Person-Centered/Experiential Psychotherapy for Anxiety Difficulties: Theory, Research and Practice

Entry for 17 May 2013:

Last July, about a week after my return from California after the two months I spent helping care for my mother, I gave my first keynote presentation to a conference of the World Association for Person-Centered and Experiential Psychotherapies.  The talk, given in Antwerp, Belgium, was the basis for an article just published in Person-Centered and Experiential Psychotherapies.  It combines selected results from two studies: the 2008 humanistic-experiential psychotherapy outcome meta-analysis that Beth  Freire and I carried out with support from British Association for the Person-Centre Approach; and the First Strathclyde Social Anxiety Project, largely funded by grants from the New Professors Fund by the University of Strathclyde and by Counselling Unit internal funds. 

I am deeply appreciative of the help I received in carrying out the research on which this article is based, including the clients, volunteer therapists, students, research associates, and members of the Social Anxiety Study Group, University of Strathclyde, 2006-2012, especially my colleagues Brian Rodgers, Beth Freire, Susan Stephen, Lorna Carrick, Lucia Berdondini, and Mick Cooper.   In addition, Les Greenberg and Ann Weiser Cornell made helpful contributions to the theory sections of this article.  Finally, I have dedicated this article to the memory of my mother, Ann Helena Kearney Elliott, 7 April 1929 – 22 June 2012.

Although the article has been available on the publisher’s website since March, it was very nice to receive the hard copy of it the other day.

Reference:

Elliott, R. (2013). Person-Centered-Experiential Psychotherapy for Anxiety Difficulties: Theory, Research and Practice.  Person-Centered and Experiential Psychotherapies, 12, 14-30. DOI:10.1080/14779757.2013.767750

Abstract: Anxiety difficulties are an increasingly important focus for person-centered-experiential (PCE) psychotherapies.  I begin by reviewing person-centered, focusing-oriented, and emotion-focused therapy (EFT) theories of anxiety.  Next, I summarize a meta-analysis of 19 outcome studies of PCE therapies for adults with anxiety, most commonly supportive or person-centered therapies (PCT) carried out by cognitive behavior therapy (CBT) researchers.  The results indicate large pre-post change but a clear inferiority to CBT.  I then summarize promising early results from an ongoing study of PCT and EFT for social anxiety, which show large amounts of pre-post change for both forms of PCE therapy but substantially more change for clients in the EFT condition.  I conclude with a discussion of the implications for PCE therapy practice, including the value of process differentiation and the possibility of developing more effective PCE approaches for anxiety.

Render unto CCESA

Entry for 20 April 2013:

The draft NICE guidelines for Social Anxiety (SA) were issued last December.  Anxiety difficulties in general, and social anxiety in particular, has been a bastion for behaviour therapy and cognitive-behavioural therapy since the 1960’s and even 1950’s.  In 1976 I was learning an early form of CBT, working with a client with social anxiety.  Over several weeks, I had taken her through progressive relaxation and we had constructed a hierarchy of social-interpersonal fears.  One day, about halfway through the hierarchy, she suddenly became overwhelmed, burst into tears, and ran out of room.  I followed her out into the hallway, where she stood, crying.  I asked her if she would be willing to come back in and tell me what had happened.  She said that she would if we stopped with the hierarchy.  I was happy to do so, and we then worked for many months in a broadly psychodynamic manner, including exploring her fear of abandonment as a child. I can no longer remember whether her social anxiety had improved much by the end of our work, but I do remember that she was less depressed and felt better about herself.  Up to this point, I had been somewhat enamoured with behaviour therapy and had even received training in cognitive therapy (this was before Beck’s 1979 book). This however was the beginning of the end for me and CBT. 

I thought of this last December when the draft guidelines came out.  Two years earlier, I had applied to serve on the Guideline Development Group for Social Anxiety.  I was offered a place; however, after several exchanges with the person organising it, it became clear to me that they weren’t willing to look beyond what they considered to be “good quality RCT evidence”.  “Why wouldn’t we want to look at all the evidence? “ I asked.  “There’s no need”, was the answer.  “What about emerging treatments?  Wouldn’t practitioners want to know about this?”, I wanted to know.  “That’s not the mandate”, they said.  Actually, I’d read the guidelines for guideline development groups, and had been briefed previously, so I knew that this wasn’t accurate.  Instead, it meant that they had no intention of allowing any other kind of evidence to be considered.  I said I’d think about it. 

Eventually, after further reflection and consultation, I decided to resign from the NICE Social Anxiety Guideline Development Group before it even started.  At the time, it was not that long since my cancer surgery, and I really had to ask myself whether, given my limited energy, I wanted to spend the next 18 months of my life banging heads with the various hard-science folks on the committee.  In the end, I realised that I could do more good by using that time to carry on with my own research on social anxiety. The result of my efforts was the integrated EFT model of SA that emerged with our last wave of clients.

So now I was seeing the result of the committee’s work and my decision not to take part.  Reading the draft guideline, I was not at all surprised to see CBT proclaimed as the pre-eminent psychosocial treatment for social anxiety.  This has long been clear from the existing literature, with the Heimberg and Clark-Wells models being given equal weight in the draft guidelines.  What did surprise me was that Interpersonal Psychotherapy (IPT) and psychodynamic psychotherapy were listed as second-line treatments, on the strength of only two RCTs each.  Hmm…. I thought… I’ve got half of an RCT already:  Our recent treatment development study was partially randomised between EFT and Person-Centred Therapy.  I began to feel somehow obligated to at least try for an RCT on EFT for SA.

As a result I started talking to people about a possible RCT comparing the version of EFT I’d developed for SA over the past 5 years, with one of the standard versions of CBT for SA.  One thing led to another, and eventually Richard Golsworthy and Tania Saninno (from Glasgow Caledonian University) and Rachel McLeod (from the NHS and University of Glasgow) agreed to work with me, Lorna Carrick and Susan Stephen to put together such as study, focusing on early career psychotherapists/counsellors within 5 years of their main professional training.  It was a lot of work; it has eaten up large amount of my time over the past month in particular, not to mention the anxiety about whether we’d actually be able to pull this together in time for the 12 April deadline.

Finally, about 8pm on the 10^th of April, I clicked on the Send button and submitted the proposal.  It turns out that RCTs today have to have a cute acronym-based title, so ours is called “Comparison of Cognitive-Behavioural Therapy and Emotion-Focused Therapy for Social Anxiety”, abbreviated CCESA, as in “Render unto Caesar”.  I have no idea whether this will be funded or not.  Frankly, given that only about 10% of submitted grants are funded today in most countries, it’s not terribly likely.  However, to quote T.S. Eliot, “But perhaps neither gain nor loss./ For us, there is only the trying.  The rest of not our business.”

At any rate, here’s the abstract from our proposal:

Social Anxiety (SA) is a common, chronic psychiatric problem characterized by social withdrawal, significant psychological distress, and educational/employment difficulties. In NHS settings, resources and choices for effective treatment for SA are currently limited.  In a pilot partially randomised study we developed a promising SA-specific form of Person-centred/humanistic psychotherapy called Emotion-Focused Therapy (EFT), aimed at reducing SA by enhancing client self-compassion; we found large amounts of client pre-post change, superior to a comparison treatment and equivalent to comparable studies of CBT and medication. We are seeking funding for a pilot RCT study comparing this new treatment to a NICE-recommended Cognitive-Behavioural Therapy (CBT) based on the Heimberg model. Two groups of early career psychotherapists will be trained in the use of these specialist models for SA, with 52 clients assigned randomly either to CBT or EFT for up to 20 sessions.  Target outcome measures will assess SA symptoms and individualised presenting problems.

My Mother’s 84th Birthday/Science My Mom Taught Me

Entry to 7 April 2013:

I’ve been working late to finish a grant proposal, so it’s well after midnight in Scotland, Monday, the 8^th of April.  In California, however, it’s still Sunday, 7 April, my mother’s birthday.  Last year, my siblings and I gathered at Anna’s house on this day to celebrate our mom’s 83^rd birthday.  We knew something was wrong then, and we also knew at the time that she believed that she had reached her last year, her 84^th, the completion of her 3^rd Saturn Return.  What neither she nor we knew then was that she would be dead by the end of June, a few days past the summer solstice.  So tonight her children are marking what would have been our mother’s 84^th birthday by reflecting on her passing.   A little while ago, my brother Conal and sister Louisa checked with poignant reflections about both of our parents.  This is my contribution to the process.

A year ago, on her birthday, I read her 75^th birthday poem to her again and gave her a mobile of multi-coloured butterflies made from bird feathers to represent the final image in the poem.  After she died I brought this mobile back with me to Scotland to remember her by, and it’s in my living room now, a bit of her. 

I know that she and my dad are in my head and heart, a part of me.  They are my psychological and spiritual DNA and of course their actual DNA is in every cell of my body. (And my mitochondrial DNA?  That’s all my mom’s, matrilineal descent, you know?)  Nevertheless, I still miss her physical presence and the opportunity to experience the unpredictability of her continuing evolution.  So tonight it’s a kind of intermediate stop on the way to her year’s mind, an interim Kaddish at which I, along with my siblings, remember fondly, longingly, and with deep gratitude and joy for what she gave us.  Bittersweet, like the strong chocolate that she loved.

I can’t think of a better way for me to remember her than by offering again the poem I wrote 9 years ago for her 75^th birthday:

Science My Mom Taught Me

(For her 75^th birthday, April 7, 2004)

1. Science as Love and Relationship

A good place to start is that ancient photograph,

Recently rediscovered, from 1950:

There the two of you are, the same age

As the youngest of my grad students. 

Both of you are tall, almost toothpick thin.

He is looking at the camera, tight jeans and shirt,

Like a rebel with cause to smile.

But you are looking down, through large glasses,

Your face framed by billowing hair,

With toothy grin, and your arms

Awkwardly but carefully wrapped round

A very small bundle.

The two of you look like nothing

So much as a couple of computer nerds

From half a century in the future.

Code geeks, rolling out your first promising program,

Ready for beta-testing.

But the code is genetic,

The language is life,

And the program is … me.

 

2. True Science is Risky

Although I learned magic from my dad,

It now seems clear to me that it was you

From whom I first learned science,

To which I have now devoted so much of my life.

But yours was never the normal, safe kind,

Digging away at the coal face

In the mines of knowledge,

Like Disney’s happy dwarves.

No, not that kind, but instead

The one that goes off to Far Tortuga,

Toward distant Galapagos unknown,

In search of the evolution of the human soul.

For you, big ideas have never been too big:

The nature of reality; the journey of the soul;

Jung’s famous paper on flying saucers;

The archetype of the Mandala: As without, so within.

Instead of Aristotle … Plato’s forms;

Instead of Archimedes … Pythagorus’s numbers;

Instead of Moses’ law … the Kabbalah’s secrets;

Instead of chemistry …alchemy’s transformations.

Oh, you did chemistry, too, at least early on:

You would disappear for hours,

Into your laboratory at the back of the house,

Full of strange smells and odd bits:

Broken glass, mosaic pieces,

Rolls of wallpaper, bolts of cloth,

Cans of precursors and catalysts,

When plastics was new technology.

And you would emerge from your lair,

To confront your family with some new concoction,

Sometimes lovely, or quirky, or primitive;

At times, a disaster, but always something new.

No, for you, science has always been risky:

Working at the edge, making something new,

You have become an expert in the peril of experiment,

And I have followed you, where I could.

3. Science as Inspiration and Passion

Your mother (my grandmother) taught me many things:

How to travel and how to be in a new place;

The importance of hard work and getting up early;

The ninety-nine percent of sweat that makes up genius.

But you taught me a far more valuable lesson:

The one percent of inspiration that redeems all the rest,

The moment of epiphany, the pattern opening,

The intensity of the new connection breaking through,

The science of cutting to the center of the world,

Of seeing what others don’t choose to see,

Of waking to awareness when others sleep,

And the flow of following the spirit far into the night.

When I see these things in myself, I recognize you.

The passion of discovery is too powerful to resist,

Even if we wanted to; the daemon must be honored;

It is ours, and we must let it speak through us or die.

4. Science as Always Starting Anew

I find it odd that I describe my dad in a series of narratives,

But you as a set of ideas, a paradigm, a model.

There is, however, one story that is always you,

The story in which you are always re-inventing yourself:

Child of the Depression with a single mom;

Big city girl; prep school party-er;

Young, anxious mother and seamstress;

Small town society woman in a flat land.

But your life makes a strange turn: You take up philosophy;

You quit smoking just because you feel like it;

You return to religion and start teaching Sunday school;

You become a small business owner and a writer.

Years pass: You’re CEO of a large and raucous family,

With the habit of taking in strays (both human and animal);

And you’ve gradually evolved into a spiritual leader

Of a small but loyal group of friends.

Then, your life turns again:  Warned in a vision

Of the impending end of civilization, you become

A gentle survivalist and take your family

Into the mountains, like Noah waiting for her flood

You seal several tons of wheat into cans,

Which are still there after twenty-five years.

Well, we can’t get everything right, but now you live

In a beautiful little valley: Murray Creek.

Now you are matriarch to three generations and 60 acres.

A combination of Ariadne, Daedalus and Theseus,

You become a labyrinth designer and unwinder

Of ritual journey spaces of stones, words and image.

Reading widely and deeply, you map the interweaving

Stories of your own and humanity’s spiritual development,

Join a religious order, become a spritual director,

And finally, start a Crone Circle of wise women.

Curiously, all these things somehow fit together:

Clearly, you’ve never stopped starting over;

For you, science is leaving behind what no longer works,

A selfsame process of adding on, differentiating, elaborating,

Just as you are always the same person,

The passionate, intellectual adventurer, the one

Who keeps transforming herself, like an endless succession

Of butterflies, emerging one from the other. 

Photo by Conal Elliott, Upper House, Murray Creek, 27 March 2013, by permission.

“No New Meds”: Article in Science News

Entry for 30 March 2013:

I didn't think I'd live long enough to see the psychopharmacology movement begin to run out of steam! While drug companies defund research on new psychopharm drugs, others in the field continue to search desperately for ways to save the paradigm, such as cutting corners in the drug development process. What is bracing and unexpected here is the range of scientists admitting that there are real problems with the field, including the fact that no new classes of psychiatric drugs have been introduced in the past 30 years. What they seem to be missing in all of this is the idea that psychotherapy/counselling is a much more refined and differentiated psychopharmacological agent for helping people change their brains by changing their experiences and behavior. Let's hear it for neuroplasticity!

No New Meds | Humans | Science News

Web edition: February 7, 2013 Print edition: February 23, 2013; Vol.183 #4, (p. 26)
With drug firms in retreat, the pipeline for new psychiatric medications dries up
Psychiatry seemed poised on the edge of a breakthrough. In early 2011, after decades of no radically new drugs, a fundamentally different schizophrenia treatment promised relief from the psychotic hallucinations and delusions plaguing people with the disease. The new compound, devised by chemists at Eli Lilly and Co., hit a ...

http://www.sciencenews.org/view/feature/id/348115

Music for Good Friday

Entry for 29 March 2013:

I think George Crumb's Black Angels (Thirteen Images from the Dark Land), written during the Vietnam war for amplified string quartet, captures the battle between the forces of light and darkness in the Passion story, and speaks to the horror of the crucifixion, going beyond the mood of sadness say at the end of Bach's St Mark Passion, played live tonight on BBC Radio 3.  

I thought of Crumb's dramatic and eerie music tonight during our Good Friday evening service, when Jesus' last words were shouted out,  but it could also be a sound track also for the rest of the story: the arrest in the garden, the trial, the scourging etc.  It has a similar modernist starkness to Gwyneth Leach's Stations of the Cross paintings, used in the service tonight (see http://wanderingmedic.wordpress.com/2013/03/29/death-on-the-cross/) with their depiction of soldiers carrying automatic weapons, guard dogs, and barbed wire.  If you don't know Black Angels and are curious (it's definitely not going to be to many people's tastes), you can find live performances of it on You Tube for example: http://www.youtube.com/watch?v=m5a2RXA2Jn8 .  (Yes, they really are playing musical water glasses with their violin bows.)

Questions from 2013 EFT 1 in Turnhout, Belgium

Entry for late March 2013:

Questions: At various points during EFT training workshops I like to ask the participants to tell me what questions they have about EFT.  At the beginning of the month I spent a couple of days in Turnhout, Belgium, east of Antwerp, running the last two days of an EFT level 1 training.  It was a great group and by the afternoon of the last day many of the participants had experienced big emotional change processes, which was exciting to see.

Here are a couple of the questions they asked, along with some answers:

1. Question: How directive do I have to be if the client is reluctant to change chairs?

Answer: If you’re in the middle of a two chair process and they decline an offer to change chairs, it is likely that the client has more to say from the part they’ve been speaking from; therefore, it’s a good idea to follow their lead, perhaps asking for what else comes to them. 

More difficult is when a client refuses chair work altogether.  Then, it’s important to empathically recognise and explore the client’s reluctance, while at the same time validating their choice.  It’s hard for clients to say no to therapists, so it’s useful to assume that they have a good reason for doing so, rather than attributing this to “resistance”.

2. Question: How do we balance relationship and task aspects of EFT? 

Answer:  This is another example of a dialectically constructive process, but in general in EFT we try build a strong relationship early on in order to support later difficult work on tasks.  Once that is established, often by around the third or fourth session, we work on tasks with the client, to as great an extent as the strength of the relationship and the client’s resilience/fragility allows.  In the process, we empathically hold small relational issues, concerns or hesitations; but if the relationship is ruptured, we stop working on whatever task we were trying to facilitate at the moment, because at this point, the relationship becomes the task.

3. Question: What do you do when a chair task seems to run out of energy? 

Answer: It’s often useful to ask an exploratory question, such as: “What are you experiencing right now?” or  “Where are we with this? “  “What do you need?” Alternatively, you can ask if the client is still experiencing the conflict. (I call this “going back to the marker”).  Yet another possibility is to go back to the most powerful/important/difficult part (getting back to the trail).  Finally, running out of energy for a task may simply mean that it is time to look for a different task (eg focusing, self-soothing, unfinished business).

Thursday Symphony Adventure: What does the Sibelius Fifth Symphony Have to do with Emotion Focused Therapy?

-->Entry for 21-23 March 2013:

Diane’s away in the US helping her mother, and I’ve been away working in various places for the past 3 weekends, so Adventures have been a bit scarce lately.

On Thursday, however, there was a concert of the BBC Scottish Symphony Orchestra, featuring the Sibelius Fifth Symphony, conducted by the rising Finnish conductor Hannu Lintu. 

The Sibelius Fifth is one of my most favourite pieces of music, ever since I bought my first recording of it in 1971.  It has sweeping melodies, pumping rhythms, and lots of emotional dynamics, from quiet solos to intense crescendos …. and one of the most amazing endings in the whole symphonic repertoire.

So when I saw this on the schedule 6 weeks ago, I marked it on my schedule and resolved to go.  City Halls, the home of the BBC Scottish SO, is only a five-minute walk from my office, after all. 

Various complications intervened during the week to throw my Symphony Adventure into jeopardy, but in the end I made it with five minutes to spare, sitting down next to two little old ladies who were pleased indeed with their £7 concession tickets. 

The BBC Scottish SO looked stylish but casual dressed in the their black tops and trousers for this afternoon concert.  Hannu Lintu bounded out form the wings, very tall and Nordic, big hands, baton at times threatening to collide with the microphones over the stage.  He danced his way through the Ravel’s Tombeau de Couperin and Haydn’s Symphony 98, both very tasty, the latter quite amusing actually.  Then, after the intermission, what I’d been waiting for: the Sibelius 5^th Symphony. 

I think Sibelius is a composer whose music really is even better when experienced live up front in concert.  He passes melodies all around the orchestra in a way that’s hard to capture in recordings.  The plucked pizzicati are more dramatic.  There are several places in the piece, one in the first movement and then again in the final movement where it all builds up to such a level of intensity and you can see the intensity of everyone in the orchestra playing in unison for all they’re worth.  It’s almost unbearably powerful.  It reminded me of those moments of really intense emotional contact in therapy when the client contacts their core pain, and something inside them shifts and you go with them, you feel it in your body and all over.

According to the program notes, the Fifth Symphony was inspired by a spiritual experience Sibelius had in 1915, in which he saw a ring of 16 swans flying high in the air in a large circle.  It took him five years to get it right to his satisfaction, but this was the inspiration for soaring melody of the last movement.  This performance, which the audience applauded enthusiastically for several minutes, was certainly the high point of my week, and as I walked back to my office, appropriately enough through the bitter Nordic wind and blowing snow, I felt elated and inspired.  As I said the next day to this year’s EFT Level 3 supervision group, it’s these moments of intense contact that makes life worth living.  Long live Sibelius and EFT!