Int J Adv Counselling

https://doi.org/10.1007/s10447-018-9352-0

O R I G I N A L A RT I C L E

Theory Use in Counseling Practice: Current Trends

Amy L Barth 1 & Steven J. Moody

2

# Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract The purpose of this study was to explore current trends in counseling practice. The
authors surveyed a randomly selected, U.S. national sample of American Mental Health
Counselors Association members (N = 140) regarding which theoretical approaches influenced
their current practice and which counseling skills were most often used in their current practice.
Cognitive behavioral, person-centered, strengths-based, and solution-focused were the most
influential theoretical approaches reported. Cognitive-behavioral theory was reported as having
at least some minor influence for all participants completing the survey. The most frequently
used counseling skills were demonstrating empathic understanding, general encouraging, en-
couraging self-care, conveying genuineness, and demonstrating unconditional positive regard.
Implications for the field of counseling and future research are discussed.

Keywords Counseling . Practice . Theory . Skills . Integration

Introduction

Competent and ethical practice requires counselors to base their work in Btechniques/proce-
dures/modalities that are grounded in theory and/or have an empirical or scientific foundation^
(American Counseling Association 2014, Standard, C.7.a.). Theory acts as a guide for why
counselors do what they do and techniques provide the how (Anderson et al. 2011; Rønnestad
and Skovholt 2013). Furthermore, research has demonstrated that developing a guiding theory
is one piece of overall professional identity development (Moss et al. 2014; Rønnestad and
Skovholt 2013).
In 1993, Young evaluated trends of then-practicing counselors in the United States by
conducting a survey on theoretical preferences and counseling skills most often used.

* Amy L Barth
bartha@uww.edu

1
Department of Counselor Education, University of Wisconsin-Whitewater, 800 W. Main St,
Whitewater, WI 53190, USA
2
Department of Counseling, Idaho State University, Pocatello, ID, USA
 Int J Adv Counselling

Participants were also asked to predict which theories would most likely be emphasized in the
field in the next five years; the cognitive-behavioral approach was predicted to replace the
person-centered approach in popularity among counselors. However, no follow-up research
has yet been conducted to explore this prediction or to update trends on theory use among
counselors. Furthermore, there is a lack of research regarding theory use specific to the field of
counseling, with most research being focused on psychologists and psychotherapists. The
purpose of this article was to contribute to and update the current knowledge regarding trends
in theory use among professional counselors in the United States.

Literature Review

In the United States, the field of counseling is seen as a separate discipline from psychology
and social work with its own unique philosophy and distinguishing educational and licensure
requirements. The beginning of the profession of counseling as a distinct discipline can be
traced to the formation of the American Personnel and Guidance Association (APGA; now
known as the American Counseling Association) in 1952 (Glosoff et al. 2017). A variety of
influences comprised the development of the field of counseling including vocational guid-
ance, education, psychology and key figures such as Carl Rogers with his non-directive,
client-centered approach. As the counseling profession has grown there has been a focus on
developing a distinct identity along with promoting the field, licensure portability, and a
research base for the field (Kaplan and Gladding 2011), with little focus on developing our
own theories. As a result, the counseling field relies heavily on the field of psychology and
other disciples for theory and methodology.
In preparation for this study, we began with a review of the literature, which produced
limited research specific to the field of counseling. We augmented this review by the
examination of several omnibus textbooks (Theory and practice of counseling and
psychotherapy, Corey 2016; and Current Psychotherapies, Corsini and Wedding 2014) often
used in counselor education. Additionally, we reviewed literature from the field of psychology
and found several studies (Jaimes et al. 2015; Norcross and Prochaska 1983; Norcross et al.
1993; Norcross and Rogan 2013) that surveyed psychologists about theory use across time.
Finally, to get a view of the current theoretical landscape, we expanded our review to consider
studies that included input from a variety of mental health professionals including psychia-
trists, psychologists, social workers, counselors, and family therapists (e.g., Cook et al. 2010;
Orlinsky and Rønnestad 2005; Orlinsky et al. 2011; Schofield and Roedel 2012) and also
included mental health professions from outside of the United States (e.g., Orlinsky and
Rønnestad 2005; Orlinsky et al. 2011; Schofield and Roedel 2012). It should be noted that
in such material there exists a lot of variety regarding which theories are listed, how
participants were surveyed and how responses were summed.

Theoretical Trends in the Field of Counseling

Young’s 1993 study was the impetus for the current study as the authors wanted to update
knowledge on trends regarding theory use among counselors. A review of the Journal of
Counseling & Development back to 1952 yielded two additional studies (Calley & Hawley
2008; White 1980) in which participants were surveyed regarding theoretical approaches used.
Participants in Young’s study included both mental health counselors and counselor educators
Int J Adv Counselling

who were currently practicing. Young found that 32% of participants reported using an eclectic
approach, 22% used a person-centered approach, and 10% practiced a family systems ap-
proach (para. 22). Whereas, the participants in the Young study were a mixture of practicing
counselors and counselor educators, the participants in both the Calley and Hawley and White
studies were counselor educators. Fifty percent of the participants in the White study reported
an eclectic approach, 29% humanistic, 11% client-centered, and 9% behavioral (p. 32). In the
Calley and Hawley study 41% of participants reported a broad humanistic (including
person-centered, existential, and gestalt) theoretical approach, 23% constructivist, 15%
cognitive-behavioral, and 6% psychodynamic (p. 11).
In addition to the counseling literature, two series of omnibus textbooks were reviewed to
investigate changes in theories represented over time. Theory and practice of counseling and
psychotherapy (1977, 1982, 1986, 1991, 1996, 2001, 2005, 2009, 2012, 2016) by Gerald
Corey and Current Psychotherapies initially edited by Corsini (1973, 1979) and later edited by
Corsini and Wedding (1984, 1989, 1995, 2000, 2005, 2008, 2011, 2014), were chosen as both
series have 10 editions and are often used in counselor education programs. In the Corey text
there are five chapters that have been in every edition: psychoanalytic, person-centered, gestalt,
behavior, and reality therapy. In the 5th edition (1996) the cognitive behavioral approach was
added as a standalone chapter as well as a chapter on family systems. Feminism was added as a
chapter in the 6th edition (2001). The postmodern approaches of solution-focused brief therapy
and narrative therapy were added in the 7th edition (2005).
Similarly, there are five chapters that have been in every edition of Current psychother-
apies: psychoanalytic, Adlerian, person-centered, behavior, and rational-emotive behavior
therapy. Other theories that have been in numerous additions include existential, gestalt, and
multimodal. A chapter on family therapy was added in the second edition (1979). Unlike the
Corey text, which includes a chapter on cognitive-behavioral therapy, this text has separate
chapters for behavioral and cognitive approaches. Distinctive from the Corey text, the last
several editions (2011 and 2014) have included chapters on the following theories interper-
sonal, contemplative, integrative, and multicultural.

Theoretical Trends in the Field of Psychology

Several studies will be summarized that examine trends in theory use among psychologists.
We begin with a review of a series of studies conducted by Norcross and various colleagues
(Norcross and Prochaska 1983; Norcross et al. 1993; Norcross and Rogan 2013) of American
psychologists in 1983, 1993, and 2013. In the 1983 study by Norcross and Prochaska, 31% of
participants reported using an eclective/integrative approach, 28% a psychodynamic and
psychoanalysis approach (combined percentages), 6.2% behavioral, and 7.6% cogni-
tive (p. 874). The results of Norcross et al.'s 1993 study were very similar to the
1983 study with Bone-third … endorsing eclecticism, one-third a variant of
psychanalytic therapy, and one-third various other approaches^ (p. 695). Some differ-
ences that were noted included that behaviorism dropped by 3% and the cognitive
approach increased by 3% (p. 695). Participants in the 2013 study (Norcross and
Rogan, p. 492) reported using the following orientations: psychodynamic/relational
(27%), integrative/eclectic (25%), and cognitive (17%). Psychodynamic approaches contin-
ued to be one of the top choices for psychologists, with an integrative/eclectic choice still being
near the top, but having dropped by 5%. An interesting result to note was the increase in the
cognitive approach from 10% in 1993 to 17% in 2013.
 Int J Adv Counselling

Next we examined Jaimes et al.’s (2015) study on trends of theory use among clinical
psychologists from Quebec, Canada. Jaimes and colleagues examined the annual psycholog-
ical board registration forms comparing psychologists’ choice of theoretical orientation from
1993 and 2013. Results demonstrated, Bpsychologists increasingly chose cognitive-behavioral
therapy (CBT) as their primary approach, while identification with other approaches declined^
(p. 1044). The percentage of participants choosing CBT as their main theoretical approached
grew from 18.4% in 1993, to 38% in 2013. Additionally, declines in other theoretical
approaches included the existential-humanistic approach lowering from 28 to 21.7%,
psychodynamic-analytic changing from 26.4 to 21.5%, and the systemic-interactional ap-
proach falling from 11.2 to 6.9% (p. 1044).

Current Trends in Theory Use

Finally, we reviewed several studies in which the participants included a variety of psycho-
therapists from the U.S. and other countries. In 1989, the Collaborative Research Network
(CRN) of the Society for Psychotherapy Research (SPR) conducted an international study of
psychotherapists (Orlinsky and Rønnestad 2005), in which only 2% of participants were
counselors while the remaining participants included psychologists (57%), psychiatrists
(28%), social workers (6%), nurses (2%), and lay therapists or those who had training in
another field (p. 29). Participants were asked to rate their most saliently used theoretical
orientation. Results showed, BThe type of orientation most commonly rated as salient by the
therapists... was analytic-psychodynamic (58%), followed by... humanistic (31%), cognitive
(24%), systemic (21%), and behavioral (14%)^ (p. 31). Other interesting results included that
8% of therapists reported having no salient orientation and 5% reported having three or more
salient orientations.
In 2010 Cook et al. conducted a study of psychotherapists from the United States and
Canada. Participants included social workers (36%), professional counselors (23%), psychol-
ogists (17%), and marriage and family therapists (17%) (p. 261). The results indicated that
CBT (79%) was the most popular approach followed by family systems (49%), then mind-
fulness (41%), psychodynamic/analytic (36%), with Rogerian/client-centered/humanistic
(31%) rounding out the top five (p. 262). In addition, only 2% of participants reported using
a single-theory approach.
Orlinsky et al. (2011) surveyed psychotherapists from the United States, Canada, United
Kingdom, Ireland, Australia, and New Zealand. Thirty-eight percent of participants identified
as counselors, 32% as psychologists, and 9% as social workers (p. 832). Participants reported a
strong preference for a broadly humanistic approach (48%), followed by analytic/dynamic
(38%), cognitive-behavioral (29%), plus another 9% for cognitive (other than
cognitive-behavioral), and systemic (25%) (p. 832).
Schofield and Roedel (2012) conducted a study in Australia in which 70% of the participants
identified as counselors. Similar to the results of Orlinsky et al.’s (2011) study participants in
this study also demonstrated a preference for a humanistic approach (39%). Other saliently
preferred theories included interpersonal 38%, family/systems theory 33%, experiential 32%,
analytic/psychodynamic 32%, and cognitive 25%. Five percent of participants reported no
salient orientation, whereas, 36% reported 3 or more salient orientations (p. 16).
The results of the reviewed studies indicated no one preferred theoretical approach among
mental health professionals. American psychologists appeared to continue to prefer a
psychodynamic/analytic approach, whereas, psychologists in Canada demonstrated a
Int J Adv Counselling

preference for a cognitive-behavioral approach. Additionally, psychotherapists from North

America in the Cook et al. (2010) study also had a strong preference for CBT (79%). In several
of the more recent studies (Calley & Hawley 2008; Orlinsky et al. 2011; Schofield and Roedel
2012), a humanistic approach was the most popular. Several studies (Norcross and Prochaska
1983; Norcross et al. 1993; Norcross and Rogan 2013; Young 1993) offered a category of
eclectic or integrative that was often chosen by participants. It should be noted that there was
never a specific definition provided as to what the authors or participants meant by eclectic or
integrative. Several studies (Calley & Hawley 2008; Cook et al. 2010; Jaimes et al. 2015;
Orlinsky and Rønnestad 2005; Orlinsky et al. 2011; Schofield and Roedel 2012) went in a
different direction; instead of offering an eclectic or integrative option, participants were asked
either to check off their primary orientation or to rate how each of the theoretical approaches
listed influenced their current practice.

Counseling Skill Use

As a way to examine current trends in counseling practice, several studies (Cook et al. 2010;
Schofield and Roedel 2012; Young 1993) explored the counseling skills used by participants.
A common pattern found in the results of these studies involved a strong preference for using
relational skills and humanistic techniques. Results of Young’s (1993) study demonstrated that
techniques most often utilized were empathic understanding, encouragement, and uncondi-
tional positive regard. Likewise, in the Cook et al. (2010) survey the top three
techniques reported were: convey warmth, caring, and respect, communicate that the
client is accepted and prized, and communicate understanding of the client’s experi-
ence. Schofield and Roedel (2012) found that over 80% of participants endorsed the
following relational skills: being ‘natural’ while working with clients, being effective in
engaging clients in a working alliance, and being effective in communicating understanding
and concern to clients (p. 41).

Theoretical Integration

Because the technique of integrating theoretical approaches has been suggested in the literature
(Cook et al. 2010; Jaimes et al. 2015; Norcross and Rogan 2013; Young 1993), part of our
current review of the literature examined theoretical integration. There are various methods of
theoretical integration, but the four most popular are technical eclecticism, assimilative
integration, theoretical integration, and common factors (Norcross 2005). Technical eclecti-
cism involves the use of different techniques from different theories, where the goal is to find
interventions that will work best for each client (Norcross 2005). Similar to technical eclec-
ticism, assimilative integration involves assimilating techniques and practices from other
theories into one system of counseling in which the counselor is firmly grounded (Norcross
and Beutler 2011). Theoretical integration moves integration to a more sophisticated level by
synthesizing the principles and methodologies of two or more theories into a new conceptual
framework. The goal of theoretical integration is to Bcreate a conceptual framework that
synthesizes the best elements of two or more theories^ (Norcross and Beutler 2011, p. 503)
in order to enhance therapy.
The final and most frequent approach to integration is the common factors approach. The
essence of this approach focuses on elements that create positive therapeutic outcomes that are
common to almost all theories (Hubble et al. 2011; Wampold 2012). Hubble et al. (2011)
 Int J Adv Counselling

identified four categories of common factors: client and extratherapeutic factors; therapists as
people; models and techniques; and the therapeutic relationship or alliance. It is difficult to
determine which of the common factors has greater influence on positive therapeutic outcomes
given that every relationship between client and counselor is unique, with certain factors
dominating over others at any time during the therapeutic process. This approach does,
however, highlight the necessity of each category of factors being present to some degree
within the therapeutic relationship in order to achieve client goals (Anderson et al. 2011;
Hubble et al. 2011).
From our examination of the most recent literature on the use of theoretical approaches and
skill use in mental health professions, we identified several separate inclinations regarding
trends in practice. However, the question of relevance of these findings for current counselors
was central to the present study. It seemed to be time to extend Young’s (1993) counseling
research particularly with today’s counselors to better understand the trends in counseling
practice, with a focus on the United States. The research questions for the present study
included (1) What theories are currently influencing the practice of professional
counselors? and (2) Which counseling skills are most frequently used by counselors
in their practice? Following the results of previous studies we also asked three
additional questions (3) Are there any significant correlations between theory [prefer-
ence] and skill usage? (4) Will professional counselors show a strong preference for
using a cognitive behavioral approach? and (5) Will professional counselors show a strong
preference for an integrative approach? The aim was to enable findings from the current
research study to provide the counseling profession with information regarding current trends
in counseling practice within the United States.

Method

Research Design and Participants

We utilized a survey protocol (Fowler Jr. 2009; Heppner et al. 2016) to address the research
questions. Heppner et al. (2016) described the basic aim of survey research as Bdocumenting
the nature or frequency of a particular variable [e.g., the incidence and extent of
alcohol use] within a certain population [e.g., U.S. college students]^ (p. 288). Our
research questions included descriptive and correlational elements lending themselves well to
the use of this methodology.
The first step in our process was determining an appropriate sample. Because previous
studies (Cook et al. 2010; Jaimes et al. 2015; Norcross and Rogan 2013; Orlinsky et al. 2011)
included multiple mental health disciplines or were conducted over 20 years ago
(Young 1993), our target population was 'currently practicing professional counselors
within the United States'. In particular, we were looking for those working directly in
the mental health counseling field. We chose to select participants through random
sampling of the membership of the American Mental Health Counselors Association
(AMHCA). We also wanted to control our sampling processes in a way where simple
random sampling within an organization could occur. Sampling the AMHCA mem-
bership allowed us to have access to two thousand names randomly selected from
their entire membership, as opposed to requesting participation through listservs or
discussion forums.
Int J Adv Counselling

Survey Design

The survey included a demographic questionnaire and specific questions about theory and
counseling skill use. The demographic information was collected to provide a description of
the participants sampled and to determine if any differences existed in the results when
comparing different demographics. The first question regarding theory use asked the respon-
dents to rate the influence the listed theoretical approaches had on their current practice.
Following the trend of more recent studies (Cook et al. 2010; Orlinsky et al. 2011; Schofield
and Roedel 2012) we did not offer an option for eclectic or integrative, but rather asked
participants to rate the influence of each theoretical approach listed. The list of theories
included Psychoanalytic, Adlerian, Existential, Gestalt, Behavioral, Cognitive-Behavioral,
Solution-Focused, Narrative, Constructivist, Family Systems, Feminist, Strength-based, and
Multicultural. Theories were selected based on previous research (Cook et al. 2010; Jaimes
et al. 2015; Norcross and Rogan 2013; Orlinsky and Rønnestad 2005; Young 1993). The
responses were arranged in a Likert scale ranging from 1 indicating no influence to 4 indicating
a strong influence.
The second question highlighted the frequency of use of a variety of counseling skills drawn
from basic counseling skills texts and previous research (Cook et al. 2010; Hill 2014; Ivey et al.
2010; Young 1993), and a pilot study as mentioned below. Focusing, summarizing, paraphras-
ing, reflection of feeling, early recollections, confrontation, general encouraging and encour-
aging self-care were some of the active skills listed. Other interventions focused on a way of
being in session and included demonstrating empathic understanding, promoting instillation of
hope, genuineness, and unconditional positive regard. Again, the response format was present-
ed as a Likert scale with scores ranging from 1 representing no use to 4 where interventions
were used frequently. For each of these questions, we provided space for respondents to write in
another theory or intervention. Prior to utilizing this survey at the national level, we performed a
pilot study to refine our instrument and clarify goals, as described below.

Pilot Testing

A pilot study provided an initial evaluation of the research questions and developed a final list
of items to include. The pilot study included 74 professional counselors from a state in the U.S.
mid-west. The authors designed the survey to allow participants to delineate what theories and
skills informed their counseling practice. Results regarding theoretical approach, showed CBT
(58.1%) as the most frequently cited theory being used by participants, followed by
person-centered (51.4%), family-systems (44.6%), and solution-focused and strengths-based,
both with 40.5%. Additionally, participants were asked if they used a single theory approach or
an integrative approach. Results demonstrated an inclination towards an integrative approach,
with 85.1% of participants reporting using an integrative approach and only 13.5% reporting
using a single theory approach. Results regarding counseling skills used were based on
frequency. Participants were provided a list of counseling skills and asked to rate the frequency
with which they used each skill. Demonstrating empathic understanding was the most
frequently used skill, followed by general encouraging, encouraging self-care, conveying
genuineness, and demonstrating unconditional positive regard, rounding out the top five most
frequently used skills.
The pilot study allowed us to receive feedback regarding the questions contained in our
survey as well as providing the opportunity to determine if correlational statistics were well
 Int J Adv Counselling

suited to the findings. Following the pilot study, we moved forward with conducting the
survey on a national sample of professional counselors.

Procedures

In the study, two thousand professional counselors were randomly selected from the member-
ship of the American Mental Health Counselors Association (AMHCA). AMHCA is a
national organization within the United States that maintains a membership of between 6000
and 6400 members. An introductory letter with consent to participate was sent out to these
members, with a link to the on-line survey. If the member agreed to participate, they would be
directed to the on-line Qualtrics survey. Of the two thousand e-mails sent out, 163 responded
to the request for participation with 140 completing the survey such that data could be used.
This constitutes a low response rate of 7 % of usable surveys from this initial call. Due to the
limited funds for this project and the overall cost of solicitation through the organization, we
were only able to complete a single call for participation through the on-line survey software
provider. We left the survey open for just over two weeks as response rates fell off dramatically
with only 1.8% of the 163 total surveys completed in the final three days. We then exported
our data to JMP Pro 12® for analysis.

Data Analysis

The first two research questions focused on percentages related to theory and skill use. Next,
we explored the relationship between theory and skills usage. The final two questions focused
on use of cognitive-behavioral theory specifically, and the integrative nature of the counselors’
practice. Descriptive statistics including mean and standard deviations were used for the first
two questions. Correlational statistics were used to explore relationships between specific
theories and skills. Additionally, determining the z score for cognitive-behavioral therapy
provided a simple indicator of preference for this theory. For the question investigating the
preference for integrative practice, Pearson r correlations were run to determine what theories
were often used together.

Results

Statistical analyses from the national sample (n = 140) were conducted based on the five
research questions. Thirty-six states were represented in the data. Of the individuals complet-
ing the survey, 89 identified as female and 51 identified as male. The mean age for participants
was 57.2 years old and ranged from 24 to 81. The majority of the respondents identified as
white/Caucasian (91%, n = 128). Other identified ethnicities included Latino/a (n = 4), African
American (n = 3), Asian (n = 1), Native American (n = 1), Native Hawaiian or other Pacific
Islander (n = 1). Fifteen participants identified as biracial or Bother^.
Although the majority of those completing the survey identified as licensed counselors (n =
129), training, service longevity, and work settings varied. Ninety-seven participants had
completed a master’s degree, six a PsyD, nine an EdD, and 27 a PhD. Eighty-five graduated
from a program accredited by the Council for Accreditation of Counseling & Related
Educational Programs (CACREP). Those completing the survey had extensive experience,
with an average of 21.5 years and a range of one to 47 years. Private practice (n = 85) was the
Int J Adv Counselling

primary work setting. Community mental health centers (n = 17), hospitals (n = 6), and
educational settings (n = 12) rounded out the majority of work settings. Results for the
completed surveys are summarized below. Each research question was addressed individually
and pertinent data are provided. The majority of respondents completed major portions of the
survey. Missing data are reported in the findings as content areas are discussed.
The survey allowed space for respondents to add in theories and skills that were not overtly
listed. Although various different theories and interventions were listed, a consistent theme
across participants was not determined. Several theories mentioned several times included
rational emotive behavior therapy (REBT), dialectical behavior therapy (DBT), acceptance and
commitment therapy (ACT), logotherapy, and attachment theory. Skills included relaxation,
eye movement desensitization and reprocessing (EMDR), trauma-informed care, and mind-
fulness exercises.

Theories Influencing Current Practice

Current theory use in counseling was determined by asking participants to rate the influence
each theoretical approach listed had on their current practice on a Likert scale from no
influence (1) to strong influence (4). The top four influential theories reported were
cognitive-behavioral (mean = 3.5, n = 140), person-centered/interpersonal (mean = 3.3, n =
135), strength-based (mean = 3.1, n = 133), and solution-focused (mean = 3.0, n = 136). A
mean score of 3.0 indicated a moderate influence. Theories that were slightly below
this moderate influence included behavioral (mean = 2.9, n = 136), reality/choice (mean
= 2.7, n = 135), family/systemic (mean = 2.8, n = 137), and multicultural (mean = 2.7, n = 132).
The two lowest ranking theories were constructivist (mean = 1.8, n = 131) and feminist (mean
= 2.0, n = 131). Other theories such as existential, Adlerian, psychoanalytic, and gestalt ranged
from 2.3 to 2.5.

Counseling Skill Use

Participants reported using a majority of the counseling skills listed at a frequency of at least
sometimes. This was evidenced by the tallied scores for the 21 skills presented. The mean score
was 3.54 with a standard deviation of 0.34. The scores ranged from 2.65 to 3.98. A score of
three indicated a skill was used sometimes and a score of four represented a skill being used
frequently. The most frequently used counseling skills were demonstrating empathic under-
standing (mean = 3.98, n = 138), general encouraging (mean = 3.86, n = 138), encouraging
self-care (mean = 3.86, n = 136), conveying genuineness (mean = 3.85, n = 138), and demon-
strating unconditional positive regard (mean = 3.79, n = 138). Other skills ranking high
in frequency of use included exploration of healthy coping skills, open questions,
reflection of feeling and meaning, and reframing (ranging from 3.67-3.78). Self-disclosure and
early recollections were the only two with mean scores below 3.0. They were 2.65
and 2.74, respectively.

Relationship between Counseling Skills and Theory

Relationships between preferred counseling theories and interventions traditionally associated

with theories generally corresponded. Table 1 displays the significant correlations between
counseling skills and theories that were moderately correlated. Several significant correlations
 Int J Adv Counselling

were found, but were weak (r < .30). Of particular interest, skills often associated with the core
conditions in person-centered theory for the counseling relationship scored highly across all
theories. Interestingly the relationships between person-centered theory and demonstrating
empathic understanding, genuineness/congruence, and showing unconditional positive regard
were all weak, with one not being significant. Demonstrating empathic understanding (r =
0.06, p = .5) had no significant relationship, genuineness/congruence (r = 0.22, p = .0095) had
a significant yet weak relationship, and showing unconditional positive regard (r = 0.22, p =
0.012) also had a significant yet weak relationship.

Use of Cognitive-Behavioral Approach

All participants completing the survey responded to the question pertaining to the influence of
cognitive-behavioral theory. As reported above, the mean score for influence of
cognitive-behavioral theory was 3.5 (indicating a moderate to strong influence). When com-
pared to the mean scores of all 15 theories (mean influence of all theories = 2.65, SD = .47)
presented to the participants, the corresponding z score for cognitive-behavioral theory was
1.8. Of the 140 responses, 83 identified cognitive-behavioral as having a strong influ-
ence on his or her practice. Rounding out the rest of the responses for
cognitive-behavioral theory, 45 participants reported a moderate influence and 12
reported a weak influence. Of the 140 participants, none reported
cognitive-behavioral theory as having no influence on their current practice. We found
no significant differences in CBT influencing practice depending on CACREP schooling, sex,
or ethnicities. Additionally, there was not a significant correlation involving CBT and age.

Preference towards an Integrative Approach

The majority of respondents reported being influenced in their current practice by multiple
theories. Only one participant reported a clear theoretical preference. This individual reported
being strongly influenced by both behavioral and cognitive-behavioral theories and left all
other theories blank. Four other individuals only rated four to six theories, and of these
respondents, theoretical influences extended across paradigms. A correlation matrix was
developed to determine if there were any significant relationships between influential theories

Table 1 Significant Correlations

between Counseling Skills and Skills/Theories Pearson r Significance (p)
Influential Theories
Encouraging/Solution-focused 0.33 0.0003
Reflection of Meaning/Existential 0.39 <0.0001
Reflection of Feeling/Existential 0.38 <0.0001
Early Recollections/Psychoanalytic 0.41 <0.0001
Instillation of Hope/Strength-based 0.32 0.0005
Here-and-Now Awareness/Existential 0.30 0.0009
Here-and-Now Awareness/Gestalt 0.30 0.0009
Interpersonal Relationships/Existential 0.36 <0.0001
Interpersonal Relationships/Feminist 0.29 .0016
Behavior-based Change/Behavioral 0.36 <0.0001
Behavior-based Change/CBT 0.35 0.0001
Behavior-based Change/Solution-focused 0.28 0.0022
Behavior-based Change/Reality 0.28 0.0022
Healthy Coping Mechanisms/CBT 0.37 <0.0001
Int J Adv Counselling

using JMP Pro 12® software. As mentioned earlier, some participants did not rate all theories
and, therefore, there were 20 missing values. We found multiple significant relationships
ranging from weak to moderate strength based on a correlational pairwise method.
To help inform the phenomenon of an integrative approach, only moderate relation-
ships with a Pearson r of .39 or greater are presented in Table 2. The only significant
negative correlations were associated with Psychoanalytic theory. Psychoanalytic theory was
negatively correlated with Behavioral theory (r = −0.26, p = 0.004), CBT (r = −0.24, p = 0.008),
Reality/Choice (r = −0.25, p = 0.007), Solution-focused (r = −0.35, p < 0.0001), and
Strength-based theory (r = −0.30, p = .001).

Discussion

The results of the present study contribute to the counseling field literature by updating
information on current trends in counseling practice of professional counselors within the
United States. Several similarities and differences between the results of this study and
previously reviewed studies exist. CBT was found to have a strong influence not only in the
current study, but also in the surveys by both Cook et al. (2010) and Jaimes et al. (2015). These
results support the prediction from Young’s (1993) study regarding the increased popularity of
CBT among counseling professionals. Given the popularity of CBT and its demonstrated
efficacy, it should be noted that in several studies (Norcross and Rogan 2013; Orlinsky and
Rønnestad 2005; Schofield and Roedel 2012) CBT was not listed as a theoretical choice for
participants; cognitive and behavioral being listed as separate choices.
Participants in the Young (1993) study predicted a significant decline in the person-centered
approach. This prediction was not supported by the current study in which the person-centered
theory ranked 2nd in influence. Cook et al.’s (2010) study also demonstrated high rates of
person-centered theory. Even though the broader term humanism was used in the studies by
Orlinsky and Rønnestad (2005), Orlinsky et al. (2011), Schofield and Roedel (2012), and
Jaimes et al. (2015), participants here, likewise, rated a humanistic approach as having a strong
influence. Humanism, or specifically the person-centered theory, ranked within the top five
theoretical choices in all the studies except the Norcross and Rogan (2013) study of psychol-
ogists in which only two-percent of participants endorsed a humanistic theoretical approach.
Furthermore, several notable differences exist. The strengths-based and solution-focused
approaches were rated to have a strong influence in the current study and not in any of the
previous studies reviewed. The high ranking of the strengths-based approach is not surprising
considering the philosophical similarities evident in the counseling field and this approach.

Table 2 Significant correlations

between influential theories Theories Pearson r

Existential/Psychoanalytic 0.39
Existential/Gestalt 0.45
Behavioral/CBT 0.54
Behavioral/Solution-focused 0.41
CBT/Solution-focused 0.41
Solution-focused/Reality 0.56
Solution-focused/Strength-based 0.40
Note. p < 0.0001 on reported Strength-based/Multicultural 0.54
Narrative/Constructivist 0.64
correlations
 Int J Adv Counselling

The counseling profession is based on professional relationships that promote empowerment,

wellness, and an understanding of development (American Counseling Association 2014).
Correspondingly, the strengths-based perspective emphasizes clients’ strengths and resiliency
and that people develop across the life span (Smith 2016). Additionally, the high ranking of the
solution-focused approach demonstrates that postmodern philosophy is beginning to have an
influence in the field of counseling.
Another notable difference was regarding the influence of psychodynamic theories. Both
the Orlinsky and Rønnestad (2005) and the Norcross and Rogan (2013) studies, in which
either the entire body of participants or a majority of the participants were psychologists,
demonstrated high rates of influence from psychodynamic theories. The current study and
other studies, where the participants were professional counselors or a variety of psychother-
apists, demonstrated both less influence and less reliance on psychodynamic theories. This
discrepancy may speak to the differences in underlying philosophies and training between the
fields of counseling and psychology.
The counseling skills that participants reported they used most often aligned with the
theoretical approaches that they noted were most influential on their current counseling practice.
An interesting finding in this study was regarding the skills traditionally aligned with the
person-centered approach, including demonstrating empathic understanding, genuineness, and
unconditional positive regard. Participants ranked the person-centered approach as the second
most influential theory, yet there was only weak correlations found with each of the traditional
skills. Without having asked participants the reasoning behind their choices, we can only
speculate on why this might be. One reason might be that from a person-centered lens the
concepts of demonstrating empathic understanding, genuineness, and unconditional positive
regard are seen as attitudes that a counselor holds versus skills that they use with clients (Cain
2002). Additionally, given that the counseling relationship is one of the factors common to
almost all theories that leads to positive therapeutic outcomes and that the elements of empathy,
positive regard, and genuineness have been demonstrated to be an effective components of that
relationship (Norcross 2011), these concepts are no longer seen as strictly person-centered
concepts. Therefore, it makes sense that these three skills would rank high across theories.
These results are comparable with the results from the Young (1993), Cook et al. (2010),
and Schofield and Roedel (2012) studies. There were several skills that were aligned with
specific theories. Pairings such as early recollections with psychoanalytic and here and now
awareness with existential and gestalt were anticipated. Additionally, the skills of exploration
of healthy coping skills and reframing align with the CBT approach. Finally, encouragement is
one of the main principles of the strengths-based approach.
Any conclusions need to be drawn cautiously regarding use of an eclectic or integrative
approach from the results of this study and future research, as described below, is needed. In
line with previous research studies (Cook et al. 2010; Orlinsky and Rønnestad 2005; Orlinsky
et al. 2011; Schofield and Roedel 2012), we chose not to ask specifically about eclectic or
integrative approaches, as multiple definitions of what it means to use an eclectic or integrative
approach exist, but rather to look at this phenomenon in terms of how counselors’ current
practice was being influenced by multiple theoretical approaches. Even though we did not ask
participants specifically about an eclectic or integrative approach, all participants in the current
study reported multiple theories influencing their current counseling practice. The results of
this study indicate that the counselors were no longer being influenced by a single theoretical
approach and appeared to show an inclination towards integrating approaches together in some
way in their practice.
Int J Adv Counselling

Limitations

The study was developed to explore the practices of counselors within the United States and
several limitations should be noted. Although the participants for this study were randomly
selected, the participant responses demographically favored older, Caucasian individuals who
had extensive experience and currently worked in private practice. Furthermore this study only
involved professional counselors from the United States. Suggested future research survey
designs include striving for a sample of counselors that comprises a broader scope of
counselors across all counseling specializations and consists of increased diversity of partic-
ipants, not only of ethnic and cultural factors, but also countries of practice.
Finally, even though our results reflect those of earlier studies (Cook et al. 2010; Jaimes
et al. 2015), the findings should be used with caution based upon the overall low response rate.
We attempted to control participation through random sampling of AMHCA members to
minimize sampling bias. However, this reduced our participant pool to approximately 7% of
those contacted. This, in turn, may indicate that only a subpopulation of mental health
counselors is being represented in this study. Potential reasons for non-completion may be
overloaded schedules, lack of interest, or low technological proficiency in completing on-line
surveys. Additionally, limited resources prevented multiple reminders that may have provided
more responses. Evaluating electronic dissemination of research requests may be an important
consideration given the changing culture of on-line usage and reliance on electronic means for
communication. This limitation should be of particular interest when looking to do further
research in this area.

Implications and Future Research

The purpose of this research study was to increase the knowledge-base of the counseling field
regarding current trends in counseling practice. Implications of this research study include a
better understanding of which theories are influencing current practice of counselors and
which skills are most often used. While this study adds to the literature, several new questions
that may inform future research were also brought to the forefront for the field of counseling,
including how does the strong influence of CBT impact the field of counseling that has its
foundations in humanistic principles. The results regarding the strong influence of CBT are
similar to other studies reviewed that included a variety of mental health professionals,
imploring the question what does this mean for the field of counseling as a distinct profession
from other mental health professions? Hence, it seems that research that focuses on the factors
influencing counselors’ use of theory and how counselors are developing a personal guiding
theory of counseling is needed.
The results of this study were based on participants from the United States and participants
in many of the reviewed studies were from Western countries with a strong European
influence. As the globalization of counseling continues, another question that arose was,
would the same trends in counseling practice be found in countries with different ethnic and
cultural traditions. Consequently, it seems that additional research is warranted that would
continue to explore the trends of theory use and counseling skill use of professional counselors
globally.
The final question involves the use of an integrative approach. The findings demonstrate
that the current practice of the participants was influenced by more than one theoretical
approach. This trend is consistent with previous research and, considering the large number
 Int J Adv Counselling

of theories and interventions available, it appears this trend will continue. Even though it is
clear that most counselors integrate more than one approach together and several forms of
integration exist, it is unclear how counselors are actually integrating approaches. According to
Norcross and Beutler (2011), BIt is integration by design, not default; that is, clinicians
competent in several therapeutic systems systematically select interventions and concepts on
the basis of comparative research and patient need^ (p. 504). Therefore, understanding how
counselors are making decisions about which theories and when to integrate will assist in
understanding the dynamics of developing an integrative approach to counseling.

Conclusion

This study provides an increased understanding of trends in counseling practice within the
United States including which theories are influencing the practice of counselors and which
counseling skills are most often used. The majority of participants in this study reported being
influenced by more than one theoretical approach, with cognitive-behavioral, person-centered,
strengths-based, and solution-focused being reported as the top four influential theories. The
most frequently used counseling skills were demonstrating empathic understanding, general
encouraging, encouraging self-care, conveying genuineness, and demonstrating unconditional
positive regard. Further research is recommended to gain a broader sample of counselors and
to explore how counselors integrate more than one theoretical framework together in their
counseling practice.

Acknowledgements We would like to thank Carrie Merino for providing her time and effort to assist in editing
this manuscript. I (Amy Barth) would also like to thank Concordia University Chicago for the summer research
grant which made funding this research possible.

Compliance with Ethical Standards

Ethical Approval All procedures performed in studies involving human participants were in accordance with
the ethical standards of Concordia University Chicago, University of Wisconsin-Whitewater, and Idaho State
Universities institutional review boards (IRB) and with the 1964 Helsinki declaration and its later amendments or
comparable ethical standards.

Conflict of Interest We confirm that there is no potential conflict of interest pertaining to this submission to the
International Journal for the Advancement of Counselling.

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