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Evidence-Based Counseling: Implications for Counseling Practice, Preparation, and Professionalism
Author: Thomas L. Sexton
The practice of professional counseling, like that of psychology and social work has its roots in the early humanistic, behavioral, and cognitive theoretical traditions. Lessons from the outcome and process research were only distant voices in the background. This early bifurcation between practice and research evolved into a fairly wide "research-practice gap" that has plagued the practice of professional counseling for the last two decades.
Two major issues make the artificial dicotomy between research and practice not only irrelevant but also potentially harmful to the current and future status of counseling practice and preparation. First, most practitioners know that today's landscape of counseling practice is one dominated by accountability. In fact, many have claimed that accountability is now a primary principles of professional practice- principle more important than theory congruence or philosophical allegiance (Sexton, Schofield, & Whiston, 1997). In this "era" of accountability,"concerns for service costs, intervention effectiveness, and research supported "best practice" are the primary factor in much clinical and administrative decision making. Thus, research, because of its focus on outcome, is now a major factor in the real world "practice" of counseling.
Furthermore, the counseling process and outcome research has grown into an undeniably reliable, valid, and necessary source of clinical practice knowledge. There is no question that much of the early research was irrelevant to practice. It was conducted on isolated issues in settings with little connection to the complex world of the practitioner (e. g. with Psychology 101 students). This research produced contradictory evidence, the presentation of which was most often followed by the caveat, "...our results show that more research needs to be done in this area." However, as one would expect, the methods of clinical research have evolved to the point such that many of the early problems of clinical relevance are no longer of concern. Today there is a large and ever increasing body of applicable and relevant research that is now an invaluable source guidance for both the general practice of counseling and the application of counseling to specific problems and populations (Sexton, 1997). In fact, the research evidence has become so reliable that the term "best practices" is now defined as approaches to counseling practice that have empirical evidence to support their effectiveness.
Regardless of one's position in regard to the "art vs. science" or "research vs. practice" debate, it seems clear that evidence-based counseling practice is the future of both the preparation of counseling and the practice of professional counseling. The integration of research into practice through an evidence-based approach to counseling actually brings the best elements of practice, clinical experience and reliable treatment protocols together to serve the task of helping clients with the complex problems they bring to counseling. What follows are a number of the broad implications for both the preparation of counselors and the practice of counseling.
Implications of Evidence-based Counseling Practice
The specific implications of the accumulated body of research on counseling practices are well beyond the scope of this article (see references for further sources). Research has clearly established the efficacy of individual, group, and family counseling for a variety of presenting client concerns (Sexton, Whiston, Bleuer, & Walz, 1997). More important for practice, research now points to a number of very stable trends that support the efficacy of some practices of counseling over others, the differential value of some aspects of counseling over others, and effectiveness of matching certain client problems with specific counseling models (Sexton et. al, 1997). These trends inform counseling practice and preparation and form the basis of an evidence-based model of counseling.
These broad trends can be categorized in two domains each with significant implications for the general practice of counseling: findings about clinical models and findings about the counselor. There has been considerable attention to determining the most valuable clinical models. While counseling is, in most cases, effective, there is no "best" theoretical approach. The outcome research evidence has repeatedly found that theoretical orientation is not a major factor in the outcome of counseling. Instead, the research points to a set of "common factors" that seem to be part of effective counseling regardless of counselor, client, or theoretical orientation. According to Lambert (1991) approximately 30% of outcome is attributable to common factors evident in all therapies regardless of theory. Of the remaining variance, 40% is attributable to factors outside of counseling, another 15% to client expectation, and the final 15% to specific psychological techniques. Most of the current theoretical descriptions of these common factors point to broad areas of: (1) the supportive value of a collaborative counseling relationship (Sexton & Whiston, 1994); (2) the value of learning (through affective experiencing, corrective emotional experiences, and skills acquisition); and (3) action (through behavior change, successful experiences, behavioral regulation, and mastery).
While specific theoretical models do not seem important to positive outcome, evidence-based counseling intervention protocols are differentially effective with the client problems they were developed to help. These protocols are systematic intervention models, usually manual based, with an extensive collection of efficacy and effectiveness research in multiple settings, with diverse client groups, across various counselors, that produce clinically significant results both in controlled labs and community settings that last for long periods of time (Sexton, et al., 1997). Called Empirically Supported Treatments (EST), such protocols are available for many individual problems (anxiety disorders, depression, etc.) and family problems (see discussion of Functional Family Therapy in Alexander, Sexton, & Robbins, in press). While the professional and conceptual issues surrounding empirically supported treatments are considerable and the criteria likely to evolve, they are a valuable resource for practicing counselors when faced with certain client problems. EST's also point the way for the future of counseling providing a glimpse into evidence-based counseling practice. As a result, these protocols will need to become a central component of the clinical portion of future counselor education curricula.
A second major domain of counseling research that informs evidence-based counseling practice focuses on the counselor. The counselor is probably the most studied "object" in our research history. Much of that effort has been guided by a desire to understand how to train successful and effective counselors. From all these efforts we have, however, yet to discover the prototypic effective counselor. In fact, much of what we have discovered is that many of our historic beliefs about the importance of counselor characteristics do not seem to have research support. For example, the current evidence suggests that, all other things being equal, demographic factors (race, gender, age, cultural background), professional identity (counseling vs. psychology vs. social work), and even professional experience (defined as years of practice) are unrelated to counseling outcome. Matching of clients and counselors on these dimensions (e. g. like race counselor and client working together) does not result in increased efficacy. Furthermore, the old adage, "counselor know thy self" does not seem to hold true. There is currently no systematic research that would suggest that counselors improve their work by receiving personal therapy, becoming more self aware, or learning about themselves (Sexton et al., 1997).
What do seem to be important counselor contributions to effective counseling are a level of skillfulness (defined as competence rather than experience), cognitive complexity (ability to think diversely and complexly about cases), and ability to relate and relationally match with the clients with whom they are working (see Whiston & Coker, in press). In addition, it is essential that counselors have the knowledge and ability to assess the presenting "problems" of the client so they can identify the appropriate evidence-based protocols and competently apply those protocols in order to increase the likelihood of successful intervention. The implications of these research trends are dramatic in regard to counselor education. For example, they suggest redirecting efforts from personal awareness to building cognitive complexity and increasing the knowledge of and ability to apply evidence-based counseling protocols.
Evidence-Based Counseling as the Future of Professional Counseling
Evidence-based practice has the opportunity to move the profession of counseling out of its theoretical boxes and historical beliefs into an era of integrated practice in which counselors use the best of available science combined with clinical experience to successfully help a wide variety of clients. Evidence-based practices can provide a source of clinical knowledge that can increase a counselor's effectiveness with clients, become a basis of professional education and counselor development, and serve as a unifying force for the profession that will set the agenda for the next evolution of counseling.
Alexander, J. F., Sexton, T. L., & Robbins, M. A. (in press). The developmental status of family therapy in family psychology intervention science. In H. A. Liddle, Family Psychology Intervention Science. American Psychological Association Press: Washington, D. C.
Lambert, M. J. (1991). Introduction to psychotherapy research. In L. E. Beutler, & M. Crago (Eds.), Psychotherapy Research: An international review of programmatic studies (pp. 1-23). Washington DC: American Psychological Association.
Sexton, T. L. (1996). The relevance of counseling outcome research: Current trends and practical implications. Journal of Counseling and Development, 74, 590-600.
Sexton, T. L., & Whiston, S. C. (1994). The status of the counseling relationship: An empirical review, theoretical implications, and research directions. The Counseling Psychologist, 22(1), 6-78.
Sexton, T. L., Schofield, T. L., & Whiston, S. C. (1997). Evidence-based practice: A pragmatic model to unify counseling. Counseling and Human Development, 30(3). Love Publishing: Denver CO.
Sexton, T. L., Whiston, S. C., Bleuer, J. C., & Walz, G. R., (1997). Integrating outcome research into counseling practice and training. American Counseling Association: Alexandria. VA.
Whiston, S. C., & Coker, J. K. (in press). Reconstructing clinical training: Implications from research. Counselor Education and Supervision.
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