quantitative outcome research in order to gain official recognition

7. Question 1a: What Does Positivist Outcome Research Tell Us?  Humanistic/Person-Centred/Experiential (HPCE) meta-analysis project  Meta-analysis: analysis of results  Effect size = standardized difference statistic   Creates a common for comparing results

8. The HPCE Meta-Analysis Project  1st Generation: Greenberg, Elliott & Lietaer, 1994 (n= 36 studies) ….  5th Generation: Elliott & Freire (2008):  Supported by a grant from the British Association for the Person-Centred Approach  180+ studies  200+ samples of clients  >13,000 clients  60 controlled studies (vs. no therapy or waitlist)  110 comparative studies (vs. HPCE therapies)

9. Elliott & Freire (2008) Meta- analysis Preliminary Results  1. HPCE therapies associated with large pre-post client change  Effect size: 1.03 sd [standard deviation units]  = a very large effect  2. Clients’ large posttherapy gains are maintained over early & late follow-ups  Post:.95sd => early follow-up: 1.08sd => late follow-up (12+ months): 1.14

10. Elliott & Freire (2008) Meta- analysis Preliminary Results  3. Clients in HPCE therapies show large gains relative to untreated clients  Effect size:.81 sd = a large effect size  Proves therapy causes client change.

11. Elliott & Freire (2008) Meta- analysis Preliminary Results  4. HPCE therapies in general are clinically and statistically equivalent when compared to other treatments (combining CBT and other therapies)  Effect size:.01 sd  = no difference in amount of change  Held true even when we only considered randomized (“gold standard”) studies

12. Elliott & Freire (2008) Meta- analysis Results  5. Comparison to Cognitive-Behavior Therapy (CBT):  HPCE therapies as a group slightly but trivially less effective than CBT :  Effect size: -.18 sd  =trivially worse (a small effect)  But…

13. Elliott & Freire (2008) Meta- analysis Results  6. Researcher theoretical allegiance effects strongly predict comparative ES:  Correlation between comparative ES and theoretical allegiance of researcher: -.52  CBT-oriented researchers => worse effects for HPCE  Small negative effect for HPCE therapies vs. CBT disappears after statistically controlling for researcher allegiance

14. Where does researcher allegiance effect come from?  Big differences in how different HPCE therapies do in comparison to CBT Type HPCE TherapyNComparative ES Nondirective/ supportive 37-.36 (=worse) Person-centred22-.09 (=equivalent) Emotion-Focused6+.60 (=better) Other experiential10-.14 (=equivalent)

15. What is “Nondirective/ Supportive” Therapy?  Nondirective/supportive:  87% studies carried out by CBT Researchers (40/46 in total sample)  65% explicitly labelled as “controls” (30/46)  52% involve non bona fide therapies (24/46)  76% of researchers are North American (35/46)  61% involve depressed or anxious clients (28/46)

16. The Moral of this Story:  We don’t have to be afraid of quantitative research or RCTs  But if we let others define our reality, we are going to be in trouble.  Therefore, we need to do our own outcome research… including RCTs

17. Question 1b: What does Quantitative Process-Outcome Research Tell Us?  Process-outcome research predicts outcome from in-therapy process measures, e.g., therapist empathy  Best-known process variable is Therapeutic Alliance  Most common measure: Working Alliance Inventory  Meta-analyses show that alliance predicts outcome: e.g., Horvath & Bedi, 2002; n = 90 studies: mean r =.21

18. Process-Outcome Research on Therapist Empathy  Therapist empathy is one of the strongest predictors of outcome  Bohart et al. (2002) meta-analysis  47 studies: mean r =.32  Accounts for about 10% of the variance in outcome

19. Interpretation of r =.32  1. Optimist’s view: 10% is a lot!  One of the best predictors of outcome  Maybe even better that therapeutic alliance

20. Interpretation of r =.32  2. Pessimist’s view: The glass is 90% empty!  Rogers’ “necessary & sufficient” predicts perfect correlation (r = 1.0)  r =.32 decisively refutes Rogers’ hypothesis

21. Interpretation of r =.32  3. Optimist’s rebuttal: 10% is almost 100% of what we can reasonably expect from the real world  Client individual differences in problem severity and resources predict most of outcome  Measurement error  Restriction of range (not enough unempathic therapists!)  Other stuff

22. Interpretation of r =.32  4. Pessimist’s plea: I still want the other 90%…

23. Question 2: What does Qualitative Research Tell Us?  Rogers’ Process Equation was based on proto-qualitative research:  Years of careful observation of productive and unproductive therapy sessions  Systematic qualitative research is a relatively recent development  But mature enough now to allow a few small qualitative meta-analyses

24. 1. Helpful and Hindering Factors  Greenberg et al. (1994)  Reviewed 14 studies of HPCE therapies  Selected 5 most frequent helpful and 3 most frequent hindering aspects  14 categories of Helpful aspects, grouped into 4 larger domains

25. Most Common Helpful Aspects in HPCE therapies  1. Positive Relational Environment (7 out of 14 data sets; e.g., empathy) =>  2. Client's Therapeutic Work (13 sets)  Most common : Self-Disclosure, Involvement =>  3. Therapist Facilitation of Client's Work (6 sets; e.g., fostering exploration) =>  4. Client Changes or Impacts (12 sets)  Most common: Understanding/ Insight, Awareness/Experiencing

26. Most Common Hindering Aspects  Much less common; difficult to study  Most common: Intrusiveness/ Pressure  Even in person-centered therapy  Also present:  Confusion/Distraction (derailing the client's process)  Insufficient Therapist Direction

27. 2. Client Post-therapy Changes  Qualitative outcome  Jersak, Magana and Elliott (2000; in Elliott, 2002)  5 studies, mostly Process-Experiential for depression or trauma

28. Jersak et al. (2000)  Vitalizing the Self: Internal change  4 subprocesses:  Leaving Distress Behind =>  Increased Contact with Emotional Self =>  Improved Self-esteem =>  Increased Sense of Personal Power/Coping/Self-control  Describe the first phase of a metaphorical journey

29. Jersak et al. (2000)  Changes in the Self’s Relationships to Others/World:  3 subprocesses:  Defining Self with Others/Asserting Independence  Engaging with Others,  Experiencing the World More/Mobilizing Self to Act in the World  Describe the outward phase of the client’s journey

30. 3. Effects of significant therapy events  Timulak (2007)  7 studies, most HPCE  9 common categories  All 7 studies:  Awareness/Insight/Self-Awareness  Reassurance/Support/Safety  More than half the studies:  Behavior Change/Problem Solution  Exploring Feelings/Emotional Experiencing  Feeling Understood.

31. Implication: Qualitative Studies of HPCE  May be possible to integrate these 3 types of research into a model of HPCE change process  Framework:  Helpful (hindering) aspects =>  Immediate effects (significant events) =>  Qualitative outcome

32. Question 3: How Can We Learn More?

33. 1. Be Methodologically Pluralist  Most sensible course of action:  To encourage both kinds of research  Render politically expedient quantitative data to the government and professional bodies (“Caesar”)  Simulaneously carry out qualitative research that completely honors person- centered principles  Even in the same study

34. 2. Follow Person-Centred Research Principles  E.g., Mearns & McLeod (1984)  (1) Empathy. Understand, from the inside, the research participant’s (client or therapist) lived experiencing  (2) Unconditional Positive Regard. Accept/prize the research participant’s experiencing,  (3) Genuineness. Be an authentic/equal partner with the research participant: participant = co- researcher; researcher = a fellow human being.  (4) Flexibility. Creatively and flexibly adapt research methods to the research topic and questions at hand

35. Applying Person-centred principles to different types of research  Fairly easy to see application to qualitative research, e.g.,  Clarifying expectations and other researcher pre- understandings;  Negotiating nature of participation with informant in a transparent, collaborative manner;  Carrying out data collection in a careful, intentional manner, including helping informant stay focused and clarifying their meanings; etc.

36. Person-Centred Principles Apply Equally to Quantitative Research  Always put the participant’s needs ahead of yours  Treating participants disrespectfully and inconsistently leads to resentment and sloppy, invalid data  A questionnaire is a form of relationship

37. Person-Centred Principles Apply Equally to Quantitative Research  A research participant will feel misunderstood and uncared for by a confusing questionnaire layout or an overly hot or noisy research room  An ill-prepared research packet or an anxious interviewer can betray a lack of genuine commitment by the researcher  All of our criticisms of quantitative research are really criticisms of bad research, of any kind

38. 3. Focus on Change Process Research  Much current research on HPCE therapies does not focus on how change occurs  Needed as complement to outcome research & improve therapy  Select from different genres of change process research

39. a. Important preliminary: Basic outcome research  What are the effects of HPCE therapies with specific client populations?  Can be quantitative or qualitative  Single client or group of clients  Standard questions or individualized  See Elliott & Zucconi (2006) for suggestions to implement in practice and training settings  Necessary starting point for Change Process research

40. b. Process-Outcome Research  Quantitative genre: Measure process (e.g., empathy) => predict outcome  HPCE’s not studied enough with this approach:  Only 6 out of 47 studies in Bohart et al. (2002) empathy-outcome meta-analysis were HPCE therapies  Highly appropriate to naturalistic samples

41. c. Helpful Factors Research  Qualitative genre:  Interview (e.g., Change Interview)  Helpful Aspects of Therapy (HAT) Form  Analyze with variety of methods, e.g., Grounded Theory, discourse analysis

42. d. Micro-analytic Sequential Process Research  Examine turn-by-turn interaction between client and therapist  Quantitative: client and therapist process measures (e.g., client experiencing and therapist empathy)  Qualitative: Task analysis or Conversation analysis

43. e. Complex Change Process Research Methods  Combine genres to develop richer picture  Balance strengths, limitations  Examples:  Assimilation Model (Stiles et al., 1990)  Task Analysis (Rice & Greenberg, 1984)  Comprehensive Process Analysis (Elliott, 1989)  Hermeneutic Single Case Efficacy Design (Elliott, 2002)

44. 4. Get Involved!  Elliott & Zucconi (2006): International Project on Psychotherapy and Psychotherapy Training (IPEPPT)  The project is to stimulate practice- based research, especial in training centres  Have developed a set of sample research protocols to choose form

45. Further Suggestions (Elliott & Zucconi, 2006)  (1) Contribute to dialogues on how to measure therapy and training outcomes within HPCE therapies  (2) Set an example for students and colleagues by carrying out simple research procedures with your own clients and in your own training setting  (3) Help to develop specialized research protocols for particular client populations (e.g., people living with schizophrenia)

46. Further Suggestions (Elliott & Zucconi, 2006)  (4) Contribute to method research aimed at improving existing quantitative and qualitative instruments  (5) Take part in more formal collaborations with similarly-inclined training centers to generate data for shared research

47.  Robert Elliott: fac0029@gmail.comfac0029@gmail.com  Blog: pe-eft.blogspot.com