Tuesday, February 26, 2008

Advanced Research Training 2007-08 Finishes

Entry for 25 February 2008:

The last of the 3 two-way advanced research courses for PhD-level students finished last Saturday (installments 1 and 2 were in December and January respectively). This has been the first chance I’ve had to teach the range of material I’ve been covering in the Clinical Research Methods course that I taught at the University of Toledo from 1979 to 2005. It was a real pleasure to teach to such clinically-experienced students, and it was really helpful having contributions from John McLeod, Beth Freire and Mick Cooper for the three short courses. We had some great discussions along the way. The participants set up a research support network and began helping each other, e.g., with data rating. The 2-day short-course models seems to have worked. And our research PhD students now seem to be tooled up for a variety of research projects.

Thursday, February 21, 2008

The Therapeutic Role of Guilt and Shame

Entry for 20 February 2008:

The other night in the EFT Level 3 supervision group, we had a most interesting conversation about the potential therapeutic value of primary guilt and shame. This is a further elaboration of that discussion.

Primary Guilt and Shame

Primary shame is an adaptive response to discovering that I have violated my community’s social norms. It motivates action to display my awareness of my transgression ("embarassment"), including blushing and temporary withdrawal from contact with others, in preparation for changing my behaviour in order prevent future censure.

Primary guilt can be defined as an adaptive response to finding that I have violated my own core moral values, usually but not always by injuring another person; it prepares me to make amends or otherwise repair the injury. This is evolutionarily important for maintaining and repairing attachment-bonds is therefore likely to have survival for ourselves and our families.

Thus, both primary shame and guilt are strong, but transitory, emotions about specific situations involving personal transgressions or errors, which evolved to protect and repair relationships, because humans are fundamentally social animals. In this formulation, guilt is tied to moral issues (right vs. wrong), while shame involves issues of competence, appearance and etiquette.

Furthermore, primary shame and guilt can play a productive role in psychotherapy or counselling, motivating behaviour change in individual work and relationship repair in couples work. Motivational Interviewing, Emotion-focused therapy for couples, and Hayes’ Acceptance and Commitment Therapy (ACT), for example, all see a role for primary guilt and shame, even if it is implicit. And of course the traditional religious practice of confession, penitence and absolution centrally involves these emotions.

Maladaptive Guilt and Shame

But what about primary maladaptive guilt? This is of course quite familiar to us from our depressed and guilt-wracked clients and perhaps from our own overly strict upbringings. It seems to me that while adaptive guilt is about my having inflicted some specific injury on some specific person, maladaptive guilt is more global, that is, about my experiencing my whole person as being morally unacceptable to one or more persons important to me (where “person” can include God.)

Similarly, primary maladaptive shame is also about a global social failing, about my sense that I am generally incompetent, ugly or otherwise defective in the eyes of others.

One or both of these were involved for several of my clients, who reported that one or other parent couldn't stand the sight of them, because of their attributed moral trangressions (=> guilt) or personal failings (=> shame).

Secondary Reactive Guilt and Shame

Finally, I can come to feel guilty or ashamed not because of something I have done or failed to do, but because I am feeling some emotion that is unacceptable to me, such as anger, pride, jealousy, sexual arousal, or even fear or sadness. If I experience having that feeling as a moral transgression, I feel guilty (“I have sin in my heart”), but if I experience it as being weak or incompetent, then I feel ashamed of myself. These are emotions about emotions, which makes them secondary reactive emotions. Interestingly, in Process-Experiential therapy we regard these as nonadaptive and try to facilitate the client in working back from the “reaction to the reaction” to the reaction itself.

But I am saying here that if my reaction is to something I have done rather than simply thought or felt then that can be a primary adaptive emotion worthy of fully arriving at before I can go on, by assimilating what the emotion is trying to tell me, through making amends to the person I’ve injured (in the case of primary adaptive guilt) or through improving my social behaviour (with primary adaptive shame).

Sunday, February 17, 2008

BBC Radio 4 Sunday Worship at St. Mary’s

Entry for 17 February 2008:

At 8:10 am every Sunday on BBC Radio 4, there is a broadcast church service from a different church in the UK. We listened to one of these programs in the radio in September 2006, shortly after we began going to St. Mary’s Scottish Episcopal Church in Glasgow, but we had never been to one.

According to Kelvin, our main priest (referred to as “provost” because it’s a cathedral church), the BBC 4 producers have decided that they like broadcasting from St. Mary’s, primarily because there is usually a good turn-out from the congregation, which means that the church doesn’t sound depressingly empty outwith the choir.

This time we were determined not to miss out, so this morning we got up at the crack of dawn in order to make it inside the doors by 7:45, the cut-off time. There was BBC white panel truck parked outside, and inside a bunch of microphones set up between the congregation and a huge choir of more than 30 people, including our new children’s choir in their cute red t-shirts, and 3 priests/ministers, rehearsing. A couple of the microphones were pointed menacingly at the congregation, and everyone was giving them a wide berth, sitting further back than usual. By the time people had finished arriving, there were a good 60 in the congregation, provide quite a satisfactory "lived-in" quality to the space.

Various contingency plans to cutting or filling out the time were reviewed, and we were briefly rehearsed on several potentially problematic points, including the tongue-twisting “shatter the shackles of slavery” in the opening responses. We were told to watch out for the green on-air light to come on… except that it malfunctioned, so that we had to be cued by Kelvin, who looked very technophile in his headphones and clerical attire.

In the event, the service was lovely, the music superb as always, and went off pretty much without a hitch. Diane had a coughing fit during the Old Testament lesson, but when we listened later on the Radio 4 archive, there were nary a sign of it on the recording (clever sound engineering I presume). The theme of the service was social justice, totally different form the regular service we later stayed on for. A visiting preacher name Bob Fyffe gave an excellent sermon on speaking out against injustice.

This may sound strange, but we were about 3/4 of the way through before it really hit me that there were actually people out there listening to us live. Up until that point I had been treating it live a live recording, without imagining an audience. I thought to myself, it’s 8am on a Sunday morning; no one listens to the radio that early on Sunday morning anymore! I figured there might a few thousand people out there, which would be nice but no more than that. My mom and grandmother used to watch televised church services on Sunday mornings when they couldn't get to church, but never as far I could remember listened to one on the radio.

Finally, about 8:50 we got to the end, finishing with a Messiaen organ piece in one of that composer’s famous bird song modes. I love these, but Diane hates them because they wander all over the place and don’t seem to go anywhere. I remembered the day that my mystical friend Margaret Stanberry had a vision of Olivier Messiaen over the altar at Trinity Episcopal in Toledo, and smiled to myself. Then Kelvin dropped his hand, the signal that we were off-air, and everyone heaved a sign of relief, and the organist stopped in the middle (which didn't really matter because it was a Messiaen bird piece). There was a moment, then a general stirring, and we all broke applause.

Afterwards, we chatted briefly with the producer, who was from BBC Scotland. She was talking to Kelvin; both were very pleased with how it had gone. I casually asked her about how many people might have been listening. It’s hard to tell, she said; it’s usually about 1 million people, give or take…

Friday, February 15, 2008

Mid-February Notes

Entry for 15 February, 2008:

1. At the end of January, we peeked at my schedule for February and discovered that I was scheduled to work every weekend. This was clearly Too Much, so when the folks in Leeds emailed me to ask if I wanted to go ahead with my two-day EFT workshop there because of relatively low enrollment, I asked them to cancel it. I am now enjoying the two days (plus travel) that this freed up, and we were able to invite friends from our Church for dinner tonight, an Australia couple and a Norwegian couple. (We had a lovely time, with great conversation and a special Australian-Norwegian playlist I whipped just for them.) I was also able to begin to get on top of my email, and we are planning a Saturday Adventure to Edinburgh for tomorrow. So now I am making a small space for a bit of a blog.

2. For the past week, the long period of rain and high winds has died out, and most days have been sunny but cold (at least for Glasgow), around freezing. With reprieve from the rain and the lengthening days (we’re already up to 9.5 hours of daylight), I have been taking my bike into work, enjoying the light system I had installed last Fall. The cool, crisp air makes for nice riding.

3. I’ve had a large pile of papers to mark. (Note: we don’t “grade” papers in the UK; we “mark” them, a phrase I’ve never really understood.) It got so bad, that I had to give up writing my blog. I’ve finally got through the Counselling Psychology research proposals, but now have to turn to Diploma course marking and various other pieces of work I owe people. Still, this feels like a enough progress to be able to write a wee bit: hence, this entry.

Tuesday, February 05, 2008

The Narcissism of Small Differences

Entry for February 4, 2008:

On Saturday night, over dinner at a small French bistro in Islington, Georgia Lepper referred to Freud’s phrase, “the narcissism of small differences”. She meant to include firstly the emphasis on differences among different psychodynamic approach, and the consequent in-fighting there. But as a psychotherapy researcher and long-time SPR member, she was also referring to the way in which all the different major approaches to therapy tend to focus on what makes them distinct rather than what they have in common, which was also a key theme of Peter Fonagy’s presentation to UKCP.

But after reading today about an exchange between a couple of people I know, I find myself growing increasingly weary of attacks by some classical person-centred therapists on people like me, and in this case on a friend who was attempting to equally affirm both classical nondirective therapists and others like me who don’t display sufficient ideological purity. This seems to me to be an example of what Freud was referring to. Increasingly, I believe, it is an attitude that we can’t afford anymore. It is also a problematic mode of being that I also have often fallen into, especially when I had tried to promote PE-EFT by claiming it as a distinctive and unique approach.

But the thing that bothers me the most about the whole debate is how it is conducted almost entirely at the purely conceptual level, without us actually looking at each other’s practice. I want to paraphrase Husserl: “Back to the videos themselves!” I don’t think we should talk about nondirectiveness or process differentiation or client deference without specific reference to recordings of actual therapy sessions.

The Social Anxiety Therapy Development group has started playing each other’s video and audio recordings (so far it’s just Mick and I, but we’re looking forward to others joining in as well). Based on this limited experience, and others that I have had over my career, I want to hypothesize that, among experienced, qualified therapists, when we look at each other’s actual work, we are going to see several things:
-First, we will see much that we recognize in common in each other’s work;
-Second, we will see responses, phrases, even words that we wouldn’t necessarily have thought to use but that might be a good idea to try in the right context;
-Third, we will see and recognize the other therapist’s (or our own) humanness and fallibility;
-Fourth, we will see places where we might have preferred to have said something different.
But even here I am going to predict that it will usually be the case that our preferred response would have led in the same direction, or in a somewhat different but not necessarily better (or worse) direction. So it seems to me that only rarely will we see a place where what we would have said or done would have been clearly better than what the therapist we are watching said or did; and here we are generally recognizably within the boundaries of our own human fallibility. By this I mean: Perhaps we had something better to say at this particular moment, but someplace else the opposite would likely to be the case. To pretend otherwise is to risk Freud’s narcissism of small differences, and to generate endless fruitless and divisive debate in a time when our energy is desperately needed elsewhere, such as in doing research to justify and improve our practice.

Responding to Client Anger: Cooling the Client Out vs. Therapist Mentalizing Self-Disclosure vs. Relationship Dialogue

Entry for 3 February 2008:

As noted in my previous entry, Peter Fonagy endorsed appropriate, honest disclosure of immediate therapist experience as a way of modelling mentalization for clients. It was refreshing to hear such strong support for the use of appropriate self-disclosure (or transparency) by a psychodynamic therapist.

Cooling the client out. Peter then went on to criticize the common therapist response to client anger of calm description of the client’s angry state. Speaking softly and gently to an angry client about their anger seems to me to be an attempt to deflect rather than to engage the client in their sense of my having violated them in some way, so I certainly agree that this is not a particularly facilitative response, and in fact I have sometimes observed this sort of response in person-centred counsellors as an attempt to use seemingly empathic responding to avoid real contact with the client.

Therapist mentalizing self-disclosure. Instead, he advocated disclosure in the form of “It’s hard for me to think clearly when you are yelling at me.” This is of course another example of his use of self-disclosure as a therapeutic tool to help clients develop their ability to internally represent the therapist. Interestingly, it’s also the classic “defusing anger” response advocated in 1970’s assertion training (a blast from the past!: Alberti & Emmons, 2001 [8th edition]) . It is certainly true that in situations in which I can’t think straight because the client yelling is scaring me, then I would certainly want to think about a disclosure of the type Peter was suggesting, but limiting my response to this seems to me to be not fully relational either, because I am still not personally encountering the client in their immediate distress.

Relationship dialogue. Therefore, I would also want to go on to work with this alliance rupture marker by engaging in a relational dialogue with the client. That is, I would prefer a combination of empathy and contact, rather having to choose one over the other. Thus, my preferred response, other things being equal, would be to say clearly and firmly while looking the client in the eyes, “I hear that you are feeling angry with me right now. Can we look at what’s happening between us that you are so angry about?” To the extent that I am able, I want to meet the client in their attempt to contact me via their anger, even as I realize that it is likely to be secondary reactive or primary maladaptive anger. Knowing the relational dialogue task process, I would expect the ensuing encounter to provide plenty of opportunity for the client and I to each represent our subjectivity to the other and to experience that subjectivity being received by the other. And I would also expect that the client’s initial secondary reactive or maladaptive anger to evolve through our exploratory dialogue into a more contactful emotion such as primary hurt and sadness or fear (other emotions such as primary maladaptive shame might also be present)

And of course, it would be important for me to do personal work (in supervision, person therapy or on my own) on my issues around anger so that I can face productively without counter-attacking or going into a placating mode.

Alberti, R., & Emmons, M. (2001). Your perfect right: Assertiveness and equality in your life and relationships (8th ed.). Atascadero, CA: Impact.

Monday, February 04, 2008

UKCP Research Conference: Adventures in Practice-Based Research

Entry for 3 February 2008:

On behalf of the UK Council for Psychotherapy (UKCP) Research Committee, my long-standing SPR colleague and fellow conversation analyst, Georgia Lepper invited me to come down to London to speak at their second Research Conference on 2 February. The agreed topic was basically the IPEPPT talk I have been giving in various places for the past couple of years, that is, a presentation on the IPEPPT project, its conceptual framework, and recommended research protocols.

The conference was organized as two keynotes plus small group and plenary discussion, with the goal of promoting their agenda of setting up multiple Practitioner Research Networks (PRNs).

Peter Fonagy was the morning keynote speaker. Before last December’s IAPT conference, I hadn’t seen him since the SPR meeting in Geilo Norway in the mid-1990’s, and now I ran into him again, two months latter. As I had seen before, Peter is an impressive speaker, pulling together different pieces of (attachment) theory and research. Consistent with his general psychodynamic orientation (he is head of the Anna Freud Centre), he puts a great deal of weight on a development perspective and theory. This time, however, he seemed a bit cranky as he used the research evidence criticize commonly-practiced therapies as “abdominal” vs. “keyhole” surgery, potentially producing negative effects, of which therapists are blithely unaware (citing Lambert’s recent signal alarm research).

Losing the plot. I thought that the best part of Peter Fonagy’s talk came in the last few minutes, when he described several key processes in the Mentalization-Based Therapy that he and Tony Bateman have developed for working with clients with Borderline Processes. I’ll deal with his formulation of responding to client anger for a separate blog entry, so I’m just note briefly his lovely take on the therapist difficulty micro-marker of “losing the client’s plot”, i.e., not being able to follow what the client is saying. As Peter noted, a very common response to this is to pretend you understand the client by folding your arms and nodding your head. His interesting observation is that this is in fact a reliable sign that you don't understand (an Incomprehension Marker in PE-EFT terms). Instead, refreshingly, he advocates disclosing to the client that you are having trouble following them. (You do have to be careful how you do this, so as not to leave the client feeling dismissed or inclined to blame themselves for not communicating more clearly, which is why I recommend saying something like, “It might be me, but I’m not sure I’m with you on that. It sounds like it might be important; could you take me through it again?” This is what Laura Rice used to call “empathic nonunderstanding.”)

Change of Plan. While this was interesting, overall content and feel of the talk, plus the ensuing small and plenary group discussion I attended left me feeling that this audience of research-inclined therapists needed something that spoke to them more directly and immediately. Thus, by the time lunch arrived, I had decided to somehow switch talks in the middle, and go over to my HSCED/Bridge Phobia talk, in which I model the process of doing research on my own practice. The only problem was, I couldn’t see how to plug into the sound system, and I hadn’t brought my powered speakers with me.

Encountering Humanistic and Integrative Therapies. However, there more challenges waiting for me at lunch: While waiting in the lunch line, Richard Cleminson identified himself to me as chair of HIPS, the Humanistic and Integrative Psychotherapy Section of UKCP. He expressed concerns about the possibility of Humanistic and Integrative Psychotherapies (and UKCP) being cut out of the process Skills for Health competencies process the Mick, Nancy, Sally and I had begun exploring with Tony Roth and Steve Pilling the previous Tuesday. He also argued that UKCP is the largest body of psychotherapists in the UK (as opposed to “counsellors”), and therefore shouldn’t be left out of the consultation process.

Bad Karma? I had a sinking feeling that I was about to move in the Bad guy column (or already had): In our efforts to stay true to the research evidence -- while also supporting our Person-Centred/Experiential base -- had we really sold out our Humanistic/Integrative colleagues? Mick had told me that the Humanistic/Integrative designation was an obscure, not well-understood construction, but suddenly I was confronted with the existence of a discrete body of humanistic therapists, my erstwhile comrades in therapy, as concerned by our leaving them out, as we were with being left out ourselves. In my book, this is Bad Karma.

Leaving the door open. I heard Richard out, and finally explained to him that I’ve been trying to collect all the quantitative outcome research evidence on humanistic therapies since 1992, trying to be as inclusive as possible. I explained the remit and method the Roth-Pilling process of identifying therapies based on RCT-like studies, manuals (defined broadly), and coherent theory. I said that I felt that this is a fairly broad gate and that to the extent that humanistic-integrative therapies could meet these criteria, there was a good chance they could be included. I then gave him the criteria for candidates for the Expert Reference Group, and asked him to get suggestions for ERG members to me by next week.

Improvised sound system. We were unable to get the sound working for me to play the videos of my client, but I decided to go ahead with the presentation of the case anyway. I drove parts of my audience crazy by flipping through the highlights of my original talk in about 10 minutes before switching over to the case study. I introduced the HSCED method and the client, then I decided they should at least see the client, so I played a bit of the opening to session 1. Someone suggested that I put the microphone up to the speaker, which doesn’t usually work, but did here. So in the end I was able to play the remarkable segment from session 4 where the Unfolding task goes into the client accessing trauma memories and linking his phobia-related panic feelings to his abuse.

Modelling vulnerability. The result was a demanding but I think inspiring talk that illustrated how one can study the process and outcome of one’s own work as a therapist. Someone noted that I had made myself vulnerable, and indeed I did feel nervous presenting this client to a largely psychodynamic audience. The last time I had done so, someone opined that I was potentially re-traumatizing my client, and indeed this time, I was subsequently characterized as (a) deliberately using hypnosis with this client; (b) has having led my client to my interpretation that his panic symptoms were linked to his childhood abuse; and (c) having missed an opportunity to help the client consolidate his insight by explicitly interpreting the link to him.

PE-EFT as an integrative humanistic therapy. But the most interesting unintended consequence of playing the video was that Richard Cleminson came up to me afterwards to tell me that he considered what I had played as a clear example of what he and his section of UKCP mean by Integrative Humanistic therapy. I said I had no problem with that and looked forward to hearing from him.

In fact, Richard is correct: PE-EFT certainly is an integrative humanistic therapy (it even says so on our website!). But it’s also person-centred therapy (broadly if not Brodley). This makes it a natural bridge between the more classical or traditional Person-Centred therapy and much of the rest of the humanistic therapy family. I’m not sure what to do yet about the humanistic therapies that are further out, like bioenergetics, transpersonal therapy or the various energy therapie, but the absence of research evidence on outcome means that we don’t have to answer this question yet. Now the integrative humanistic therapies have to decide what to do: to stand with PE-EFT or do their own outcome research. This smartest thing would be for them to do both! But in any case, once again, it’s clear that psychotherapy/ counselling is a small community of overlapping, competing interest groups, and that the weave among them just keeps getting richer and more complex.

Friday, February 01, 2008

St. Brigid’s Eve Again

Entry for 31 January 2008:

Looking back on my entry for the beginning of Celtic Spring a year ago, I am aware of how much I have in the meantime settled into life here with all its complications, and in particular its politics: The beginning dialogue with CBT and all of that; the project to reform research training in counselling throughout the UK; and the local politics of the Jordanhill campus of the University of Strathclyde in a process of radical transformation in the direction of research. Two different faculty members contacted me (and Mick) today to see if one of us would run for the newly created position of deputy head of department for research. There is a lot of change in the air, and it feels like I am right in the middle of it, like the gales of wind and rain (and occasional snow, sleet & hail) that have been buffeting us in Scotland for the past week or more. Quoting T.S.Eliot, my favorite poet, “Winter kept us warm” but “April is the cruellest month”; and here in the UK right now it feels like April (which is barely Spring in the American Midwest) has come early this year, and I am being blown around quite a bit.

What I’d like most right now is to see clients and write. When I see the two clients I am currently able to fit into my crazy schedule, I find it exciting and energizing, and I come away with more than I arrived with, deepened and refreshed. Similarly, when I get to do what little writing I am able to squeeze in right now, I find that I also enjoy that as a source of creativity and accomplishment. Being deputy head of department leads in the wrong direction for me, away from all that brings me joy.

I actually did get a wee paper written this week (on the train to and from London on Tuesday, a short piece of reforming counselling training for Healthcare Counselling and Psychotherapy Journal) and the paper on the student field test of the Leuven Systematic Case Study Protocol (with Nele Stinkens and Mia Leijssen from KU Leuven in Belgium) was finally accepted by Person-centred and Experiential Psychotherapies after many revisions. So there are signs of hope. That’s the kind of Celtic Spring that I want to celebrate!