Saturday, September 29, 2007

PE-EFT and Motivational Interviewing

Entry for 28 September 2007:

Paper presented to Alcohol Focus Scotland National Alcohol Counsellors Forum, September, 2007.

I. A Bit of Family History…
-Two Main Clans (“Tribes”) of the Person-Centred Approach (PCA)
-Depends on which side of Carl Rogers’ famous “process equation” you focus on:
-Therapist facilitative conditions => Client experiencing

(1) Classical
-From early/middle-period Rogers:
-Focus on therapist relational conditions:
-Empathy, nonpossessive warmth, genuineness
-Person-centred counselling/ therapy
-Various names: “Classical”, “Nondirective”, “Relational”
-Most prevalent in USA, UK
-Also: Pre-therapy (Prouty): Help psychotic clients re-establish psychological contact

(2) Experiential
-From Late Rogers:
-Focus on client experiencing/ process
-Focusing (Gendlin)
-Process-Experiential/Emotion-focused therapy (PE-EFT) (Greenberg, Rice & Elliott)
-German version of person-centered (Sachse: “goal-oriented”)
-Most prevalent in Canada, Belgium, Germany

(3) Integrative PCA
-Existential (Cooper: PC practice + existential theory)
-Expressive (N. Rogers; add play, expressive arts)
-Other Integrative (add other bits to PC base)

(4) Neighboring Peoples (“Cousins”)
-Third Generation CBT: Mindfulness-based CBT (Williams & Teasdale); Acceptance & Commitment Therapy ACT; Hayes); Dialectical Behavior therapy (Linehan); Schema-focused CBT (Young)

II. Contemporary Person-Centred Therapy: PE-EFT
A. History:
-Sources: Humanistic therapy tradition: Person-centered, Gestalt, existential therapies
-Early development, 1970-1985: York University (Canada):
-Early information-processing psychology; Laura Rice; Task analysis
-Late 1980’s: Piloted at University of Toledo
-Early 1990’s: Formalized in Greenberg, Rice & Elliott Facilitating Emotional Change, 1993
-Late 1990’s: Became known as Emotion-Focused Therapy (EFT; Johnson, Greenberg, Paivio)

B. PE-EFT: Distinctive Features
1. Neo-humanistic: Revival/ reformulation of humanistic/ experiential approach to therapy
2. Emotion-focused: Emotional awareness and reprocessing as central to client change
3. Relational stance: Active following of content with some direction of process
4. Exploratory therapist response style: Empathic exploration responses, exploratory questions
5. Marker-guided: Client indicators signal readiness for specific therapeutic tasks
6. Research-informed: Based on research on client change processes; supported by outcome research

C. PE-EFT Therapy Principles
Relationship Principles: Facilitate safe, productive relationship:
1. Empathic Attunement: Enter, track C’s immediate & evolving experiencing
2. Therapeutic Bond: Express empathy, caring and presence to C (bond aspect of alliance)
3. Task Collaboration: Facilitate mutual involvement in goals and tasks of therapy (task/goal aspect of alliance)
Task Principles: Facilitate work on specific therapeutic tasks
4. Experiential Processing: Foster relevant client micro-processes (e.g., attending, experiential search, active expression, interpersonal contact; self-reflection, action planning)
5. Task Completion/Focus: Facilitate client completion of key therapeutic tasks
6. Self-development: Foster client new experiencing, inner strength, agency or empowerment

D. Theory: Emotions are Fundamentally Adaptive
-Emotions tell us what is personally important (information)
-Emotions help us to survive by providing an efficient, automatic way of responding rapidly to important situations
-Emotions prepare us for action: emotions generate wishes/needs, which generate action
-Emotions integrate experience; give it meaning, value & direction
-Three basic concepts: Emotion Schemes; Emotion Response Type; Emotion Regulation

1. Emotion Schemes
-Involved in implicit/automatic processing of experience
-Not available to awareness until activated and reflected upon
-Idiosyncratic and highly variable
-Complexity: Many operate simultaneously
-Empathy, evocative and exploratory work required to foster access, activation & self-reflection
-Complete processing involves all elements

2. Emotion Regulation Necessary for Adaptive Functioning
-Optimal level of emotional arousal or distance
-Varies with situation/task
-Too little & too much both dysfunctional
-Ability to self-regulate emotion derives from early attachment experiences
-Requires both: Ability to access, heighten or tolerate; & Ability to contain or distance

3. Forms of Emotion Response
-Primary adaptive: unlearned, immediate response to situation
-Primary maladaptive: learned, overgeneralized immediate response to situation, no longer fits
-Secondary Reaction: Emotional reaction to a primary emotion response
-Instrumental: Produced for intended effect

4. Change Principles of Emotional Processing (from Greenberg, 2004)
(1) In general, promote emotional awareness/symbolization: (Emotion scheme model)
(2) With overwhelming emotions, promote emotion regulation
(3) With avoided or secondary emotions, help clients deepen and differentiate experience: “You have to arrive at an emotion before you can leave it.”
(4) With maladaptive emotions, change emotion with emotion: Help client find overlooked adaptive emotions and use these transform maladaptive emotions
-E.g., Anger <=> Sadness

E. Therapeutic Tasks
-From research on human problem-solving
-Clients bring specific immediate concerns (tasks) to sessions
-Elements of a therapeutic Task:
1. Marker: observable sign that client may be ready to work on a problem
2. Client steps to resolution
3. Therapist facilitating responses
4. What resolution looks like

A. Examples of PE-EFT Tasks: Marker => Task
-Beginning of Counselling => Alliance Formation
-Unclear feeling => Focusing
-Vulnerability => Empathic Affirmation
-Problematic Reaction => Systematic Evocative Unfolding
-Internal Conflict Split => Two Chair Dialogue
-Unfinished Business => Empty Chair Work

B. Two Chair Work for Internal Conflict Splits
1. Conflict Split Marker: (1) Two wishes or action tendencies; (2) Description of contradiction, conflict between; (3) Expression of struggle, coercion
-Experience: uncomfortable "tornness"
-Types of Conflict Splits: Decisional conflict; Self-Evaluation (self-criticism); Coaching (self-coercion); Externalized splits: over-reaction to others

2. Client Resolution Stages for Internal Conflict Splits:
(1) Marker/Task Initiation: Client describes internal conflict in which one aspect of self is critical of, or coercive toward, another aspect.
(2) Entry: Clearly expresses criticisms, expectations, or "shoulds" to self in concrete, specific manner.
(3) Collapse/Deepening: Experiencing chair agrees with critic (“collapses”); primary underlying feelings/needs begin to emerge in response to the criticisms. Critic differentiates values/standards.
(4) Emerging shift: Clearly expresses needs and wants associated with a newly experienced feeling.
(5) Softening: Genuinely accepts own feelings and needs. May show compassion, concern and respect for self.
(6) Negotiation. Clear understanding of how various feelings, needs and wishes may be accommodated and how previously antagonistic sides of self may be reconciled.

3. Internal Conflict Splits: Therapist Facilitating Responses
-Stage 1: Identify client marker (including pre-marker work); Offer task to client
-Stage 2: Structure (set up) experiment; Encourage separation & contact; Promote owning of experience; Help intensify client emotion
-Stage 3: Help Experiencer access and clarify underlying feelings; Help Critic access, clarify values and standards; Follow deepening forms of the conflict; Facilitate identifying with; expressing; or acting on organismic need; With collapse: Accept/deepen/ differentiate Hopelessness; or Encourage greater specificity in Critic; Without resolution: Bring contact to an appropriate close
-Stage 4: Facilitate emergence of new organismic feelings; Help create a meaning perspective (=processing)
-Stage 5: Facilitate softening in Critic (into fear or compassion)
-Stage 6: Facilitate negotiation between aspects of self re: practical compromises

III. … and What of Motivational Interviewing (MI)?
A. Nature of MI:
-“We define motivational interviewing as a client-centered, directive method for enhancing motivation to change by exploring and resolving ambivalence.” (Miller & Rollnick, 2002)
-Emerged as an alternative to directive/confrontive approaches to substance misuse
-Miller credits Carl Rogers & Tom Gordon as a primary source for MI
-But: commonly combined with information/ feedback = Motivational Enhancement Therapy (MET) (e.g., Project Match)

B. Further Applications of MI
-Extended to other forms of health-related behavior (e.g., over-eating, smoking; Rollnick et al., 2007)
-Being applied to broad range of client presenting problems (e.g., anxiety, depression; Westra, 2004; Arkowitz et al., in press)

C. MI: “Directive” (Guiding) use of Client-centred therapy
-Guide process (not content)
-Help person work with their own ambivalence and access self-motivation
-"Resistance" is generated interpersonally by pressure/control => psychological reactance.
-Avoid confrontation of avoidance & self-damage
-Instead, explore, help person access self-motivation
-Explore both sides of self-damaging behavior
-Miller & Rollnick: If you are acting as a “change advocate”, you are not doing MI!

D. Comparing “Spirit of MI” with PE-EFT Concepts:
Motivational Interviewing || Process-experiential/ Emotion-focused Therapy
-Collaboration || Task Collaboration Principle
-Evocation || Experiential Processing Principle; Task Stage 2
-Autonomy || Self-Development Principle

E. Comparing General Principles of MI & PE-EFT Concepts:
Motivational Interviewing Process-experiential/ Emotion-focused Therapy
1. Express Empathy || Empathic Attunement & Therapeutic Bond Principles
2. Develop discrepancy || Experiential Processing & Task Focus/Completion Principles
3. Roll with Resistance || Relationship Principles (Attunement, Bond, Collaboration)
4. Support Self-Efficacy || Self-Development & Therapeutic Bond Principles

F. MI: Person-Centred or Not?
-Pure MI = Person-centred in contemporary, process-guiding sense
= Member of client process-oriented Experiential Clan
-Cautions: “Change Advocate MI” is not MI, and is not person-centred; Information/feedback element is not “pure MI” (Miller & Rollnick); Zuckoff: Growing dissatisfaction with adding feedback to MI; can be counter-productive

F. The Weird Paradox of MI’s Evidence Base
-Burke et al., 2002, review of MI outcome research:
-No research on MI without feedback or other directive intervention
-Instead: Cite Greenberg, Elliott & Lietaer (1994; update: Elliott et al., 2004) meta-analysis of effectiveness of person-centred & PE-EFT to support effectiveness of pure MI
-But doesn’t include research on substance misuse

IV. A PE-EFT View of Motivational Interviewing
n MI represents an well-developed approach to working with a particular type of internal conflict split
A. Self-Damage Split marker:
-Person is aware that something is harmful to them (e.g., drinking, over-eating)
-They engage in the behavior anyway
-They experience distress over their behavior or its consequences

B. Self-Damage Splits
-Applies to broad range of unhealthy behaviors
-Things we do that aren’t good for us
-food, dangerous behavior, putting ourselves in stressful situations, not sleeping enough, failing to get enough exercise, ignoring health warnings

C. Working with Self-Damage Splits: MI Therapist Facilitating Responses
-MI: Empathic but focused exploration of both sides of the ambivalence about the self-damage split
-Explore: “Reasons to change” vs. “Reasons not to change”
-Help client access, clarify, consolidate, and eventually act upon self-change side of split
-Counsellor must do personal work in order to address critical reactions to client self-damaging processes, avoid becoming “change advocate”

D. Working with Self-Damage Splits: PE-EFT Therapist Facilitating Responses
-Offer Two Chair Work to help client explore both sides of their ambivalence
-Makes the conflict explicit
-More evocative => access emotions attached to each aspect
-Helps counsellor detach from critical reactions
-Strong evidence base for effectiveness of Two Chair Work with depressive splits (Greenberg & Watson, 2006)

E. Engle & Arkowitz (2006): Comparing MI with Two Chair Work
1. Share assumptions and relational stance
2. 2-chair/PE-EFT: Greater access to emotion; Access more complex experiences (Should Self, Reactant Self, Desired Self, Feared Self); Work is more fluid and evolving. But may be too much for some clients, especially early on (< session 3 or 4); Harder to teach to counsellors
3. MI: Use for more highly distressed or self-conscious clients
4. Useful complements to each other

F. Work with Self-Damage Splits: More Research Needed
-No research focused specifically on self-harm splits
-Needs more study to identify nuances in the work, e.g.,
-Strengthening ineffectual coach/self-change parts
-Avoiding internally-generated self-reactance

V. PE-EFT Resources
Recommended books for learning more:
-Elliott, Watson, Goldman & Greenberg, 2004: Learning Emotion-Focused Therapy
-Greenberg & Watson, 2005, Emotion-Focused Therapy for Depression.
-Engle, D.E., & Arkowitz, H. (2006). Ambivalence in Psychotherapy.

Trip to Dublin

Entry for 25 September 2007

In 1963, when I was 13, my grandmother took me on a trip to Europe. We took the boat (the Oriana) from San Francisco, through the Panama Canal, and across the Atlantic. It’s so long ago that I don’t remember many of the details, such as how we got from Southampton to Ireland, but this trip was one of the turning points in my life, in which I developed a more expansive, adventurous sense of myself. Our first major destination was Dublin, where we spent a week while my grandmother researched a novel she was working on at the time. Last weekend we returned to Dublin.

Six years ago, my friend Laco attempted to fly to the US on 11 September, 2001. He was on his way to spend 6 months working with me at the University of Toledo on a Fulbright Fellowship. He ended up along with 15,000 other people at a refugee camp outside of Amsterdam, but eventually, in spite of his airplane phobia, was able to get to the US, where he, his wife Katka and young son Adam, had a fruitful, if somewhat stressful time, in Toledo. Two years ago, they moved to Dublin, where Laco works at Trinity College running the Counselling Psychology course there. He has been anxious for us to come see him since we arrived in Scotland a year ago.

It has taken us a year, but last weekend we finally made it Dublin: We grabbed an early dinner and took the train to Prestwick Airport, where we caught the flight to Dublin on budget airline Ryanair. Our flight was a bit late, and the people on it were in high spirits, talking loudly and excitedly and teasing one another. Laco was waiting for us in the crowd as we came out of international arrivals. By midnight we were at his place in Clontarf, a nice northern suburb on Dublin Bay. It was a delight to see him and Katka again, and we sat around the kitchen table for awhile, reminiscing about their time in Toledo, catching up on families and figuring out what we were going to do for the next couple of days.

The next morning was clear, bright and lovely. Since Katka and Laco had kindly lent us their bedroom, various of their three small children were startled and somewhat disconcerted to discover that their parents had been Replaced by Strangers. By the time we got up, somewhat blearily, there were 5 people crammed into the little bedroom at the end of the hall. Adam looked as he had the last time I saw him, in Bratislava, about 3 years ago, but bigger. The twins Domenika and Natalia, one dressed in blue and the other in pink for easier identification weren’t just walking now but were running busily around intent on various activities. Altogether a really charming set of kids!

Laco and Katka live only about a quarter of the mile from the water, so on Saturday morning we walked out along the northern breakwater of Dublin Bay, as far as the statue of the Virgin Mary. There was a light wind and the tide was out. Away to the north we could see the cliffs above Howth, while across the bay and in the distance to the south we could see another set of cliffs. As we walked, we watched a freighter was coming in from the Irish Sea, past the twin light houses at the ends of the pair of breakwaters that frame the entrance to the inner part of the Bay, passing in front of the stacks and oil refineries on the south side.

The night before, we had agreed on a set of goals for the day, organized around things that I remembered from my previous visit to Dublin in 1963. Like our visit to Sheffield the previous weekend, this trip turned out for me to be partly about recontacting another part of my past.

There were too many of us to fit into their car, and the kids insisted on taking the bus as an adventure, so Laco and I drove in while Katka and Diane and the three kids took the bus. Laco parked at Trinity College, which was full of tourists, and we walked north, across the Liffey River to meet the rest of our families. The city centre was full of people, out on a warm Saturday afternoon. Maybe my sample was biased, but in comparison to Glasgow, the people seemed to me to be less rowdy (there was a buzz of talk but it was more of a murmur); there seemed to be less obesity (a serious cause for concern in Scotland); and finally, people were more modestly dressed than seems often to be the case in Glasgow.

After lunch at one of their favorite places, a patisserie, and a wander over to Saint Stephen’s Green, Laco took us back to Trinity and got us tickets to see the Book of Kells. I remembered having seen this in 1963, in the same building, but there is now a modern style museum, complete with museum shop, built up around the famous illuminated manuscripts, which are now displayed under low light conditions to protect them. The Book of Kells is actually four books, the four Gospels, two of which were on display, open to an illustration from the Book of John and to the parable of the unfaithful steward from the Book of Luke. (I read a little Latin, but know this only because there was like legend next to the latter. However, I was startled as Mass the next morning to discover that the Luke passage was this week's Gospel reading.) One of the things that struck me was the way in which the scribes sometimes drew their illuminations around the naturally-occurring holes in the vellum.

Over the course of the afternoon, we also visited the Shelbourne Hotel, which my grandmother and I had stayed before (parts looked familiar but it had been substantially remodeled over the ensuing years). But the high point of our museum visits was our quick visit to the National Museum, where my grandmother had taken me to see St. Patrick’s Bell. The story is this: Her family, the Mullens, had according to legend been entrusted with the keeping of this bell by St. Patrick, on the condition that they not go to war with other tribes. When they broke this trust, she had told me, the bell was taken from them. So the Bell is both a mark of pride and a symbol of reproach for the Mullen family, my Irish ancestors.

It was almost closing time, but a quick tour around the museum located two bells of St. Patrick (bells were big with medieval Irish saints, because they were used to call people to worship): First, we found the Black Bell of St. Patrick, in the medieval section, but this didn't seem quite right. Then, finally, we found the Iron Bell of St. Patrick, in the Treasury section (a selection of national treasures). I knew that to be the right bell, because of the fancy, jeweled encrusted case for it, also on display. This was The Bell of family legend. It was good to see it again. Another circle connected, past to present.

* * *
By the time we flew back to Glasgow on Monday morning, we had had lovely dinners out at a fine French restaurant and a Japanese noodle place; we had wandered around the city centre for several hours, through pedestrian malls; sat among the crowds sunning themselves on St. Stephens Green; bought Irish chocolate at Butler’s; visited the cliffs on both north and south ends of Dublin Bay, including driving past Howth Castle & Environs (HCE), of Finnegans Wake fame; bought Irish music; and stumbled across the James Joyce Museum in the old Napoleonic-era defensive tower at Sandycove, the scene of the opeing of Ulysses. Diane had visited Ireland for the first time and I had made another connection with my past, both to my visit with my grandmother in 1963 and to my reading of James Joyce’s Ulysses, almost as long ago. As important, we had reconnected and deepened our friendship with Laco and Katka. We plan to return again before another 44 years!

Tuesday, September 25, 2007

Counselling Skills: It Ain’t Necessarily So

Entry for 23 September 2007:

In the mid-1970’s, together with fellow UCLA grad students Chris Barker & Nancy Pistrang (and others), I embarked on a research program to examine the assumptions of the helping skills training programs that were widespread at the time. We had been trained by our advisor, Jerry Goodman (who had studied with Carl Rogers at the University of Chicago) in a client-centered/person-centered approach to therapy that encouraged (with varying degrees of directness or subtlety) empathic reflection, silence, and self-disclosure, that discouraged the overuse of questions and interruption, and that was skeptical of the value of interpretations and advice-giving. While there was a small research literature bearing on the effectiveness of each of these response modes, no one had ever asked clients what they thought about actual therapist responses in their own sessions.

This was exactly what we proposed to do, using a new research application of Norman Kagan’s Interpersonal Process Recall method, in which we played videotapes of sessions back for clients right afterwards. True to our training, we believed that clients would generally report that empathic reflections to be the most effective therapist response.

However, we were disabused of this notion in our initial one-session analogue study, when our very first research participant told us, in no uncertain terms, that he hated his helper/counsellor's reflections, explaining to us that they reminded him of a previous unsuccessful therapy. It was clear to us that he had acquired a kind of “allergy” to not-particularly-deep, mechanical-sounding (“wooden”) reflections of content. Our conclusion: There is nothing as bad as a bad reflection! (This phenomenon of the interpersonal allergy to a particular kind of helping response is something that I have seen repeatedly over the years, but have never seen documented in the literature. It would be really interesting to do research on it.)

And so it went: we found something like that for each of the response modes we were investigating: Some were very helpful; many were slightly or somewhat helpful, and a few were hindering. We also found that, on average, clients found interpretation most the helpful, and questions the least helpful. (Questions were often viewed as "help neutral" -- for the therapist rather than for the client.) But as I said, there were exceptions in every case: They hated interpretations when they were incorrect or implicitly critical of them, and they loved questions when these were open-ended, focused on unpacking implicit emotional experience, and occurred with a good working alliance.

In other words, all the generalities we had been taught about therapist response modes (also known as types of therapist response, speech acts, or “skills”) were wrong! Instead, we learned, the helpfulness of therapist responses is highly contextual and strongly influenced by specific content, verbal and nonverbal manner (which in turn reveals the therapist’s attitude toward the client), and timing. It took me 15 years to work this all out systematically, but eventually I developed a method for unpacking all these factors: Comprehensive Process Analysis (Elliott et al., 1994).

Now I have returned, full circle, to my person-centred roots and to the question of counselor response modes. The students on the diploma course come to us, most of them, having had a counselling skills course in which they have been taught, just as my friends Nancy and Chris and I had been, many generalizations about different counselor responses. In particular, they have been taught use reflections and silence, and to avoid questions (and also advisements and interpretations). But, to quote from Gershwin’s famous American musical, Porgy and Bess, “It ain’t necessarily so.”

Last week the Monday Parttime Diploma Counselling course began with a weeklong intensive, culminating in a day of skills training and their first supervision group. And so it came to be that many of the students I worked with in counselling skills sessions or supervision left in a state of confusion, after having been informed that most of what they had learned on their counselling skills courses was wrong. For some the confusion was unsettling, but for others it was liberating. For my part, I came away from the experience with a fuller understanding of why my colleagues de-emphasize skill training in the diploma course: to get away from the simplistic approach to helping skills that many of our students have been exposed to on counselling skills courses.

I have been saying for almost a year that our students need more specific skills training, but that’s not the kind of skills training I meant at all! I would say rather, that what students need from skills training is an opportunity to try out different kinds of helping response in order to discover for themselves what works and what doesn’t work: which questions open things up and which ones close them down; which reflections deepen exploration, and which ones fall flat; and so on. In other hands, they need to learn how to learn from their clients!

Sunday, September 16, 2007

Introduction to The Strathclyde Diploma Course Study

Entry for 17 September 2007:

This text introduces Research Input 1 for the Parttime Diploma Course, which involves completing the pretest for the Diploma Course Study.

The Strathclyde Diploma Course Study was approved by the Departmental Ethics Committee in August and is being initiated with this year’s entering classes on the Fulltime and Monday Parttime Counselling Diploma Courses. This week, the Monday Parttime Course begins, so the pre-test is being given to this group of students during their initial intensive week.

The study has been initiated by Julie Folkes-Skinner, from the University of Leicester, as part of her dissertation research, in collaboration with a local coordination team consisting of Tracey Sanders, Beth Freire and Robert Elliott.

The main research questions being addressed by the study are as follows:
-How do counselling trainees change over the course of their training?
-What kinds of changes do they experience, personal and professional?
-What training processes do they find most helpful?
-What training processes do they find unhelpful or even hindering?
-How do these changes unfold over time?
-What effects, if any, are apparent in their work with clients?
This research is important questions for several reasons:
1. They can be used to improve counselling training.
2. They can be used to support the continued training of students in person-centred counselling.
3. Taking part in the research will familiarize students with research methods, including common quantitative and qualitative data collection tools and research designs.
4. All of this will help prepare us for emerging government regulation, which is likely to involve increased training in research and evaluation methods and the use of evidence based training methods.
Because this is research, we cannot require you to take part; however, we believe that you will find the research tools to be useful and educational. You may find some of them useful when you begin your counselling practice. If you choose not to take part, we nevertheless ask you to either read over the various forms carefully or even to fill them out without turning them in.

This study is just one level of larger study:
1. Quantitative pre-post study: This is the first part of this level; there are three more parts, one right before you begin seeing clients, one at the end of Year 1, and a final posttest at the end of Year 2
2. Qualitative post-test study: We’ll ask for 8 – 10 volunteers to be interviewed at the end of Year 1 and at the end of Year 2. Let us know if you’re interested in doing this.
3. Intensive case study: We’ll ask for 2 volunteers (probably one from each course) to see clients in the Counselling Unit’s new research clinic as part of their of their counselling opportunity and to be interviewed every month or two during each year of the course. We will track the clients you see while you are working there.

Returning to Sheffield after Many Years’ Absence

Entry for 16 September 2007:

In 1984-85, we spent a sabbatical year in Sheffield, England with David Shapiro and his team, which included, among others, Michael Barkham and Gillian Hardy. This was my first sabbatical, and the year Diane, Brendan (then two years’ old) and I spent there was in several ways the turning point in my academic career. There, I learned how to set up a research clinic and to carry out complex process-outcome studies, which I have been doing ever since. As I have recounted elsewhere (Elliott, 1999), I also experienced an encounter with an old analyst (whose name I don’t even remember now), which led me to abandon eclecticism and embrace the form of person-centred/experiential therapy that eventually became Process-Experiential/Emotion-Focused Therapy. Further, this visit marked us as citizens of the world, capable of living and thriving in other countries, an attitude later played out in extended visits to Australia, Canada, and Belgium and which has now made it emotionally possible for us to move to Scotland, moreorless permanently.

We loved our year in Sheffield, going on lots of daytrips with our young son, savouring the daily strangeness of living in a foreign place, listening to the musical sound of the South Yorkshire/Sheffield dialect. I began a many-years’ collaboration with David and his team, and designed the Toledo Depression Project to parallel the first Sheffield Psychotherapy Project. The mature form of Comprehensive Process Analysis emerged out of this year, along with Brief Structured Recall, the Simplified Personal Questionnaire, and Bill Stiles’ Assimilation Model.

So last Friday, we got up at an ungodly hour to take the train down to Sheffield so I could give a colloquium on case study research at the School of Health and Related Research (ScHARR). Glenys Parry had invited me, and I was looking forward to re-encountering old colleagues and the city and it surroundings.

However, our trip soon ran into trouble when, upon arriving into Edinburgh Waverly Station at 7am, we were informed that train service south on the East Coast Line had been interrupted by a freight train fire not far east of Edinburgh. After spending the next hour trying unsuccessfully to figure out to get to Sheffield before my 12:30pm talk, the line suddenly opened up again and we were off.

We managed to arrive just at 12:30 and were able to start only a couple of minutes late. The talk went well, although I did choke up briefly at the beginning as I shared my pleasure at returning to Sheffield after so many years, a reaction that took me by surprise. After a quick bite to eat afterwards, Glenys dropped me off at David and Diana’s place.

Sheffield is much changed since 1984-85, with the grotty bits of the city centre now replaced by nicer things like the fountain-wall that now faces the train station and the Supertram that now rumbles down West Street and elsewhere. I found myself in a completely rebuilt shop, Sinclair, that we had visited 22 years ago but which I somehow recognized anyway.

I am convinced that catching up with old friends and having long heart-to-heart talks about trials and tribulations is one of life’s greatest pleasures. It is an opportunity to reconnect, to experience the continuity of life (even in the face of the death of parents and others), to re-evaluate what has transpired, and to reflect on present and future possibilities. It is what Burns felt when he wrote (or rather revised from an older source), Auld Lang Syne.

Among other things, we made visits to old haunts: I ran along the Porter Brook up past Forge Dam (reliving memories from later visits in the early 1990’s). We drove by the house David and Diana used to live in, and the house that we lived in in 1984-85. We went out for a long walk in the Peak District Park, on the Derbyshire Moors, around Burbage Edge and Higger Tor, among the fading heather and bracken just beginning to go brown, clambering over the rocks of the Edge, the fierce winds on moor blowing us to bits in the bright sunny day.

David also took us to Chatsworth, a famous stately mansion and 18th Century garden that we had fond memories of our previous time. David has taken up photography as a second career (see and is is making a study of photographing sculpture), and there was a large outdoor sculpture exhibition on, so we had fun going from one piece to another, studying how best to photograph it. This involved a lot of talk about the limitations of our small digital cameras, which was actually quite instructive.

However, the most amusing part of the afternoon was our encounter with a piece incongruously entitled, “Winter Kept us Warm”. I recognized the title from T.S. Eliot’s “The Wasteland.” The sculpture is a piece of conceptual art, about the size of an old-fashioned London police box (i.e., Dr. Who’s TARDIS) and about 9 feet tall, made of translucent glass bricks, most with a single word printed on it. I recognized words and phrases from the first section of “The Wasteland”; then I noticed the words “April is the cruelest…” in the top row of the western face of the structure. I dropped down about half way, where it was easier to read, and began reciting aloud one of my favorite parts, “Madame Sosostris, famous clairvoyant…” as I walked counterclockwise around the sculpture, occasionally stopping – professor that I am – to explain one of T.S. Eliot’s obscure references. A crowd gathered to observe the spectacle, as I circled, gradually becoming somewhat dizzy. Finally, I caught sight of Diane, who was looking somewhat embarrassed (she said she was impatient to get onto the other sculptures…) and I awoke from my ecstatic state. David remarked, wryly, as we walked off up the hill, “Isn’t it nice to be old enough not to care what other people think?”

Michael Barkham has just moved from from the University of Leeds to the University of Sheffield, where he is joining Glenys Parry and Gillian Hardy to start of new research centre integrating mental health services and psychotherapy research. They have just invited me, along with Bruce Wampold, to give a brief talk as part of their inaugural event on the 9 November. It looks like it will be considerably less than 13 years before I return to Sheffield again!

reference: Elliott, R. (1999). The Origins of Process-Experiential Therapy: A Personal Case Study in Practice-Research Integration. In S. Soldz & L. McCullough Vaillant, Reconciling empirical knowledge and clinical experience: The art and science of psychotherapy (pp. 33-49) . Washington, D.C.: APA Books.

PE-EFT Level 3 Training Begins

Entry for 14 September:

Last Tuesday, Level 3 training in Process-Experiential/Emotion-Focused Therapy formally began at Jordanhill. By a process of attrition from 30-plus at Level 1 in Summer 2006, to about 15 at Level 2 through the last academic year, we are now down to an dedicated group of 8 for the Level 3, which will focus primarily on supervision, meeting monthly between now and next June.

These folks have now been together for over a year, and so we know each other fairly well, which contributed to warm, reflective, almost intimate atmosphere. Of course cramming us into a small room roughly the size of boxcar also helped. As each of us walked in, we groaned at the absence of windows and comfy chairs, the institutional walls and table. Grahame in particular found it oppressively similar to the school rooms he often works in.

After sorting the important issues, like food (in contrast to this year’s Level 2 cohort (which started last week), we decided we wanted to continue the tradition of taking turns bringing food), we discussed the supervision process: I proposed task-focused, process-oriented supervision centred around participants bringing in video and audio recordings of their work. Specifically, the model of supervision that I use is characterized by the following:

1. It is always useful to begin supervision by saying what your supervision task is: Perhaps it is a question about a particularly difficult situation with a client, a stuck place, or a part of a session that you didn’t feel you handled as well as you would have liked to, or that didn’t go very well. Or perhaps it is a personal issue that has been activated by something that happened with a client. Maybe you simply want feedback about how you’re doing, because you’re not quite sure. Or maybe you are particularly pleased by how something went and want a bit of time to celebrate and share what you’ve learned. These are all different supervision tasks, and it really helps to know what the supervisee wants to get out of a piece of supervision work.

2. It is very helpful for supervisees to identify a segment or two needing attention and to cue the recording up to those segments. Then, the supervision can focus efficiently on these.

3. In pursuing different supervision tasks, a variety of supervision methods can be used, including micro-analysis of segments of recordings; more holistic listening to 10- 15 min of a session; more general work on personal issues raised by the material being supervised; disclosure by supervisor or group members of similar situations; group brainstorming on strategies for handling situations; role playing of situations being supervised; and mini-lectures on issues raised.

4. Issues of vulnerability and safety are important to the supervision process, as is the quality of the supervisory relationship or alliance, and therefore need to be addressed, particularly when problems emerge.

I’m not sure we addressed all of these issues, but we did cover most of them on Tuesday, After mastering the new AV set-up, we entered into the process of listening to and discussing cases and by the time break arrived, we (well, most of us) had come to see the space as quite conducive to in-depth exploration of the therapeutic and personal issues related to the cases we discussed. I haven’t seen anything on relational depth in supervision or in a group setting, but it really seemed to me that we managed to arrive at a deeper sense of one another, as we grappled with key elements of our practice, revealing pretty personal things to each other along the way. We left feeling pleased with the beginning of EFT-3.

Thursday, September 13, 2007

The Exam Board

Entry for 11 September 2007:

There is nothing exactly like it in American higher education: Once (or twice) a year, an Exam Board is convened by a high-ranking academic faculty member and a senior member of the administrative structure to review the grades and status of all students in the various courses run by a department or centre. This meeting has been planned for months, with many preparations and some degree of stress for office staff and team managers as final preparations were underway throughout much of August.

An interesting feature of the Exam Board is the use of an External Examiner for the course, that is, a person who reviews a sample of student work in order to provide quality control on a course’s grades and grading processes. For the past 3 years, Judy Moore, from our sister course at the University of East Anglia, has played this role.

Last year, Mick dissuaded me from attending the exam board, so the mystery remained; therefore, I decided it was important to me to go this year, even though I didn't have to. Yesterday finally rolled around, and Judy arrived for a round of preliminary meetings and dinner. Apparently, taking the external examiner out for dinner is part of the ritual, because there was another large party from Jordanhill at the restaurant we took Judy to last night.

The first thing that surprised me was how informal our interactions with Judy were. Mick described her role as that of “critical friend”, which seemed pretty accurate. In the pre-meetings we had before the Exam Board, Judy shared her impressions and discussed issues of concern, offering mostly positive feedback but with a few suggestions for improvement.

Then, this morning at 11am, the course managers and Judy met with the exam board, consisting of the head of another department in the Faculty of Education, and the assistant faculty officer for the Faculty of Education. I came along as part of my ongoing enculturation process, i.e., to learn what the heck is going on.

Mostly, the meeting consisted of us going over lists of names, confirming their grades and telling the convener and administrator what the student’s status was. However, this was not at all as simple as it sounds. They started by telling us that we had to provide grades for all the students for whom we’d left blanks because they were still working on their theses or in the middle of a module (UK edu-speak for a course; what they call "courses", North Americans call "programs"). Then, after discussing this with us to 10 minutes, they decided that it was OK to leave these blank after all. There was also considerable discussion of what progress categories to use for these students. We had a long document with the different grade and status categories, organized somewhat bizaarely, into two main categories: Portrait and Landscape. After studying the list carefully, I somewhat sheepishly asked if a category named (not numbered) “35” might possibly be appropriate. Yes, they said, after studying it for a moment, that should do it. And so, some substantial number of students now have their current degree status listed as “35”, which roughly translates in English as “in progress”.

Finally, Judy, our external examiner, delivered her report, which was quite glowing in its terms of praise. Among other things, she noted improvements in the quality of our feedback to MSc students this year, which she judged to be more substantial and less focused on picky details. Although it is evidence of my poor character, I must confess to a moment of silent gloating at this, having spent much of the month of July arm-wrestling with my colleagues on the MSc course over the need to raise research standards.

We are greatly relieved after this somewhat surreal event ended, and retired to the cafeteria downstairs to debrief and hang out until it was time for Judy to leave. My strongest impression from my first encounter with the Exam Board process was that in spite of the detailed document describing procedures and categories, and also in spite their having done it before, the convener and administrator actually appeared to be making the whole thing up as their went along…

Sunday, September 09, 2007

BAPCA Conference in Cirencester: Personal Highpoints

Entry for 9 September 2007:

I arrived at the BAPCA Conference with some apprehension: Would I know anybody? Would I be bored? Would anyone want to hear what I had to say about research (or process-guiding experiential therapies)? And, after my late night introduction, would anybody be sober?

However, the next morning at breakfast I found the atmosphere to be quite convivial, with people freely introducing themselves to one another. For example, I met an very interesting, 40-ish fellow named Krog who is on the Person-centred therapy course in Leeds and with whom I had quite a nice conversation.

The BAPCA large group ended up occupying a lot of my attention (and is covered in a separate entry), but it was by no means the main focus of my attention. In fact, the rest of the conference turned out to be quite enjoyable and productive. High points:

1. At Pete Sanders’ urging, I made contact with Isabel Gibbard, a person-centred counselor working in the NHS who has managed over the past 5 years to collect pre-post CORE data on some 800 complete cases of person-centred counselling in a Level 3 Stepped Care setting (i.e., between the graduate mental health worker/guided self-help and secondary care clinical psychology specialist levels). She was disappointed that only 6 people showed up to her workshop, but those of us who made it were impressed and there was a great discussion about where things are heading in the NHS. I hoping that we will be able to get access to her data set for the outcome meta-analysis that Beth and I are doing.

2. My workshop on Person-Centred Science was based on a paper I’ve recently written for the German-language journal Person. Because it was one of 7 parallel sessions, including Brian Thorne, I was expecting a small audience. However, in the end, there were 30-40 people in the session, and I was able to take the audience through the existing meta-analysis results and a stimulating discussion of quantitative research and evidence. I was very pleased with how it came out, and hopeful that something will come out of it, such as a BAPCA Practitioner Research Network or further plans for increasing the scientific literacy of Person-Centred counsellors and therapists.

3. On Saturday night, after the conference dinner, there was a “Barn Dance”, i.e., a dance in the Tithe Barn (a 19th century structure, presumably not a real tithe barn, a place for storing farmers’ payments of a 10th of their crop yields). This featured a band called the Bee’s Knees, playing traditional country dances, familiar to me from years of listening to Steeleye Span and the Albion Country Band. The dances themselves were great fun, and somewhat less vigorous and therefore more manageable than Scottish Ceilidh dancing (which helped as prior training, especially on Strip the Willow). I love it when a group of conference attendees is able to really have fun, and this group definitely passed the test, dancing on into the night even after the band went home (I left about 12:30 but Mick stayed to the bitter end about 2:30).

4. In general, however, my main impression of the conference is the openness and friendliness of the people, the emerging possibilities for research and looking more closely at each other’s work, the opening of dialogues, many of which are likely to last for years. In short, I felt welcomed, not as a visitor but as a meaningful part of a larger community. The BAPCA conference has expanded my community here in the UK, yet again, enabling me to feel more at home, and in some way larger. Thank you BAPCA!

Relational Ruptures in Large Groups

Entry for 9 September 2007:

Although I wasn’t particularly looking forward to them, I was curious about what the large groups would be like at BAPCA (British Association for the Person-Centred Approach). These were scheduled for an hour each, generally at the beginning and the end of the day. The two I went to were attended by 100-150 people, sitting in 3 or 4 concentric circles in a large room. the size of the room necessitated the use of microphones, which had to be paased, sometimes awkwardly, back and forth, which controlled the communication process fairly strictly.

The first morning group I attended was a fairly quiet affairs, and in fact, I had trouble staying awake for it (always a problem for me). One of the really odd things about the large groups here is that they have no formal ending. Instead, when the time is up, first one person gets up to leave, then a few more, until suddenly, most of the people get up and leave en mass, even though someone is speaking. This reminded me ever so much of a flock of birds taking wing, and I am sure that it is a self-organizing in much the same way as described in various forms of chaos and dynamic systems theory.

The second morning group, however, was a quite bit more lively, and confirmed all my worst prejudices about large groups: After a slow start, in which people made various announcements and plugs, a series of confrontations began, featuring increasing anger and attack. The structure of these relational ruptures, in which someone expressed anger toward someone else, seems to me to be something like this: First, someone (Person A) offers something with the ostensible purpose of helping a particular person or the group as a whole. However, something about Person A’s behavior is taken by someone else (Person B) as unfair in someway (e.g., an insult, intrusion, control). Person B either waits for the next available microphone opportunity or interrupts Person A (e.g., by standing up and physically moving). Person B then angrily expresses a public complaint about Person A’s behavior, including attributions about Person A’s character or lack of sensitivity. In a large group of this many persons, it seems clear to me, there is a very high probability that Person B’s public complain will (in EFT terms) induce primary shame in Person A.

What happens next varies. In some cases, the complaint is ignored, which then becomes the subject of further complaints; in interpersonal cycle terms, this is a pursuer-distancer cyle (Person B pursuing Person A, who then withdraws further). In other cases, there is some kind of defense on the part of Person A. Both of these responses lead to a continuation of the confrontation, and sometimes to an escalation into a mutual attack interpersonal cycle.

In PE-EFT terms, this relational breach is an alliance rupture marker, which would strongly signal the suspension of other ongoing activities and lead to structured processing of what had just happened in order to try to resolve it through a relational dialogue. In the unstructured large group I saw this did not happen. Instead, the initial response of the group was for some to come forward to support one person or the other, in effect taking sides in the rupture. However, others came in to try to take the conversation in a different direction, especially as other complaints/ruptures accumulated. As time begins to run out, still others offered empathy (generally in the form of claims to understand) and support to both of the conflict parties, in an apparent attempt to bring some closure to the rupture. Finally, there were several complaints about the group process itself (this analysis can be understood as a delayed instance of this). What was again missing, for me, was any focused, effective attempt to resolve the rupture. It was clear to me that several people had been left with untended emotional injuries as a result of the group process we had witnessed. What also became clearer to me from this experience is that the size and complexity of the group, together with the noninterventionist philosophy of the participants, militates against resolving relational ruptures; and most participants, including me, would consider it too risky to attempt to do.

In fairness, these folks might have engaged in various processes to extract meaning out of the experience, and may even through this further work derive growth out of the experience, in the same way that trauma survivors commonly extract some sort of gain from their traumas. However, this is by no means assured. Furthermore, it seems clear to me that the real issues of shame, injury, and secondary reactive processes are not being addressed. For example, Person B’s angry reactions are taken at face value, rather than as secondary reactive emotions; the primary shame and emotional pain are not being acknowledged, making the interaction less than genuine. To my mind, large groups that unfold in this manner simply replicate everyday circular (structure-bound) processes of blame and attack; I can see little value – and potentially much harm – in replicating these interpersonal patterns.

On the other hand, I can see much value in a group process in which relational ruptures are recognized as such and subjected to alliance dialogue, in which both parties are encouraged to honestly examine and unpack what happened between them, in order to access their underlying primary emotions and to truly understand the other’s experience. Focused relational work is not hand holding or depriving parties of the opportunity to work things out for themselves, as my colleagues on the diploma course at Strathclyde have objected when I proposed holding rupture processes more strongly. It’s difficult and scary and requires training and scaffolding. In my opinion, not properly training counsellors to deal with ruptures leaves them with unresolved issues and thus increases the possibility that they will replicate the process with their clients. In other words, such processes may make counsellors less rather than more safe to practice. A full articulation of a model for resolving relational ruptures in groups is badly needed. The PE-EFT Alliance Dialogue task provides a starting point, but needs to be adapted for groupwork, which is an inherently more complex situation, but which also provides more potential resources to aid resolution. A starting point, I believe, would be preparing students for large groups by teaching them the Alliance Dialogue model and having them practice in role-play situations.

Journey to Cirencester

Entry for 6 September 2007:

Mick and I escape from an intense afternoon meeting with the teaching team of the new Counselling Psychology doctoral course. It’s hard going starting a new course, and it feels like there is always another crisis in the offing. We’ve covered a lot of ground in the three hours, but of course much is still left to do. But not by us, today. We are off to Cirencester (pronounced Sye’-ren-cester), and the conference of the British Association for the Person-Centred Approach (BAPCA), to put in some face time with our person-centred brothers and sisters!

South of Carlisle: Late sun is bright on the green hills, dotted with sheep, a few black ones among the white. The train passes through valleys above streams, follows the highway from time to time, but mostly taking its own path south.

Oxenholme: Japanese tourists board train. Mikio reports that Japanese tourists are expected to visit the Lake District, but that he found it boring. From the train, though, it is lovely in the late afternoon.

As we pass into northern England, the train begins to fill up with people heading south toward London.

It turns out we are not on a train journey, singular, but on a journey of many trains: four to be exact: Glasgow to Stafford; Stafford to Birmingham, Birmingham to Cheltenham Spa, and Cheltenham Spa to Kemble, until, at last, we are deposited in Kemble, a dark, deserted station apparently in the middle of nowhere. Mick phones a local taxi, who picks us up and proceeds to drive us at a high rate of speed down narrow, dark country roads with lots of a narrow one-lane bits, while listening to old Marvin Gaye songs on the radio. Fortunately, this doesn’t take very long, although it does seem longer than the 10 minutes it actually takes. The experience brings back memories of driving with my grandfather, a former race-car driver.

Finally, we are deposited at the Royal Agricultural College (which I keep wanting to call the Rural Agricultural College, because we are clearly out in the middle of nowhere). It’s after 11, and various person-centred people are sitting around in the warm evening drinking. One gets up, wobbling slightly, to direct us to the Tithe Barn, which is filled with more folks, also drinking and somewhat wobbly and a bit disinhibited. It turns out that they have already had two community meetings, so it’s not just the alcohol that makes them wobble! This is my introduction to BAPCA.

EFT-2 Starts Again

Entry for September 6, 2007:

When I got to the end of the EFT level 2 training series last June, I felt that I had finally reached the point of feeling confident in what I was doing. I had a realistic sense of the needs and abilities of counsellors at this level, and at least some of what I have to offer them. I was then able to carry this clearer understanding into the Level 1 training that Jeanne Watson and I did last summer, to good effect.

Now the cycle continues with a new Level 2 training, which started last night. I was pleased to see 15 students, including one person from the previous years’ training, show up, full of enthusiasm and interest. Here are my impressions and reflections:

This group seems less anxious and more enthusiastic that last years’ group did. Is it me or is it the particular mix of people? In fact, most of this group have already started experimenting with PE-EFT methods with their clients, and are interested in things like supervision. One person is here partly because she had been supervising some of my students from last year and wanted to learn what they were talking about!

The main changes for this year are: (1) Sessions are every three weeks instead of every two weeks. This seems to have made it possible to people to come from farther away, because this year we have two people from Aberdeen. (2) I’ve given up even pretending to do supervision in this series, but offer it as a possibility if folks want to bring material in for supervision at the beginning, during the unfinished business period. (3) Instead, I make a solemn promise to the group that I will provide some kind of example in every session, either a video or a live demonstration. This is something I hardly did last year, until the end, which was out of character for me (in retrospect, I think I was a bit intimidated by the experience level of the participants).

Proving that every group is different, this group decides that most would rather try to meet up for a quick bite beforehand at the Three Craws Pub than have to worry about whose turn it was to bring food. The rest of us will bring our own food to eat before or during the break.

Most of the session is spent with (re)introductions, preliminary processing of structure and ground rules, but we do get down to the business of considering therapist experiential response modes, i.e., what is often disparaged as “counselling skills”. As usual my exposition of the response modes takes longer than I expected, and partway through I begin to wonder if maybe they’ve actually already heard all this last summer from Jeanne and I. Finally, we get to the video I’ve brought in, which is session one of one of my clients from the PTSD project. I stop it every time I say something and ask them to say what kind of therapist response mode they think it is. Many in the group find this procedure to be startling and distracting; they are used to watching things through, instead of micro-analyzing. In the end, after watching 7 minutes of the session, the exercise seems to work nicely at (a) demonstrating a wide range of therapist responses; (b) helping folks look at therapy in a much more process-oriented way; and (c) demonstrating how PE-EFT therapy starts. We leave on a high note, heading our separate ways home in the comfortable early autumn evening.

An interesting development is the interest expressed by several in the possibility of having assignments, to help them learn the material. I respond with a bit of market research re: the possibility of validating the courses as credit-bearing; i.e., toward a certificate, say in PE-EFT. There seems to be enough interest to warrant further exploration of the possibility.

Tuesday, September 04, 2007

Process-Experiential/Emotion-Focused Therapy: Level 3 Supervision Series

Facilitated by Robert Elliott
Professor of Counselling, University of Strathclyde

Tuesday, 6-9pm, 11 September, 2007 – 10 June, 2008
Sir Henry Wood Building
Jordanhill Campus
University Of Strathclyde
(Sponsored by the Professional Development Unit, University of Strathclyde)

The Counselling Unit at the University of Strathclyde are pleased to offer continuing training in Process-Experiential/Emotion-Focused Therapy (PE/EFT) for counsellors and psychotherapists (Diploma level or above) who have completed Level Two training in EFT. This 10-week series will meet approximately every four weeks throughout the 2007-08 academic year, beginning in September. The format will primarily focus on supervision of recorded therapy sessions, supplemented ass appropriate by viewing of archival video-recordings, brief lectures, experiential practice exercises in small groups, and discussion. Emphasis will be on putting PE-EFT into practice.

This series is scheduled for the following dates. Sessions will take place in Wood W510, except where otherwise indicated:

Autumn 2007:
11 September
9 October
6 November
4 December
Winter-Spring 2007:
22 January
19 January
19 February
18 March
15 April
13 May (W613A)
10 June

-Enrolment is set for a maximum of 12.

- Course fee: Until 15 August: £295; after 15 August: £345.

- The course could be taken for continuing professional education credit.

Professional Development Unit applications may be downloaded at (Note that that this course is not on the official list.)

Please direct enquiries to the PDU office (0141 950 3734) or Robert Elliott ( or ).

Pluralism Day Conference, Scottish Society for Psychotherapy Research

Entry for Sept 3, 2007:

Overview of the day. Today was the first event of the new Scottish local area group of the Society for Psychotherapy Research. Stephen Goss, a colleague of John McLeod’s at the University of Abertay, took the lead in organizing the day, which featured presentations by Stephen (on the philosophical background for pluralism), John McLeod and Mick Cooper (the latest installment of the pluralistic therapy model they have been working on), and me (Process-Experiential therapy as a Pluralist therapy; see previous blog entry), concluding with a final plenary discussion. The conference, attended by 40 – 50 people (mostly practicing counsellors), took place at Dudhope Castle. The castle sits on a hill above the city of Dundee, with a view out across the Firth of Tay and has a very nice garden, where many of us took our lunch and coffee breaks, enjoying the uncharacteristically sunny, pleasant day.

My presentation. I had worked on hard on my presentation, trying to articulate the somewhat ambivalent position of Process-Experiential/Emotion-Focused Therapy vis-à-vis pluralism. On the one hand, as I tried to explain in my talk, the original inspiration for PE therapy was fundamentally pluralist: that there is more than one kind of productive client process in therapy, and that the heart of PE-EFT is a kind of systematic therapeutic pluralism in various forms, the most obvious being therapeutic tasks. On the other hand, we have generally described PE-EFT as integrative rather than pluralist (it brings together person-centred and gestalt therapies, plus a bit of existential therapy), and I have long felt that my own practice benefited greatly from my becoming less pluralist after my transition in 1985.

The further complicate matters, I have been concerned about Mick and John running away with certain elements of PE-EFT (the idea of tasks and markers in particular) and claiming it for their own, which activated some territoriality in me. So I felt the need to be there to represent my point of view. Having volunteered myself, I then became concerned about making a reasonable contribution and not being obnoxious, so I felt I should really take a serious look at the relationship between PE-EFT and pluralism. And this is what I did, finally arriving at a positioning of PE-EFT as what I referred to as a form of “integrative pluralism”, and offering guidelines for the continued assimilation of other ways of working (e.g., CBT techniques) from other approaches into my approach.

Providing video of what it actually looks like in practice really helps to ground the theory, so in the end I was pleased with the content and presentation of my contribution to the day. But what made the day for me was the following two ideas that emerged:

Rigorous pluralism. The first interesting thing for me was that Stephen and John and Mick have all being thinking all the same lines about the limits of pluralism, so that each of us came up with our own qualified pluralism. Mine is “integrative pluralism”; Stephen’s is “systematic pluralism”; and Mick & John’s is “collaborative pluralism.” It appears that pluralism by itself just won’t do; it has to be tempered or balanced or combined with something else. This “rigorous pluralism” works for me!

The possibility of a task analysis of radical collaboration. The second thing that really struck me was that the heart of what John and Mick have been developing is really an intensely collaborative way of working with clients, which goes beyond what we have been able to articulate in the PE-EFT approach. I would call it “radically collaboration” (cf. Ann Weiser Cornell’s “radical acceptance”), even to the point of offering CBT techniques to a client with obsessive-compulsive difficulties (one of John’s cases he briefly presented today). The high level of therapeutic flexibility, via meta-communication, responsiveness to client needs, and in-session process evaluation was truly impressive.

In my opinion, the emphasis on the collaborative process would be an excellent way of addressing potential difficulties of lack of focus in writing, training and researching their collaborative pluralist model of therapy. I have long been concerned with the difficulty in carrying out interesting, focused research on integrative or eclectic therapies, and have been afraid that this would be the case with their pluralist therapy also. However, the articulation of the emerging body of therapeutic wisdom on the process of developing radical collaboration is eminently researchable.

For this reason, my first impulse is to encourage them to initiate a task analytic research program on establishing therapeutic collaboration. This would actually an elaboration and further development of the alliance formation task, which I have done some work on, but haven’t been able to develop in a really powerful or illuminating way. A task analysis of radical collaboration would be very interesting to see, and I’m sure that it could have a broad impact, sort of like Safran-Muran (interpersonal-psychodynamic) or Kernberg-Yeomans (transference-focused dynamic therapy), but humanistic rather than psychodynamic therapists!

Altogether a successful day, then! May Scottish SPR long prosper!

Sunday, September 02, 2007

Process-Experiential/ Emotion-Focused Therapy as a Pluralistic Approach

Entry for 3 September 2007:
Presentation at one-day conference of Scottish SPR, "Pluralism in Counselling and Psychotherapy: Practice, Training, Research and Theory". University of Abertay, Dundee, Scotland.

Pluralism vs. Monism: The fox knows many things, but the hedgehog knows one big thing. -Archilochus (7th-century bce)

I. Introduction:
A. Pluralism (American Heritage Dictionary)
• 1. The condition of being multiple or plural.
• 2.a. A condition in which numerous distinct ethnic, religious, or cultural groups are present and tolerated within a society.
– b. The belief that such a condition is desirable or socially beneficial.
• 4. Philosophy
– a. The doctrine that reality is composed of many ultimate substances.
– b. The belief that no single explanatory system or view of reality can account for all the phenomena of life.

B. Pluralism: Etymology
• From plural = Relating to or composed of more than one member, set, or kind
• From Latin pluralis, plus = more
• From Proto-Indoeuropean: pel' = to fill (cf. plus, poly; full, plenty, folk; supply, plethora)
• Root metaphor: Pluralism as hunger (greed?)

C. Pluralism(s) in Therapy
• Multiple causes of client problems
• Multiple people (client & therapist): relational
• Multiple perspectives (client, therapist, observer)
• Multiple client processes (modes of engagement)
– productive & unproductive
• Multiple therapeutic processes (tasks)
• Multiple outcomes

II. Process-Experiential Therapy as a Pluralist Approach
A. Starting point:
- There is more than one form of productive client process
– Classical PCA specified a single form of productive client process
– Exploration and formulation of self-relevant experience
– Client Experiencing Scale (Rogers, Gendlin, Klein, Kiesler, et al.)

B. Process-Experiential/Emotion-Focused Therapy (PE-EFT)
• 1985-1992: Greenberg, Rice & Elliott developed Process-Experiential therapy as an alternative to existing humanistic therapies
– Best for communicating within the PCA/humanistic therapy realm
• 1990’s: Re-branded as Emotion-Focused Therapy for communicating with therapists from other orientations

C. Multiple Forms of Productive Client Process
• Greenberg & Rice (1990): Modes of engagement (micro-processes)
– Attending
– Experiential search
– Active expression of emotion
– Contacting/connecting with therapist
• More recently, expanded to 14 (Elliott, 2006)

D. Multiple Forms of Productive Therapeutic Process
• Different therapeutic processes will facilitate different client modes of engagement:
– Focusing => Attending
– Systematic Evocative Unfolding => Experiential search
– Chairwork => Active expression of emotion
– Empathic Prizing => Contacting/connecting with therapist
• Referred to as “Tasks”
– From research on human problem-solving
– Research method: Task Analysis
– Now expanded to 13 tasks (Elliott et al., 2004)

E. Multiple Client Markers
• How do we know when particular client modes of engagement will be most productive?
• Unclear felt sense => Focusing => Attending
• Problematic reaction point (PRP) => Systematic Evocative Unfolding => Experiential search
• Conflict split or unfinished business => Chairwork => Active expression of emotion
• Vulnerability => Empathic Prizing => Contacting/connecting with therapist

III. Organizing Frameworks:
A. Pluralism Risks Chaos
• Complexity theory: Self-organizing systems emerge at the boundary/ dialectic between order and chaos
• Without some chaos => excessive order kills/stifles/rigidifies
• Without some order => chaos/entropy
• Thus: Need organizing frameworks to contain plurality

B. Organizing Framework 1: Therapeutic Principles
• Formulation of Process-Experiential approach began with a qualitative analysis of principles or guidelines for practice (Elliott, Greenberg & Rice, 1986)
• Organized into 2 broad groups
– Relationship principles: Foster safe, productive relationship (has precedence)
– Task principles: Foster therapeutic work on specific therapeutic tasks
• Operate in tension with each other
• Three main treatment principles within each
• Framework holds the plurality of causes, processes, outcomes
(A) Relationship Principles
• Facilitate safe, productive relationship:
– 1. Empathic Attunement: Enter, attend & track client’s immediate experiencing
• Always start with this
– 2. Therapeutic Bond: Offer empathic, caring presence to client
• = bond aspect of alliance (Bordin)
– 3. Task Collaboration: Offer and facilitate involvement in therapeutic work
• = task/goal aspect of alliance (Bordin)
(B) Task Principles
• Facilitate work on specific therapeutic tasks
– 4. Experiential Processing: Help client work in different ways at different times
• Foster relevant client modes of engagement
– 5. Task Completion/Focus: Facilitate client completion of key therapeutic tasks
– 6. Self-development: Foster client growth, empowerment & choice
C. Organizing Framework 2: Therapeutic Tasks
• Clients bring specific immediate problems (cognitive-affective tasks) to sessions
• Elements of a therapeutic Task:
– 1. Marker: observable sign that client may be ready to work on a problem
– 2. Client steps to resolution
• Measured by 6-point Degree of resolution scale
– 3. Therapist interventions: What therapist can do to help client resolve
– 4. Resolution state: What resolution looks like

IV. General Empathic Exploration for Problem-Relevant Experience
• Generic/baseline task for PE-EFT
• Client Mode of engagement: Experiential Search

• A. Marker: Problem-relevant experience:
• Any experience that draws client’s attention
– a. Client expresses energy/ interest in the experience
– b. Experience has personal relevance to client
– c. Incompleteness/complexity: Experience is powerful, troubling, incomplete, undifferentiated, global, abstract or external

B. Empathic Exploration Micro-sequence:
• (a) Therapist Initiation: Exploratory question
• (b) Client Response: Answer (description of experience) (may elaborate, initiate new topic)
• (c) Therapist Formulation: Exploratory Reflection (or similar comment showing receipt of answer) (may ask “fit question”)
• (d) Client Confirm/disconfirm (may initiate new topic)

C. Task Model for Empathic Exploration
• Stage 1: Marker
• Stage 2. Task initiation. Help identify particular client experience worth exploring further.
• Stage 3. Deepening: Exploratory manner & responses; Forms of Deepening Exploration
• (1) Redirecting client to internal experiencing:
– When C is external, abstract or intellectual: T:“So what does that feel like inside?”
• (2) Re-experiencing of particular experiences:
– Re-living particular experience(s) in imagination. (episodic memories) (T: “Can you take me through that? So there you were...”)
• (3) Searching edges of awareness:
– Explore unclear, vague, general; troubling, painful; puzzling, confusing; tangled, stuck, blocked; unfinished, missing; or incipient, emerging ("inklings") (T: “So the part that’s not quite clear to you is...”)
• (4) Differentiating experiencing:
– Specifying experience (T: “There are lots of kinds of anger; what is the quality of the anger you’re feeling right now?”)
• (5) Elaborating Experiencing: Filling in missing pieces of emotion schemes
– (a) Missing context or “aboutness”: sources, origins, situations (T: “What it is the sadness about?”) (=situational/perceptual)
– (b) Missing internal/bodily experiencing (T: “What does it feel like inside you?”) (=bodily/expressive)
– (c) Unsymbolized experiencing: global or unverbalizable (T:“How you describe it or picture it to yourself?”) (=verbal/symbolic)
– (d) Missing needs, wants or action tendencies (T: “How would you like it to be?”) (=motivational/behavioral)
• Stage 4: Client experiences some clarification of experience
• Stage 5: Client attains a sense of full understanding, and an appreciation and owning of the experience in its complexity or richness (“Now I know what that’s all about”)
• Stage 6: In addition to the above, client also feels a marked sense of relief (not feeling so distressed about it) or empowerment about the experience (knowing what to do about it)

V. Two Chairwork for Self-Evaluation Splits
• A. Conflict Split Marker
– 1. Two wishes or action tendencies
– 2. Description of contradiction, conflict between
– 3. Expression of struggle, coercion
• Prototypical Split = Decisional conflict
• Experience: uncomfortable "tornness"
• Alternative Forms:
– 1. Self-Evaluation (self-criticism)
– 2. Coaching splits (self-coercion)
– 3. Attribution splits (externalized; over-reaction to others)

B. Two Chair Dialogue for Conflict Splits: Client Resolution Model
1. Marker/Task Initiation: Describes split in which one aspect of self is critical of, or coercive toward, another aspect. Broadly: Describes two aspects, whether attributed or in somatic form.
2. Entry: Clearly expresses criticisms, expectations, or "shoulds" to self in concrete, specific manner.
3. Deepening: Experiencing chair may agree with critic (“collapse”); primary underlying feelings/needs begin to emerge in response to the criticisms. Critic differentiates values/standards.
4. Emerging shift: Clearly expresses needs and wants associated with a newly experienced feeling.
5. Softening: Genuinely accepts own feelings and needs. May show compassion, concern and respect for self.
6. Negotiation. Clear understanding of how various feelings, needs and wishes may be accommodated and how previously antagonistic sides of self may be reconciled.

C. Therapist Facilitating Responses
•Identify client marker (including pre-marker work)
•Elicit client collaboration in task
•Structure (set up) experiment
•Create separation & contact
•Promote owning of experience
•Intensify client arousal
•Access and differentiate underlying feelings in the experiencing self (including collapsed self process)
•Differentiate values and standards in the critical aspect
•Follow deepening forms of the conflict
•Facilitate identifying with; expressing; or acting on organismic need
•Bring contact to an appropriate close (=closure/ending experiment w/o resolution)
•Facilitate emergence of new organismic feelings
•Create a meaning perspective (=processing)
•Facilitate softening in critic (into fear or compassion)
•Facilitate negotiation between aspects of self re: practical compromises

VI. Conclusions:
A. Task Plurality
• Empathic Exploration and Two Chairwork are clearly different processes:
– Different markers
– Different primary client modes of engagement
– Different facilitating therapist responses
– Different end points/resolutions
…Common Therapeutic Frame
• Yet both can be readily contained within one therapeutic frame:
– Therapeutic relationship: empathic attunement; genuine/caring personal bond; spirit of collaboration
– Way of working: constantly being adjusted to current client mode of engagement; focusing on key client tasks; supporting client growth, choice, empowerment
– Task structure: Six stage model: Marker; Entry; Dialectical Deepening; Emerging Shift; Broader Reflection; Empowerment/Action

• B. Also: Organization Framework 3: PE Emotion Theory
• Multiple aspects of experience connected by emotion
– Emotion Scheme model
– Perceptual, conceptual, bodily, need/action
• All emotions play important roles in human adaptation
– Even so-called negative emotions:
– Fear, shame, disgust, hopelessness etc.
• Multiple types of emotion response
– E.g., different kinds of anger
– Primary adaptive, primary maladaptive, secondary reactive, instrumental
• Multiple forms of emotion regulation:
– Access/approach
– Contain/distance

C. Broader Reflections : Pluralism vs. Integration
• We have consistently referred to PE (and EFT) as an Integrative therapy (primarily Person-centred, Gestalt)
• Tried to argue that this integration of different causes and client/ therapist processes also makes PE therapy pluralistic
• Also: Tried to show how plurality can be usefully organized within integrative frameworks
• But: Can integration be truly pluralistic?
– Is integrative pluralism an oxymoron?

D. Broader Reflections: Limits of Pluralism in PE-EFT?
• Left unanswered: How much can be integrated into Process-Experiential therapy without violating its integrative frameworks?
• What about elements of CBT? E.g.,
– Systematic desensitization
– Thought stopping
– Rational disputation of thinking errors
– Assertiveness training in groups

E. Proposed Test for Integrating New Elements in PE Therapy
1. Apply Therapy Principles:
• 1. Can empathic attunement to client immediate experience be maintained while carrying out this kind of work?
• 2. Can the therapist continue to offer an empathic, caring presence?
• 3. Can task collaboration be established with the client?
• 4. Can key client processes and facilitating therapist responses for this work be identified?
• 5. Is this a key task for clients?
• 6. Most importantly, can this work be pursued without the therapist becoming an expert on the client’s experience, thus interfering with the client’s personal power, responsibility and growth?

F. If a CBT Technique is not Consistent with PE principles?
• Strategy needed for developing parallel PE task models
– Accomplish what CBT techniques do
– Without violating relationship and client autonomy
1 Questions for Developing PE Task Models from CBT Techniques
• 1. What is the client marker for this kind of work?
• 2. What is the desired immediate outcome (resolution) of this kind of work?
• 3. What client modes of engagement does the technique seek to activate in order to reach resolution?
• 4. What therapist responses might facilitate these client modes of engagement without making the therapist into a content expert?
2. Developing PE Task Models from CBT Techniques: Resources
• 1. Empathic, caring, genuine, flexible, task-focused, empowering relationship
– Research evidence supports
• 2. Task analytic approach
– Leads to specificity of CBT without need for theory-driven expertise
• 3. Power of primary adaptive emotion processes to motivate change
– Don’t need therapist expertise/persuasion

VII. Beyond Foxes and Hedgehogs
• What we need most is to be able to integrate many things within a broader pattern
• Integrative pluralism
• Eagle… or homo sapiens?