Brief and nontraditional approaches to mental health counseling: practitioners' attitudes. (Research).

This study examined differences between professional work setting, gender, and ethnic group membership, and attitudes toward brief and nontraditional therapeutic approaches. Respondents' preferences and attitudinal dimensions were assessed along each of these domains. Results indicated that practitioners of minority classification, males, and individuals employed in private practice held more favorable attitudes toward brief therapeutic' approaches, and ethnic minority group members were significantly more likely to hold favorable attitudes toward nontraditional clinical practices. No significant differences were revealed between male/female, white/ethnic minority population, and professional work settings regarding projected perceptions of attitudes toward nontraditional practices. Discussion and implications of the present research highlight key attitude differences between participants and the impact of these divergences on the practice of mental health counseling.

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Traditional psychotherapy typically signifies a long-term and intensive commitment to dialectical cures (Hayes & Heiby, 1996). Recently, however, managed care companies have rejected lengthy therapeutic commitments in favor of time/cost effective alternatives. This shift has facilitated a proliferation in the use of brief and nontraditional therapies in counseling settings. For example, by approving 10 or less visits for outpatient mental health care, managed care initiatives compel mental health counselors to adopt short-term therapies (De Shazer, 1985). While health maintenance organizations typically define brief therapy as a limited number of visits (e.g., 6 to 10), therapists tend to define brief therapy as a set of pragmatic, goal-oriented methods and techniques designed to benefit clients within a limited number of therapeutic sessions.

In light of this divergence, investigation of mental health therapists' attitudes toward nontraditional and brief approaches, consumer demands, and ethical standards is warranted. This study examined the attitudinal favorability of a variety of mental health care professionals of diverse ethnic, professional, and gender classifications. Specifically, the authors explored the overall degree of attitudinal favorability regarding the use of and perceptions of brief and nontraditional therapeutic approaches to mental health counseling. In concluding, the authors discuss implications for mental health practice and directions for research in the study of nontraditional and brief therapies.

In broad terms "an attitude may be defined as a psychological tendency that is expressed by evaluating a particular entity with some degree of favor or disfavor" (Eagly & Chaiken, 1993, p. 1). Attitudes are multi-component constructs consisting of global evaluations, cognitions, and affect (Zanna & Rempel, 1986). Cognitive components include both attributions and beliefs about the attitude-object as derived from continual interactions and reactions to attitude-objects (Zajonc, 1984). In contrast, the affect component arises in response to emotionally evoking environmental outcomes and is later bolstered by processing cognitive information congruent with these affective-based attitudes.

Several important cognitive, emotional, and experiential mechanisms are implicated in shaping the strength, direction, and endurance of individual attitudes. For instance, Pomerantz, Chaiken, and Tordesillas (1995) demonstrated that the attitude's importance, an essential aspect of its development, is positively associated with resistance to persuasive social influence and behavioral actions congruent with the attitude. Thus, as individuals acquire more experience with an attitude object (i.e., with brief and nontraditional therapies), they develop convictions and values that are resistant to social mechanisms of change. Moreover, past experience with behavioral objects increases the strength of attitude-behavior consistency (Eagly, 1992) such as in mental health counselors' implementation of nontraditional and brief approaches throughout the duration of their practice.

BRIEF THERAPY

Gradually, short-term or brief psychotherapy has emerged as the most favored and practiced form of psychological intervention (Garfield, 1989; Koss & Butcher, 1986). Among the specific models of brief psychotherapy, the short-term psychodynamic psychotherapeutic approaches are the most numerous and widely employed (Svartberg & Stiles, 1991). Eight technical features commonly define the various forms of brief therapy (Cooper, 1995): (a) maintenance of a specific treatment focus, (b) limited therapeutic goals, (c) emphasis on interventions in the present rather than focusing on past etiologies, (d) use of rapid and integrated assessment to quickly identify and ameliorate client issues, (e) frequent review of progress, (f) a high level of client-therapist activity, (g) utilization of time is a deliberate and careful process, and (h) practicality and flexibility in usage of techniques. In addition, brief therapy includes a focus on client attributes, strengths, and predilections (De Shazer, 1985). However, despite the many technical benefits of this type of therapy, two critical areas of concern remain. First, is brief therapy ethical? Second, does brief therapy work effectively to resolve client issues?

The effectiveness of brief therapy is well documented. Many studies address the efficacy of brief therapy by comparing it to long-range, psychodynamically based techniques. Koss and Butcher (1986) found nearly equivalent outcomes when examining the effects of comparable short-term and long-term psychodynamic therapies. Similarly, recent trends in mental health literature recommend brief treatments with cognitive and behavioral components for a variety of disorders (Lambert & Bergin, 1994; Shapiro & Shapiro, 1982), perhaps because brief and cognitive behavioral therapies require less time and more directive activity than longer range, traditionally based approaches.

Ethical practice includes ensuring the client's welfare, using techniques acceptable to the client, and taking extreme care not to abandon the client (American Mental Health Counselors Association, 2000). Cooper (1995) states that contrary to the presumptions of many clinicians who associate brief therapy with diminished care, brief treatment may actually be more consistent with ethical practice than longer-term approaches. Specifically, brief therapy coincides with ethical mandates to employ unrestrictive procedures, to obtain patient consent (since treatment is collaborative), and to demonstrate respect for patient autonomy (Budman & Gurman, 1998; Pekarik, 1990; Wells, 1993). Similarly, as brief therapy is a collaborative, consumer-oriented approach, the issue of psychological manipulation may be of minimal ethical concern.

NONTRADITIONAL THERAPY

With time constraints dictated by managed care initiatives, client demands, and movement toward brief therapy, a growing number of mental health service providers incorporate nontraditional techniques within their practice. The term nontraditional therapy typically denotes a technique regarded by Western medicine as scientifically tenuous or used as an adjunct to more orthodox medical methods (Carper, 1997). Much of the philosophy behind nontraditional therapies is drawn from Ayurvedic or Eastern Indian medicine, curandismo or cuentas, Native American Shamanism, and Far Eastern philosophies (Eisenberg et al., 1998). The shared link among these therapeutic modalities is the holistic approach to physical and mental wellness: that mind, body, and spirit are interconnected and wellness depends on equilibrium between these three components (Carper).

In 1992, the praxis of nontraditional therapies gained momentum when Congress instituted the Office of Alternative Medicine (OAM) to investigate their safety and effectiveness (Weiss, 1998). The current definition of nontraditional therapy used by the OAM is as follows:

   Complementary and alternative medicine (CAM) is a broad domain of healing
   resources that encompasses all health systems, modalities, and practices
   and their accompanying theories and beliefs, other than those intrinsic to
   the politically dominant health system of a particular society or culture
   in a given historical perspective. CAM includes all such practices and
   ideas self-defined by their users as preventing or treating illness or
   promoting health and well-being. (p. 1)

Complementary or nontraditional techniques utilized in the counseling profession include methods such as acupuncture, meditation, Tai Chi, and the Japanese-oriented Morita and Naikan therapies.

In light of the increasing proliferation of nontraditional therapeutic methods, there appears to be a legitimate case for examining the nontraditional approaches used in the mental health counseling profession. Several researchers have attempted to address this issue. For instance, research demonstrating the efficacy of holistic therapies such as yoga (Wardlaw, 1994), massage therapy (Verhoef & Page, 1998), and aromatherapy (Tisserand, 1977) is beginning to appear in reputable journals and scholarly reviews. Other nontraditional or alternative therapies--meditation, energy healing, diet therapy, herbal therapy, and Rolfing--have received much trade press attention and research. In light of these trends, it appears a substantial faction of practitioners in the mental health field retain positive attitudes toward these types of therapeutic approaches. For example, in a study by Conroy, Siriwardena, Smyth, and Fernandez (2000) of the 200 general practice physicians surveyed by the researchers, more than half applied at least one form of a nontraditional technique to their patients. Similarly, in an investigation by Knaudt, Connor, Weisler, Churchill, and Davidson (1999) among psychiatric patients with a variety of disorders including anxiety disorder, bipolar disorder, and major depression, 75% reported that nontraditional therapeutic techniques improved their symptoms and their existing attitudes toward these approaches.

Nontraditional techniques collide with traditional therapies in two areas. First, many nontraditional therapies are currently not considered effective, safe, or reliable (Weiss, 1998). Second, these new therapies frequently elude scientific epistemological explanation. Therefore, inquiry regarding these techniques and therapists' attitudes toward them is warranted so that greater attention can be focused on those approaches that show clinical utility.

The purpose of the present investigation was to explore the attitudinal favorability of currently practicing therapists to determine who is using nontraditional methods and/or brief therapies and their reasons for using them. The current investigation examined gender, ethnicity, and work setting differences in mental health practitioners' and their attitudes toward brief and nontraditional therapeutic approaches as well as practitioners' use of and perceptions of their clients' attitudes toward nontraditional therapeutic practices. Further, the attitudes of practitioners were examined via a qualitatively designed survey instrument to explore general perceptions of the feasibility of utilizing nontraditional and brief therapeutic techniques. The authors predicted, first, that (a) males would report significantly greater attitudinal favorability toward brief therapeutic approaches than females and (b) individuals of ethnic minority status would report generally more favorable attitudes toward brief therapy than their dominant culture, White, contemporaries. Second, the investigators anticipated that female participants would indicate a significantly greater preference for nontraditional clinical approaches when compared to male respondents, and ethnic minority participants would endorse significantly greater attitudinal favorability toward nontraditional clinical techniques than White individuals. And third, the authors predicted that women and minority participants would report that their clients possess favorable impressions of nontraditional therapeutic practices.

METHOD

Participants and Procedure

The investigation included 151 mental health service providers of diverse racial, ethnic, and gender classifications. Research participants for the present investigation were randomly selected from a list provided by the American Counseling Association of practitioners throughout the American Counseling Association--Southern Region (ACA-SR). States represented in the sample include: Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, South Carolina, Tennessee, Texas, Virginia, and West Virginia.

Research materials were mailed to 350 mental health practitioners. Of the 350 respondents receiving questionnaire materials, 151 participated, yielding a response rate of 43.1%. Of the 151 obtained surveys, 98 (65%) of respondents were women while 53 (35%) were male. A large number of participants designated their race as White (n = 114, 75%), while minority groups accounted for 25% (n = 37). The average years practicing as a therapist was 13.25, SD = 9.5. The vast majority of respondents (80%,) reported having a license or certification. In terms of age groupings, 10 (7%) were between 21 and 30 years of age, 24 (16%) were 31 and 40, 51 (34%) were 41 and 50, 54 participants (36%) were 51 and 60, 11 (7%) were 61 and 70, and one individual (.7%) was over the age of 70.

In this sample, 132 (87%) were employed as counselors, 2 (1%) were employed as social workers, 9 as psychologists (6%), 3 (2%) as educators, and 4 (3%) in other areas. Sixty-three participants (42%) worked in private practice settings, 35 (23%) worked in community/agency settings. Thirty participants (20%) designated their work setting as rural, 89 (59%) were in urban areas, and 29 (20%) were in suburban areas.

Measures

The researchers constructed a questionnaire consisting of four separate sections to assess participants' attitudes toward brief and nontraditional therapies. The first domain of the instrument gathered demographic information such as gender, age, race, highest educational level, field of study and practice, professional setting, and certifications/licensures.

In the second domain of the survey instrument, attitudes toward nontraditional clinical practices were measured using two separate indices. The first index measured practitioners' perceptions of nontraditional therapies, and the second index assessed practitioners' perceptions of clients' attitudes toward nontraditional techniques. For each item, a five-point Likert-type response format was utilized, with anchor points ranging from strongly agree to strongly disagree. The first index, consisting of 10 items, yields scores ranging from 10 to 50, with higher scores depicting the participant's strong belief in nontraditional clinical practices. For instance, one index item states, "I have had mostly positive experiences using nontraditional therapies with my clients/students." Item reliability analysis for this scale yielded a Cronbach alpha of .86, p < .05. In the second index, therapists' perception of clients' attitudes toward nontraditional clinical practices were measured with six items. Scores ranged from 6 to 30, with greater scores indicating that the therapist perceived clients' attitudes toward nontraditional practices as favorable. This scale includes statements such as, "Clients choose alternative therapies because they let the client take a more active role in managing their mental health care." Item reliability analysis of this six-item scale yielded a Cronbach alpha reliability of .65, p < .05.

The third index of the survey instrument, consisting of six items assessing each participant's impression of brief therapeutic practices, employed a five-point Likert-type response format, anchored by strongly agree to strongly disagree. The item structure yielded scores ranging from 6 to 30, with higher scores on this scale also representing favorable attitudes toward brief therapeutic interventions. This scale is composed of items such as, "All patients can benefit from brief therapy techniques." Cronbach reliability analysis of this scale resulted in an alpha of .71, p < .05.

The final section of the survey instrument included a number of questions designed to gather qualitative data regarding participants' attitudes toward brief therapeutic practices and the use of nontraditional therapies. Specifically, respondents were asked to reply to questions regarding their ethical concerns as they pertain to nontraditional therapeutic techniques, their opinions as to why nontraditional techniques are growing in popularity among practitioners and consumers, and the general response of clients to these implemented nontraditional approaches.

RESULTS

Quantitative Analyses

Given the dichotomous nature of the independent variables employed in the investigation (e.g., male versus female, White versus other ethnicity), t-tests for independent samples were employed to test hypotheses. For the first hypothesis about brief therapy, as predicted a t-test revealed a significant difference for participant gender classification, t (149) = -2.27,p < .05. This result indicates that males reported significantly greater attitudinal favorability for brief therapy than females (M = 3.03 and 2.76 respectively). Also, as predicted, t-test computations revealed a significant difference for ethnic classification, t (149) = -2.92, p < .01, with ethnic minority participants citing a greater preference for brief therapeutic approaches than White participants (M = 3.14 and 2.76 respectively). Finally, a t-test using private practice versus school work setting as the independent variable revealed a significant t value, t (149) = -2.95, p < .01. Participants in the private practice setting, as opposed to school settings, reported significantly greater favorability in their attitudes toward brief therapeutic approaches (M = 3.09 versus 2.69 respectively).

To test the second hypothesis, t-tests were applied to opinions of nontraditional therapeutic approaches. Results revealed a significant difference between minority groups' and White participants' attitudinal favor ability, t (149) = -2.03, p < .05, indicating ethnic minority group members were significantly more likely to hold favorable views of nontraditional therapeutic techniques than were White participants (M = 3.86 and 3.63 respectively). However, the findings for sex (male versus female) failed to reveal significant group attitudinal differences, t (149) = 1.80, p > .05, as did the t-test for professional work setting, t (99) = .751, p > .05.

For the third hypothesis, practitioners' beliefs about client attitudes toward nontraditional clinical practices were examined for gender, ethnic, and work setting differences. Contrary to prediction, no significant findings emerged (t = 1.69 for gender, t = -.64 for ethnicity, and t = .76 for work setting).

Qualitative Analysis 

The final section of the survey solicited participants' responses to four questions exploring types of nontraditional therapy used, overall client response to these therapies, perceptions regarding client's attraction to nontraditional approaches, and ethical concerns regarding nontraditional therapies. Responses were analyzed with QSR NUD * IST 4.0 (Nonnumerical Unstructured Data Indexing Searching and Theory-building, 1997) and organized in cluster categories that captured expressed concepts and themes. After transcribed responses were analyzed and categorized, responses from each of the four questions were merged, and four separate transcribed documents were created for analysis.

The first question analyzed was "Have you ever used any alternative or nontraditional therapies in your practice? If so, which ones?" Of the 151 participants, 109 (72%) responded that they used nontraditional approaches and elaborated as to what type(s) were employed (See Table). As indicated by participant responses, many individuals elected more than one nontraditional approach in their practice. The most frequently used were Art Therapy, Hypnotherapy, Dreamwork, Nutrition, and Massage Therapy. The least frequently used were Movie Therapy, Feng Shui, Primal Scream, Tai Chi, Eye Movement Desensitization and Reprocessing, and Acupuncture.

Of the 151 participants, 97 (64%) responded to the question, "How have your clients responded to your use of alternative therapies or to your suggestions about using them to complement traditional therapies." Of those 97, 83 (85%) expressed that their clients responded positively. Only 14 (15%) participants articulated that clients experienced negative, unknown, or moderate receptivity to nontraditional approaches.

Seventy-seven (51%) of the 151 participants responded to the question, "Why do you think clients might choose nontraditional therapies?" After analyzing the data, three major concepts emerged: (a) frustration with traditional approaches, (b) attraction of a holistic approach, and (c) quick fix and trendy. Twenty-seven percent (21) of respondents reported that they perceived clients as frustrated with traditional approaches to therapy. General statements emerged such as clients are "frustrated with medical profession" and "nontraditional therapy uses new routes whereas traditional approaches have not." Participant therapists also perceived that clients were frustrated with the over prescription of medication associated with traditional, biomedical approaches. Comments were mentioned such as "they [clients] don't want any more meds" and "clients are searching for something more that they can't find with pills." Related to the aforementioned category was that of attraction to holistic approaches. Twenty-two percent (17) of the therapists perceived clients as being attracted to the utilization of holistic approaches in their therapy. Specifically, participants repeatedly mentioned that clients valued the "body, mind, and spirit connection" that is associated with nontraditional approaches. Also in this category was the concept that client's attraction to the holistic approach is related to cultural imperatives. For example, a number of participants expressed that clients feel more comfortable with approaches that are perceived "as part of their cultural experience." A pejorative category that emerged from 19% (15) of respondents was the perception that clients want a quick fix to their problems. Comments such as "they want an easy cure" and "they don't want to put in the hard painful work required by therapy" were common.

The final question analyzed was, "What ethical concerns do you have concerning the use of nontraditional therapeutic techniques?" Ninety-one (60%) of the 151 participants responded to this question. Categories that emerged were (a) appropriate training, (b) no scientific proof, and (c) lack of knowledge/disregard for ethics. Others that emerged were licensure concerns, informing clientele of risks, and ethical concerns associated with touching clients. By and large, participants were concerned with the therapist's training, or lack thereof, when implementing nontraditional approaches. Forty-five percent (41) of respondents expressed apprehensions regarding skill level and experience. Expressions such as "I have concerns that these nontraditional techniques are being practiced by untrained individuals and under ill-advised circumstances" were common. Twenty-six percent (24) of the 91 respondents articulated concern regarding the lack of empirical evidence supporting the efficacy of non-traditional approaches. "I consider some alternative therapy as quackery" and "there is a lack of scientific data" to support nontraditional therapy were mentioned often. Twelve percent (11) of responding participants expressed concern that nontraditional therapists either intentionally or unintentionally "misuse these approaches" or" do not keep up with ethical guidelines." It should be noted that many of the concerns about the disregarding of ethics were in the context of touch therapies.

DISCUSSION

Attitudinal favorability can play an important role in the therapeutic approaches elected by practitioners in the mental health profession. The present investigation examined the attitudes of a diverse body of mental health service providers toward brief and nontraditional therapeutic approaches. As predicted, practitioners constituting the male, ethnic minority, and private practice classification groups reported significantly greater attitudinal favorability for brief therapy when compared to their female, White, and school/agency counterparts. This is an interesting result, with an unclear meaning, which may stimulate additional research. In addition, consistent with prediction, ethnic minority group members held significantly more favorable views of nontraditional techniques than White participants. Because, mental health counselors frequently elect therapeutic approaches in response to their own positive personal experiences (Eisenberg et al., 1998) and because many nontraditional approaches are derived from minority cultures, it could be that past exposure to these systems of treatment heightened minority participants' overall favorability toward the examined nontraditional practices.

Finally, in exploring respondents' perceptions of clients' attitudes toward nontraditional practices, no significant differences between male/female, White/ethnic minority populations, and professional work settings were revealed. Qualitative analyses indicated that mental health professionals perceive themselves as using nontraditional approaches. The majority believe their clients respond favorably to the use of these nontraditional techniques. Specifically, this study extends the implications of previous researchers by exploring dimensions commonly ignored by investigators of professional practice (i.e., differences in clinical setting, racial background, and gender). From the results of this investigation, mental health counselors can understand the frustrations clients are perceived to have with commonly prescribed techniques and practitioners' areas of attraction and concern toward novel practices such as nontraditional medicines. Finally, participants' responses indicated that they used a diversity of nontraditional approaches. Some of the reported methods incorporated commonly practiced and well-established mental health techniques. These results suggest that mental health practitioners lack a clear consensus as to what constitutes a nontraditional technique. Therefore, further investigation is merited.

However, interpretations of the results of this exploratory investigation must be made with caution. The authors conducted a pilot study to assess the overall validity of the instrument. Nevertheless, there are limitations inherent in this type of research. One such limitation of the study involves the geographical location of the mental health practitioners. Participants from this study were selected solely from a select number of Southern states, thus, potentially presenting an external population validity threat (Charles & Mertler, 2002). Results uncovered in the study may or may not generalize to other geographical locations. The qualitative data could be subject to the same validity threat. Some participants reported ethical violations, the lack of scientific data, and the absence of training as concerns when using nontraditional approaches. Also, a somewhat pejorative attitude toward people who seek nontraditional therapies as a "quick fix" was revealed. It might be erroneous to assume that clinicians in the Southern area are an accurate representation of attitudes and perceptions of those from the remainder of the United States. The exploration of the pervasiveness of these perceptions across the nation would be worthy endeavor. Another area that could pose a potential limitation is the use of self-reported measures. By the mere nature of self-reporting, validity concerns may arise. An area that could have strengthened the validity of the questionnaire would have been the inclusion of multiple questions in various forms that measured the subjective meaning of nontraditional approaches (Fowler, 1988). Note, however, that the alpha reliabilities ranged from .86 to .65.

Although mental health counselors should be cautious in generalizing the results reported in this investigation, this exploratory study does serve as a critical link in facilitating understanding concerning mental health counselors' attitudes towards nontraditional approaches to mental health counseling. In addition, future research could explore the connection between mental health counselors' cognitive and affective attitudinal development and the requisite impact on their selection of nontraditional counseling approaches. Additionally, an exploration of the linkage between mental health counselors past experiences, both through personal experience and formal training, utilizing nontraditional approaches should be implemented, along with a concerted effort to investigate how these counselors construct their definitions of nontraditional techniques and approaches.

Table 1. Nontraditional approaches employed by sample participants

Type of Technique                               No. of Responses

Art Therapy                                            25
Hypnotherapy                                           25
Dreamwork                                              20
Meditation                                             20
Nutrition                                              19
Massage                                                18
Humor                                                  16
Vitamin therapy                                        15
Yoga                                                   14
Music Therapy                                          14
Neuro Linguistic Programming                            9
Herbal                                                  8
Aromatherapy                                            3
Reflexology                                             3
Acupuncture                                             2
Eye Movement Desensitization and Reprocessing           2
Tai Chi                                                 2
Feng Shui                                               1
Movie Therapy                                           1
Primal Scream                                           1

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Marcheta P. Evans, Ph.D., is an assistant professor, Counseling Program coordinator, and Graduate Advisor of Record; E-mail: [e-mail]. Albert A. Valadez, Ph.D., is an assistant professor. Shaun Burns and Vicki Rodriguez are graduate students who have since completed their degrees. All are with the Department of Counseling, Educational Psychology, Adult and Higher Education, University of Texas-San Antonio.