Essential Research Findings in Counselling and Psychotherapy: The Facts are Friendly

The perception that therapists and their techniques play the most significant role in influencing the outcome of treatment is challenged in a new research review, launched today at the Annual Conference of the British Association for Counselling & Psychotherapy in Telford.

The book, Essential Research Findings in Counselling and Psychotherapy: The Facts are Friendly, written by Professor Mick Cooper of the University of Strathclyde, concludes that the most important factor in successful therapy is a client, or patient, who is motivated and engaged and who is able to use therapy to build on his or her strengths. Professor Cooper also finds that a strong relationship between therapist and client is one of the best indicators of a positive therapeutic outcome, and is far more significant than a therapist's particular techniques and approach.

The review is published at a time when the government has recently committed £173 million a year to be spent on Cognitive Behavioural Therapy (CBT) as part of its Improving Access to Psychological Therapies programme. Professor Cooper, of Strathclyde's Faculty of Education, said: "Many clients will benefit from CBT but there is a danger in putting too much emphasis on the type of therapy that a therapist provides, rather than the therapist's ability to relate to his or her client in caring and understanding ways, and the needs and preferences of individual clients. "Rather than moving towards a therapeutic 'monoculture', we need to be able to provide people with a range of therapies and therapists, so that they can choose the one that best suits them and build on their particular strengths." This finding is supported by the work of eminent American psychologist Barry Duncan and colleagues. They wrote in 2004 that "clients, not therapists, make therapy work."

The book, which is the first reader-friendly summary of research findings in the field, also offers advice to people who are considering seeing a therapist, on their choice of practitioner and the best type of therapy available to them. Professor Cooper said: "Think about choosing a therapist who can help you build on your strengths - for instance, if you are good at understanding why you do the things you do, a therapist who can help you develop these reflective skills may be more use to you than a therapist who wants to focus mainly on your behaviour or emotions. "Ask potential therapists what thoughts they might have on why you are facing the difficulties you are and what they think might help. If these are radically different from your own understandings, it may be more difficult to establish a good working relationship. "Ask yourself whether you like your therapist and feel respected by them – the quality of your relationship, early on in therapy, will be one of the best indicators of eventual outcomes, so don't put up with a bad relationship. Remember that probably the best predictor of the outcomes of therapy will be the extent to which you actively involve yourself in the process."

Professor Cooper also suggested that people experiencing a specific psychological disorder, such as a phobia, may wish to consult the website of the National Institute for Clinical Excellence (NICE) to find out which kind of therapy has the strongest evidence base for their problem. If, however, a particular therapy is not on the list, it is almost certainly because it has yet to be tested, rather than because it has been proven to be ineffective.

Data from a new study suggests that individuals who engage in compassion meditation may benefit by reductions in inflammatory and behavioral responses to stress that have been linked to depression and a number of medical illnesses. The study's findings are published online at www.sciencedirect.com and in the medical journal Psychoneuroendocrinology.

"While much attention has been paid to meditation practices that emphasize calming the mind, improving focused attention or developing mindfulness, less is known about meditation practices designed to specifically foster compassion," says Geshe Lobsang Tenzin Negi, PhD, who designed and taught the meditation program used in the study. Negi is senior lecturer in the Department of Religion, the co-director of Emory Collaborative for Contemplative Studies and president and spiritual director of Drepung Loseling Monastery, Inc.

This study focused on the effect of compassion meditation on inflammatory, neuroendocrine and behavioral responses to psychosocial stress, and evaluated the degree to which engagement in meditation practice influenced stress reactivity. "Our findings suggest that meditation practices designed to foster compassion may impact physiological pathways that are modulated by stress and are relevant to disease," explains Charles L. Raison, MD, clinical director of the Mind-Body Program, Emory University's Department of Psychiatry and Behavioral Sciences, Emory School of Medicine, and a lead author on the study.

Sixty-one healthy college students between the ages of 17 and19 participated in the study. Half the participants were randomized to receive six weeks of compassion meditation training and half were randomized to a health discussion control group. Although secular in presentation, the compassion meditation program was based on a thousand-year-old Tibetan Buddhist mind-training practice called "lojong" in Tibetan. Lojong practices utilize a cognitive, analytic approach to challenge an individual's unexamined thoughts and emotions toward other people, with the long-term goal of developing altruistic emotions and behavior towards all people. Each meditation class session combined teaching, discussion and meditation practice.

The control group attended classes designed by study investigators on topics relevant to the mental and physical health of college students such as stress management, drug abuse and eating disorders. In addition, a variety of student participation activities were employed such as mock debates and role-playing. Both groups were required to participate in 12 hours of classes across the study period. Meditators were provided with a meditation compact disc for practice at home. Homework for the control group was a weekly self-improvement paper.

After the study interventions were finished, the students participated in a laboratory stress test designed to investigate how the body's inflammatory and neuroendocrine systems respond to psychosocial stress. No differences were seen between students randomized to compassion meditation and the control group, but within the meditation group there was a strong relationship between the time spent practicing meditation and reductions in inflammation and emotional distress in response to the stressor. Consistent with this, when the meditation group was divided into high and low practice groups, participants in the high practice group showed reductions in inflammation and distress in response to the stressor when compared to the low practice group and the control group.

"It will require conducting stress tests before and after meditation training in order to conclusively show it was the practice of compassion meditation that resulted in reduced stress responses," says study co-author Thaddeus W.W. Pace, PhD, assistant professor, Department of Psychiatry and Behavioral Sciences at Emory. "But these initial results are quite exciting," says Pace. "If practicing compassion meditation does reduce inflammatory responses to stress it might offer real promise as a means of preventing many conditions associated with stress and with inflammation including major depression, heart disease and diabetes." Raison concurs. "Based on the promising findings from this study we are planning to offer compassion meditation classes to patients at Emory Winship Cancer Institute, and have partnered with the Emory Predictive Health Institute to study potential long term effects of compassion meditation on health and well-being," says Raison.

When a group is without a leader, you can often count on a narcissist to take charge, a new study suggests. Researchers found that people who score high in narcissism tend to take control of leaderless groups. Narcissism is a trait in which people are self-centered, exaggerate their talents and abilities, and lack empathy for others. "Not only did narcissists rate themselves as leaders, which you would expect, but other group members also saw them as the people who really run the group," said Amy Brunell, lead author of the study and assistant professor of psychology at Ohio State University at Newark.

Narcissists, by definition, are self-centered and overconfident in their own abilities.

The researchers found similar results in two separate studies involving college students, and one involving business managers in an MBA program. And while narcissists are more likely to become leaders, results of one of the studies suggests that, once in power, narcissists don't perform any better than others in that leadership role. "It's not surprising that narcissists become leaders," Brunell said. "They like power, they are egotistical, and they are usually charming and extraverted. But the problem is, they don't necessarily make better leaders."

The study will appear in an upcoming print issue of the journal Personality and Social Psychology Bulletin. It is currently available to subscribers online.

The first study involved 432 undergraduate students. They all completed assessments which measured various personality traits, including narcissism. They were then put in groups of four, and told to assume they were a committee of senior officers of the student union, and their task was to elect next year's director. Each person in a group was given a profile of a different candidate for the position, and each was to argue for their particular candidate. Following the discussion, they voted on the director, and then completed a questionnaire evaluating the leadership of themselves and the other group members.

Results showed that students who scored higher on one dimension of narcissism – the desire for power - were more likely to say they wanted to lead the group, were more likely to say they did lead the group discussion, and were more likely to be viewed as leaders by the other group members.

The other dimension of narcissism – the desire for attention – was not as strongly related to leadership roles in the groups. "It's not surprising, but the desire for power is what really drives narcissists to seek leadership positions," she said.

In a second study, 408 students were placed in groups of four and given a scenario in which they imagined they were shipwrecked on an uninhabited island and had to choose which 15 salvageable items that the group should take ashore which will best help them survive. After a group discussion, those who scored highest on the power dimension of narcissism again showed the most desire to lead the group discussion, rated themselves as leaders, and were viewed by other group members as the leaders.

This study went further, though, by seeing how well the narcissists performed as leaders. Researchers looked at the lists, prepared by each individual and group, of the 15 items that they thought would help them survive. They compared their lists to one prepared by an expert who has taught survival skills to the U.S military.

Results showed that narcissists did no better than others on selecting the items that would best help them survive. In addition, groups that overall scored highest on narcissism did no better than other groups on the task.

A third study involved 153 business managers enrolled in an executive MBA program at a large southeastern university. The managers were also put in groups of four and told to assume the role of a school board deciding how to allocate a large financial contribution from a fictional company.
Two trained observers – professors or doctoral students in industrial/organizational psychology – observed the groups and rated how much of a leadership role each participant assumed in their groups.

Results showed that the MBA students rated highest in narcissism were most likely to be identified as emerging leaders by the expert observers. "Even trained observers saw narcissistic people as the natural leaders," Brunell said. "In addition, this study showed that narcissism plays a role in leadership among real-world managers."

Brunell said the studies took into account other factors – such as gender and personality traits like high self-esteem and extraversion – that may relate to leadership development. But even when these factors were taken into account, narcissism still played a key role. It is important not to confuse narcissism with high self-esteem, she said. "A person with high self-esteem is confident and charming, but they also have a caring component and they want to develop intimacy with others," Brunell explained. "Narcissists have an inflated view of their talents and abilities and are all about themselves. They don't care as much about others."

Brunell said she believes the results apply to many parts of life, from the politics of the presidential race to Wall Street. "Many people have observed that it takes a narcissistic person to run for president of the United States," she said. "I would be surprised if any of the candidates who have run weren't higher than average in narcissism." The same is true for the leaders of Wall Street firms that have made and lost millions of dollars in the past few years. "There have been a lot of studies that have found narcissistic leaders tend to have volatile and risky decision-making performance and can be ineffective and potentially destructive leaders," she said. However, that doesn't mean all the troubles in Washington or Wall Street can be blamed on narcissistic leaders. "I'm sure some of these leaders had to be overconfident and too sure of their abilities. But there's a lot more behind the troubles of government and business than the personalities of their leaders."

A link between reduced levels of the 'stress hormone' cortisol and antisocial behaviour in male adolescents has been discovered by a research team at the University of Cambridge.

Levels of cortisol in the body usually increase when people undergo a stressful experience, such as public speaking, sitting an exam, or having surgery. It enhances memory formation and is thought to make people behave more cautiously and to help them regulate their emotions, particularly their temper and violent impulses.

The new research, funded by the Wellcome Trust, shows that adolescents with severe antisocial behaviour do not exhibit the same increase in cortisol levels when under stress as those without antisocial behaviour. These findings suggest that antisocial behaviour, at least in some cases, may be seen as a form of mental illness that is linked to physiological symptoms (involving a chemical imbalance of cortisol in the brain and body).

The scientists, led by Dr Graeme Fairchild and Professor Ian Goodyer, recruited participants for the study from schools, pupil referral units, and the Youth Offending Service. Samples of saliva were collected over several days from the subjects in a non-stressful environment to measure levels of the hormone under resting conditions. The young men then took part in a stressful experiment that was designed to induce frustration. Samples of saliva were taken immediately before, during and after the experiment to track how cortisol changed during stress.

The differences between participants with severe antisocial behaviour and those without were most marked under stressful conditions. While the average adolescents showed large increases in the amount of cortisol during the frustrating situation, cortisol levels actually went down in those with severe antisocial behaviour.

These results suggest that antisocial behaviour may be more biologically-based than previously considered, just as some individuals are more vulnerable to depression or anxiety due to their biological make-up. Dr Fairchild said, "If we can figure out precisely what underlies the inability to show a normal stress response, we may be able to design new treatments for severe behaviour problems. We may also be able create targeted interventions for those at higher risk. "A possible treatment for this disorder offers the chance to improve the lives of both the adolescents who are afflicted and the communities in which they live."

Psychodynamic psychotherapy lasting for at least a year is effective and superior to shorter-term therapy for patients with complex mental disorders such as personality and chronic mental disorders, according to a meta-analysis published in the October 1 issue of JAMA.

Evidence indicates that short-term psychodynamic psychotherapy is insufficient for a considerable proportion of patients with complex mental disorders, i.e., patients with multiple or chronic mental disorders or personality disorders. Some studies suggest that long-term psychodynamic psychotherapy (LTPP) may be helpful for these patients, according to background information in the article. LTPP is therapy in which emphasis is placed on more interpretive or supportive interventions, depending on the patient's needs, and that involves careful attention to the therapist-patient interaction.

Falk Leichsenring, D.Sc., of the University of Giessen, Germany, and Sven Rabung, Ph.D., of the University Medical Center Hamburg-Eppendorf, Hamburg, Germany, conducted a meta-analysis to examine the effectiveness of LTPP (lasting for at least a year, or 50 sessions) and whether it is superior to shorter psychotherapeutic treatments for complex mental disorders, including personality disorders, chronic mental disorders (defined as lasting at least a year) and multiple mental disorders. The researchers identified and included 23 studies for the meta-analysis (11 randomized controlled trials and 12 observational studies), involving a total of 1,053 patients receiving LTPP.

The authors found: "In this meta-analysis, LTPP was significantly superior to shorter-term methods of psychotherapy with regard to overall outcome, target problems, and personality functioning. Long-term psychodynamic psychotherapy yielded large and stable effect sizes in the treatment of patients with personality disorders, multiple mental disorders, and chronic mental disorders. The effect sizes for overall outcome increased significantly between end of therapy and follow-up."

With regard to overall effectiveness, analysis indicated that after treatment with LTPP patients with complex mental disorders on average were better off than 96 percent of the patients in the comparison groups. The authors add that further research should evaluate the cost-effectiveness of LTPP.

An analysis of news media coverage of medical studies indicates that news articles often fail to report pharmaceutical company funding and frequently refer to medications by their brand names, both potential sources of bias, according to a study in the October 1 issue of JAMA.

New articles represent an important source of medical information for many patients, and even some physicians. "An increasingly recognized source of commercial bias in medical research is the funding of studies by companies with a financial interest in the results," the authors write. Little is known about how frequently news articles report the funding sources of the medical research they report on, or how frequently news articles use brand medication names instead of generic names, which could create commercial bias.

Michael Hochman, M.D., of the Cambridge Health Alliance and Harvard Medical School, Cambridge, Mass., and colleagues reviewed U.S. news articles from newspaper and online sources about pharmaceutical-funded medication studies to determine how frequently and prominently they indicate the funding source and how often they refer to medications by their brand vs. generic names. The studies were published in five major general medical journals (JAMA, New England Journal of Medicine, Lancet, Archives of Internal Medicine and the Annals of Internal Medicine). The researchers also surveyed editors at the 100 most widely circulated newspapers in the U.S. about their publications' practices on the reporting of company funding and the use of generic medication names.

The authors identified 306 news articles, of which 175 were from newspapers and 131 were from online sources. Among the 306 news articles about company-funded medication studies, the funding source for the studies was not reported in 42 percent of the articles. There was no significant difference in nonreporting rates between articles obtained from newspaper and online sources. Of the 306 news articles, 277 concerned medications with both generic and brand names. Among these 277 articles, 38 percent used only brand names and 67 percent used brand names in at least half of the medication references.

The survey of newspaper editors found that 88 percent indicated that his/her publication often or always reported company funding in articles about medical research, and that 77 percent reported that they often or always referred to medications by the generic names in articles about medical research. Three percent of editors indicated that their publication had a written policy stating that company funding should be reported in articles about medical research, while the editor at two percent of newspapers responded that his/her publication had a written policy stating that medications should be referred to predominantly by their generic names.

However, the editors' perceptions diverged from their publications' actual performances. A total of 104 newspaper articles were analyzed from publications for which editors reported always identifying company funding. Of these articles, 45 percent failed to cite company funding. Additionally, a total of 75 newspaper articles were analyzed from publications for which the editors reported always using generic names. Of these articles, 76 percent used brand names in at least half of the medication references.

"Our findings raise several concerns. For patients and physicians to evaluate new research findings, it is important that they know how the research was funded so they can assess whether commercial biases may have affected the results. Additionally, the use of generic medication names by the news media is preferable so that physicians and patients learn to refer to medications by their generic names, a practice that is likely to reduce medication errors and may decrease unnecessary health care costs," the authors write.