A Visitor’s Death
Psychotherapists often say that psychological counseling is both a science and an art. Its art lies in the dance of the relationship between people in the counseling process: the client learns to accept themselves under the full attention of the counselor, and the counselor experiences their own growth while accompanying the client’s growth. These subtle and seemingly ineffable wonderful changes that occur during the counseling process may be the reason why many people are reluctant to attach a cold, quantifiable label to the counseling effect. But sometimes, do we forget that psychological counseling is also a science?
Psychotherapist Tony Rousmaniere once told a story in an article published in The Atlantic. Grace (a pseudonym) was one of Tony’s clients, and the treatment focused on her heroin addiction. As an unemployed, violently abused single mother, Grace’s treatment journey was full of challenges. However, she was very cooperative and would communicate with Tony about her progress every week – attending drug rehabilitation mutual – aid meetings, finding a job, and having a loving boyfriend. Every time Tony asked Grace about her feelings towards the counseling process, she always said it was very helpful to her. Along with her strong enthusiasm, she often had a relatively fast speaking speed and a somewhat strained smile.
But soon after, Grace didn’t come for counseling for three consecutive weeks. During this period, she relapsed, lost her job, and broke up with her boyfriend. Eventually, she returned to Tony’s counseling room to continue treatment and firmly said, “I must stay positive.” A few months later, Grace died of a drug overdose, and her son was sent to a welfare institution. Grace’s death was like a bolt from the blue to Tony. Why did the counseling effect turn out like this? Why was Grace’s positive feedback inconsistent with the facts? How can counselors know if the current process is really helpful to the client? Tony, who had always believed that the effect of psychological counseling couldn’t and shouldn’t be “measured,” changed his mind. For the benefit of clients, any method that can help counselors get out of their own “blind spots” might be worth trying.
When Psychological Counseling Meets Big Data
The importance of the effect is beyond doubt, but understanding the actual effect is the prerequisite for improving it. Regarding the evaluation of the effectiveness of psychological counseling, the research focus in the past three decades has mostly been from the counselor’s perspective – exploring which treatment method is more effective. Meta – analysis results based on a large amount of data show that no treatment method stands out particularly in terms of effectiveness. In 2012, the American Psychological Association summarized and stated in this field of research: “Most legitimate and structured treatment methods have little difference in effectiveness.” In addition, the counselor’s identity also determines that their evaluation of the counseling effect has its own “blind spots” and may even be over – confident.
What about from the client’s perspective? Since there is no entry point in treatment methods, can counselors understand the counseling effect through the client’s feedback? Most counselors do this, but only as part of the counseling conversation – “Do you think the counseling is helpful to you?” This straightforward and simple way is difficult to get valuable answers. In a recent study, researchers Matt Blanchard and Barry Farber from Columbia University in the United States found that among 547 clients, 70% said they over – stated in their feedback to the counselor – “pretended that the counseling was effective” and “didn’t be honest about wanting to end the counseling.” These clients who gave “untrue” answers made it difficult for counselors to understand the actual effect of the counseling, and it was precisely among these clients that the fact that the counseling had no effect was more likely to exist.
Since the credibility of face – to – face feedback results is questionable, researchers thought of using statistics. Using non – face – to – face feedback from clients to form data, predicting the counseling effect according to a mathematical model, and helping counselors understand the effect and adjust the plan in a timely manner. Michael Lambert, a researcher at Brigham Young University, and his team developed a client feedback questionnaire. Before each counseling session, clients are asked to complete a 45 – question questionnaire (OQ – 45), and a computer program will output the results, indicating whether the client may drop out midway, deteriorate, or feel that the counseling effect is not good, and grade its risk level. The following figure is an example of an OQ – 45 report, including six parts: personal information, situation summary, feedback information, summary of significant problems, sub – scale scores, and counseling trend chart.
Based on the research of Lambert et al., a counseling effect evaluation method called “Feedback – informed Treatment” (FIT for short) has been developed. One of the leading figures in this field, Scott D. Miller, established an effect evaluation system based on 250,000 completed treatment cases. Compared with face – to – face feedback, this method can reduce the degree of clients “over – stating,” and by quantifying risks using clients’ self – reported data, it can effectively make up for counselors’ over – confidence in evaluating the counseling effect and help counselors discover their “blind spots” in counseling.
Why Do Clients Lie?
Inspired by Scott D. Miller, Tony was curious about this system based on a mathematical model of more than 250,000 cases and applied it to June (a pseudonym), a dropout client with anxiety, depression, and social disconnection. Before each interview, June would spend a few minutes filling out the “Feedback – informed Treatment” questionnaire on an iPad.
Like Grace, June’s counseling went very smoothly at the beginning. Although she was shy and quiet and never made eye contact with Tony, she seemed to listen carefully and learn the methods provided by Tony. After each counseling session, when asked about her feelings towards the counseling effect, June said that the counseling was very helpful and Tony’s suggestions were very effective for her. However, after several counseling sessions, Tony was shocked when he checked the statistical results – starting from the first time, the counseling for June did not have a positive effect; and the data showed that June’s situation was deteriorating continuously and there was a risk of suicide.
Tony’s first reaction was that there must be something wrong with the software because this was contrary to what June said in the counseling. But thinking of Grace’s death, Tony thought he needed to seriously consider this result. In the next interview, he talked to June about this topic. After his repeated guidance, June finally said, “I’m sorry, I don’t feel like I’m getting better. I just don’t want you to think it’s your fault. You’ve helped a lot.”
With June’s permission, Tony recorded one of the counseling sessions. After analyzing the video, it was found that during the counseling process, June had been concentrating on practicing the methods provided by Tony but never talked about her feelings during the practice. After reflection, Tony adjusted the counselor – client relationship in a timely manner, changed the original “teacher – student” – like role allocation in the counseling, and established an equal relationship with June in a non – authoritative way.
The counseling effect evaluation scale filled out by June was of great help to Tony in discovering problems in a timely manner, avoiding the recurrence of the tragedy of the client’s situation deteriorating and leading to death. It can be seen that understanding the counseling effect – the actual effect – is the prerequisite for improving the effect. Dancers find their shortcomings by repeatedly watching videos of their practice and performances, and baseball players also analyze various data in their games to improve their athletic ability in a targeted manner. Counselors are the same. They can monitor the counseling effect through the counseling effect evaluation scale filled out by clients, adjust counseling techniques, and thus truly provide effective help that clients need.
One year later, June’s condition gradually improved; two years later, she graduated from university smoothly. In the last interview, she said to Tony, “You saw my heart from a long distance.” Who can say that such psychological counseling is not an art?
参考资料：
1.Tony Rousmaniere. (2017). What your therapist doesn’t know. The Atlantic, April 2017 Issue.
2.Michael J. Lambert. (2015). Progress Feedback and the OQ-System: The Past and the Future. Psychotherapy,Vol. 52, No. 4, 381–390.
3.Matt Blanchard & Barry A. Farber. (2016). Lying inpsychotherapy: Why and what clients don’t tell their therapist about therapyand their relationship. CounsellingPsychology Quarterly, Vol. 2.
4.Miller, S. D., Hubble, M. A., Chow, D., & Seidel, J.(2015). Beyond measures and monitoring: Realizing the potential offeedback-informed treatment.Psychotherapy,52(4),449.
