Wednesday, June 11, 2008

Expert Reference Group on HPCEs, Meeting, 9 June 2008

Entry for 9 June 2008:

When last we met, the Expert Reference Group (ERG) on Humanistic-Person-Centred- Experiential (HPCE) therapy competencies, it was to pass judgement on the scoping document that Beth Freire and I had put together from our in-progress-but-we-hope-soon-to- be-completed meta-analysis of PCE outcome research. As I wrote in my blog entry about that meeting (see entry 30 March 2008, posted in early April), I found this to be a somewhat painful experience, but ended up feeling relieved that anything had survived the cutting process. In any event, it was enough to provide Andy Hill and Alison Brettle a basis for beginning the process of reading therapy manuals and extracting competencies (or what others would call “therapy change principles”). (For an example where this is heading, see the CBT framework at: www.ucl.ac.uk/clinical-psychology/CORE/CBT_Framework.htm )

Move the clock forward 2 months to today, and you would have found our intrepid ERG sitting around the rectangle of tables in room 544 of the Sub-department of Clinical Psychology, right next to my old friends Chris and Nancy’s office. You would have heard us nit-picking (or if you prefer, “fine-tooth combing”) Andy and Alison’s (A&A’s) draft framework for the competencies they are identifying. Now it was their turn to feel they were under the knife for some unwanted surgery, as the rest of us worked through their framework (really an outline), one node at a time.

After the whacky landing at London City Airport in March, I had vowed never to use that airport again, so this time I took the train, preferring to get up in Glasgow at 4am (even before Scotland’s uncanny summer sunrise at 4:30), and to be an hour late for the ERG. (As it happened, I was more than 90 minutes late, owing to a signal failure at Nuneaton.) I slipped in next to Mick, and was immediately confronted with another document from the HIPS (Humanistic and Integrative Psychotherapies Section) of the UKCP (UK Council of Psychotherapies), this time asking that we Cease and Desist in order to give them time to marshal evidence that might persuade us to include wider range of therapies in our remit. Noting that Vanja Orlans -- whose unenviable task it was to represent this point of view – would not be arriving until even later than I had, we carried on reviewing A&A’s draft framework.

I had used some of my copious time on the train going through their work quite carefully, so I was ready for this, but really it was quite impressive what they had managed to put together. From my point of view, the main problem was that Process-Experiential (PE) therapy occupied way too large a place in it. This was understandable because of our evidence base and the clarity of our presentation. (The Learning book is basically a competency framework itself.) However, PE-EFT currently has only a tiny following in the UK, and I am not eager to attract a reaction against our work as some sort of favoured child, so I was very glad to support the group in down-sizing PE-EFT to a more modest position, and finding a way to generalize some of it in such a way as to make it relevant to a range of HPCEs.

The next order of business was the overall headline summary competence, what we call the core category in qualitative research. For example, the CBT framework has, “Ability to implement CBT using a collaborative approach”, and the Psychodynamic one offers, "Ability to maintain an analytic attitude". Alison and Andy had proposed, “Ability to facilitate experiential processing”. This was essentially a quote from Greenberg, Rice & Elliott (1993), so I knew it would never fly.

A vivid memory came back to me, of sitting around Les’ office early in the process of writing Facilitating Emotional Change (1993), when we – I think it was me – came up with “experiential processing”:
-It’s like cognitive processing, only we think it involves way more than cognitions.
-Gendlin already came with a word for it: “experiencing”.
-But that sounds like California-speak.
-Yeah, we need something that sounds more scientific!
-I know, how about “experiential processing”!
-Hm, that’s a bit ugly-sounding, but I can’t think of anything better.
-And the opposite then could be… “purely conceptual processing.”
-OK, then!
-Right!
And “experiential processing” it was.

That conversation (or one very similar to it) took place in 1986 or so. Today, as Daniel Kahneman says, the cognitive revolution is over, and the phrase just sounds ugly to me, which I noted. We worked on this for awhile, broke for lunch. Chris popped out to say hi, and I followed him back into his office where we chatted for a few minutes. Nancy came in. It’s always nice to see them. (We go back every further than “experiential processing”, to UCLA and the attempt to prove that reflections are the best therapist response modes in the world.) After lunch, my friend Germain Lietaer (from KU Leuven) earned his Eurostar fare by coming up with: “Ability to offer a relationship that facilitates experiential exploration” (later, Nancy Rowland, from BACP, added “therapeutic” in front of “relationship”).

Like the CBT (see: www.ucl.ac.uk/clinical-psychology/CORE/CBT_Framework.htm) and psychodynamic frameworks, the HPCE one has five columns:
I. Generic Therapeutic Competencies: These are shared with the other frameworks, but are languaged somewhat differently. Thus, “ability to deal with emotional content of sessions” (CBT) became “ability to work therapeutically with the emotional content of sessions” (HPCE).

II. Basic HPCE Competencies: After further discussion, these ended up being divided into two main sections: (1) Knowledge of the principles underlying HPCE therapy; (2) Initiate, develop and conclude the therapeutic relationship. These two sections have further subheadings. The therapeutic relationship section has two kinds of subheadings: (a) ability to draw on who one is as a person in order to facilitate therapy; and (b) ability to facilitate the relationship in various ways.

III. Specific HPCE Methods: We had a very interesting discussion about what to call the specific ways in which therapists carry out the basic HPCE competencies. Tony seemed to feel that we were being hypocritical in refusing to call these “techniques”, but we insisted that “techniques” was too mechanistic and would get us all kinds of grief. I pointed out the technically correct term (from a linguistic point of view) is "speech acts", but this didn't help. Finally, Tony asked us to think of a synonym (I think he meant euphemism) for “technique”. Oh, that’s easy, we said, and rattled off several, with “method” being the odds-on favourite. This section is still a bit of a mess and will need A&A’s wordsmithing, but we did manage to get in some generic versions of PE-EFT tasks, like “Ability to appropriately use therapeutic enactments”. This latter is code for chair work and related Gestalt/psychodrama kinds of things; Tony, who is understandably somewhat allergic to our jargon (as we are to his), put scare quotes around “therapeutic enactments.”

IV. Specific HPCE Adaptations: This is where PE-EFT ended up, after it was shoved out of column III, in a little black hole of its own. Right now, PE-EFT is the only thing in this column. (Don’t blame me; the chainsaw did it…) We will just have to do our best to hold the space open until more folks come along with the requisite combination of evidence and theory around specific approaches or client problems. At the moment, there is a pretty good view down the valley…

V. Meta-competencies: Competencies about the use and application of competencies, some generic, others specific to HPCE. This is where the framework brings in the “integrative” that the “humanistic and integrative” folks are worried about losing. Look: You have your own column!

This took us most of the afternoon, but Tony did save some time at the end for discussing the latest UKCP petition, hoping that all present would have seen for themselves by that point that the whole process, however many scientific and political warts, was capable of producing a pretty decent frog, with the specific competency of hopping over the various objections, both large and small, principled and paranoid. It was a pretty good argument, actually, because the emerging framework does look like an excellent next step.

However, some of us (including me) were not totally convinced by this means-justifies- the-ends argument, and the discussion will go on. Vanja spoke calmly and in a matter-of-fact manner of the unhappiness, anger and fear of some of her colleagues in UKCP, and their concerns about lack of transparency in the HPCE ERG process. Several things will in fact come from their intervention, all of them potentially useful:

1. UKCP are being encouraged to take their philosophy of science concerns to the scientific steering committee for the competencies project, which is the correct venue for many of the issues raised.

2. In addition, they have now assembled a list of RCT studies, working off the references for Beth and my meta-analysis, and adding their own. I will take these back to Beth, and we will see how many of the additional studies we are missing; we will then explore whether and how it might be feasible to incorporate these into our meta-analysis.

3. In the meantime, Tony and Steve and I will meet to look again at the research evidence. Gestalt therapy and psychodrama are still missing in action, along with EFT for trauma/emotional injury, in spite of substantial bodies of research, theory and clinical practice. It would be a crying shame to miss them out, and I think the whole project would suffer both scientifically and politically. The biggest problem with much of the research literatures on these approaches is that they are such as mish-mash of different client populations and different kinds of evidence that it is difficult to conclude anything from them without doing a meta-analysis, which is beyond the scope of the present project. However, with a little help form our friends in UKCP-HIPS and FEPTO (the psychodrama trainers organization with whom I’ve become involved), we may be able pull something out of the swamp, perhaps even a couple of bull frogs.

Afterword: I have written this entry during the homeward journey that has spanned all of a long summer’s day. It was already fully day when Diane dropped me off at Glasgow Central at 5:45am, and now, at 10:10, as the virtually empty train rumbles through the empty places of Dumfries and Galloway (southern Scotland), the sky still has a lot of blue and pink in spite of the moderately heavy cloud cover. Scotland the Braw, it's nice to be almost home!

2 comments:

Quig said...

Chairwork is not a Gestalt/psychodrama technique. It is a psychodrama technique. Fritz Perls used a pillow on the floor at his feet for the client to sit on. He did not want to copy J. L. Moreno's psychodrama technique. Wow! Very creative of Perls.

Bill Wysong

Robert Elliott said...

Umm, regardless of what Perls did or didn't do, various kinds of chairwork have become staples of Gestalt therapy, as they are of Process-Experiential/Emotion-Focused Therapy. Everyone knows that they ultimately derive from Moreno's work, but they are clearly part of Gestalt/PE-EFT/Psychosynthesis etc etc therapy practice now.