Thursday, July 31, 2008

Systematic Single Case Studies Made Easy(er) (7/08)

Entry for 29 July 2008:

Revised Presentation/Lecture notes, Day 2 RDI Training the Trainers Summer School on Counselling Research Methods, Leicester, UK, July 2008.

I. Systematic Single Case Studies at Diploma level
1. Convert standard case study requirement into systematic case study
2. Importance of having an example: Find an interesting case that has been studied systematically (e.g., Elliott, 2002; journal: Pragmatic Case Studies in Psychotherapy)
3. Needs support and guidance (Stinckens, Elliott & Leijssen, in press)
4. Systematic case studies can vary enormously in complexity, e.g.,
•Pragmatic Case Study (D. Fishman)
•Legalistic/Adjudicated case study (A. Bohart, R. Miller)
•Hermeneutic Single Case Efficacy Design (HSCED; R. Elliott)
•Uses version of IPEPPT Systematic Case Study Research Protocol
•See: Elliott (2002) Psychotherapy Research

II. General Principles of Systematic Case Studies:
A. Three Key Questions in systematic case studies:
1. Did my client change substantially over the course of counselling?
2. If the client changed, did counselling make a substantial contribution?
3. If the client changed, what brought about those changes?

B. Research Steps
1. Assemble a rich case record:
•Multiple data sources, qualitative/ quantitative
2. Outcome analysis; Analyze and interpret outcome data
3. Change process analysis: Organize and interpret evidence that counselling contributed to client change (include how counselling helped)
4. Critical reflection: Critically evaluate alternative explanations

III. Systematic Case Study Methods
A. Assemble Rich Case Record:
1. Basic descriptive information (demographics, diagnoses, problems, therapy approach)
2. Quantitative outcome measures: one or more (preferably related to theoretical model or client issues)
3. Weekly or fortnightly outcome measure (e.g., Personal Questionnaire or CORE-10)
4. Change Interview (qualitative; can be done by counsellor but better someone else; e.g., students help each other)
5. Helpful Aspects of Therapy (HAT) form (client; significant events)
6. Records of counselling sessions (tapes, therapist process notes)

B. Outcome analysis:
•Weekly change measure & one other
1. Make table showing:
•Clinical cut-off level (“caseness”) (e.g., CORE-OM: 1.25)
•Reliable change minimum value (CORE-OM: .5)
•Client pre-counselling value
•Client post-counselling value
•Indicate which values are (a) above caseness, and (b) show reliable improvement or deterioration
2. Make graph showing weekly outcome measure scores

C. Evaluating Therapeutic Influence: Change Process Analysis
•Looking for evidence of connections between what happened in counselling and outcome:
•Types of Evidence:
1. Change Interview (ratings of changes; attribution question; helpful aspects)
2. HAT descriptions of significant events (Helpfulness: 7+)
3. Sudden gains within therapy (big changes from one week to the next)
4. Changes in stable problems: Quantitative/qualitative changes from pre to post, plus information about how long client has had problem

D. Critical Reflection
•Make good-faith effort to find evidence that client didn’t change and that if they did, it had nothing to do with the counselling
1. Non-change explanations:
•Nonimprovement (trivial amount change, or gets worse)
•Relational artifacts: tries to convince therapist, research team (“hello goodbye” effect)
•Expectancy artifacts: self-deception (cultural or personal “scripts” about therapy)
2. Non-therapy explanations:
•Self-help (efforts separate from therapy)
•Extra-therapy events
•Psychobiological causes (medication or recovery from injury or illness)
•Reactive effects of research (research activities, altruism) [Construct validity]

IV. Example of Systematic Case Study “George”
A. Description of Client
1. Demographic information 61 year-old European-American male; married; some college; retired; former security administrator
2. Psychosocial History: emotional and physical abuse; suicide attempt as teenager (drove car into quarry); estranged from 2 of 3 children; wants to move to SW United States; frustrated that wife won’t.
3. Presenting Problems and Diagnosis
•Presenting problem: Panic attacks; primarily on expressway (4 yrs)
•Fear of heights, boating, and excessive speed
•Interpersonal difficulties due to “abrasive personality”
•Main goal = to cross bridges
4. DSM-IV Diagnosis:
•Axis I [based on SCID]: Panic Disorder w/ Agoraphobia; also Specific Phobia
•Past problems: Major Depressive Disorder, In Full Remission; Alcohol Dependence, Sustained Full Remission
•Axis II: None (but features)

B. Description of Therapy
1. 23 sessions: Client terminated by own choice; regarded treatment as successful
2. Process-Experiential/Emotion-Focused therapy: integration of Person-Centered & Gestalt therapies
3. Center for the Study of Experiential Psychotherapy (University of Toledo)
4. Therapist – 50 yrs. old; experienced PE-EFT therapist; one of originators of approach

C. Outcome Analysis
1. Quantitative Outcome Data:
a. Instrument: SCL-90-R GSI
Caseness cut-off: .93
RCI (p < .2): .51
Pre-Tx: .77
Post-10: .56
Post-Tx: .57

b. Instrument: Inventory of Interpersonal Problems
Caseness cut-off: 1.50
RCI (p < .2): .57
Pre-Tx: 1.96 (=clinical range)
Post-10: 1.46
Post-Tx: 2.27 (=clinical range)

c. Instrument: Personal Questionnaire
Caseness cut-off: 3.00
RCI (p < .2): .53
Pre-Tx: 4.33 (=clinical range)
Post-10: 5.33 (=clinical range; reliable deterioration)
Post-Tx: 4.83 (=clinical range)

d. Weekly Outcome on Personal Questionnaire: Varies erratically throughout therapy, between 4.3 (=Moderately distressing) and 5.8 (Very Considerably distressing)

2. Qualitative Outcome data (Change Interview):
•Can cross bridges now
•Better relationship with wife
•More tolerant
•Less afraid of flying

D. Change Process Analysis:
1. George’s Post-Therapy Account of What Helped Him
•Very general, focused on therapeutic relationship:
•Emphasized nature of relationship with T: T is “a good man”; interactions as pleasant, harmonious; T did not intrude past C’s personal boundaries, but expressed personal pleasure in C’s progress
•T helped C develop a new, broader, more tolerant perspective on others, life.
Conclusion: George describes helpful aspects of therapy, attributes some of his changes to therapy (“would not have happened without therapy”).

2. George’s Highest-Rated Significant Therapy Events (HAT):
•Session 4, extremely helpful (“9”): “When (therapist) mentioned that my childhood experiences could have a direct bearing on my problems now. Never thought of it as having anything to with my fear of bridges…”
•Session 6, extremely helpful: “The part where I talked to my daughter [empty-chair work]. Found out she is one of the bridges I cannot or at least have not tried to cross.”
George’s Highest-Rated Significant Therapy Events - 3
•Session 9, extremely helpful: “When (therapist) told me to confront my mother [empty-chair work] and tell her how disappointed I was and still am with her. Never did this when she was alive. Should have. It was a relief.”
•Session 11, extremely helpful: “Discovery of my deep-seated anger. I never knew how much anger could influence how I feel about almost everything I encounter in life.”
•Session 16, greatly helpful: “I found out that before I tackle a problem, I stop breathing. Upon facing the problem of crossing a bridge I made an effort to breathe clear across the bridge and it worked.”
Conclusion: George’s significant events, as described on the HAT form, are in the clinically significant range (Helpfulness: >7); some are also directly connected to posttherapy changes (Sessions 4, 11, 16)

3. Sudden Gains: George’s PQ scores remained high but erratic throughout therapy, showing no sustained improvements, sudden or not.
Conclusion: No evidence for therapy bringing about change here.

4. Change in stable problems:
a. Change: Can cross bridges now
•Corresponding Problem: Fear of expressway/ heights/ speed [=Bridges]
•Duration: 4 years
b. Change: Better relationship with wife
•Corresponding Problem: Problems with relatives/ Abrasive
•Duration: ??
c. Change: More tolerant
•Corresponding Problem: Problems with relatives/ Abrasive
•Duration: Long-standing
d. Change: Less afraid of flying
•Corresponding Problem: Fear of flying
•Duration: ??
Conclusion: The George showed change on at least some of his stable problems .

D. Critical Reflection:
1. Non-Change Explanations:
•Did not improve on any of the quantitative measures from pre- to posttreatment (small increases on IIP, PQ!)
•Qualitative reported changes not supported by quantitative data
•Spontaneous remarks: “I’ll talk to that nice young lady any time!”
•Discrepant data suggest possibilityof self-deception by client
2. Non-therapy explanations:
•In vivo exposure: George reported stable changes in ability to fly and cross bridges only after he flew to Florida and drove across 90 miles of bridges.
•Recent trip: in vivo exposure; Wife’s changed behavior; recurrence of daughter’s cancer
•Research intensive protocol (repeated use of questionnaires, interviews); research staff repeatedly questioned client about changes

E. Case Update:
1. 6-month Follow-up
•Client maintained ability to cross bridges; still describes himself as “abrasive”
•Recollected helpful aspects of therapy: Therapist is a “truly good man”; therapist actually cared; therapist never actually told client that he COULD cross bridges
•Client requested additional therapy to deal with interpersonal difficulties, bhut heart by-pass surgery prevented
2. 18-month follow-up:
•Able to drive across bridges at least half the time; still attributes this to his therapy
•“People tell me I’m a nicer person.”; attributes this to illnesses
3. Follow-up Outcome Data: Reliable improvement on Personal Questionnaire (6- and 18-month follow-ups)

Wednesday, July 30, 2008

RDI Training the Trainers Summer School

Entry for 29 July 2008:

After months of planning our ESRC Researcher Development Initiative-funded week-long Summer School, at the University of Leicester, got underway this week. After staying up to 4am working getting the meta-analysis data set into shape in preparation for our month away in the US, I took the train down on Sunday afternoon. After the usual Sunday train delays (they are working on the West Coast Line through the Lake District so we got stuck on a bus between Carlisle and Lancaster), I arrived in Leicester about 7pm. Sue Wheeler picked me up from my hotel about half an hour later, and whisked me off to a classic english country pub. Summer had come, belatedly and all too brief to the UK, and it was a lovely warm evening, so we dined alfresco in the garden behind the pub, where we talked on as night fell.

Roman Ruins in Leicester. When Diane and visited Leicester last Autumn, we heard that there were a Roman Ruin near Vaughan College, the site of the Summer School. However, I was startled to discover that the college actually overlooks and is built around a major Roman historical site: the foundations of a large Roman bath complex, the social centre of the ancient Roman city, with a section of wall towering over the foundations. Underneath where the college is today were the furnaces that heated the whole thing, with a run of large hot baths, then a series of less hot baths stretching to the wall, which is marked by two large entrances that connected the baths to the gymnasium, which lies under the Church of St. Nicholas. The ground floor of the college, like the foundations of the ancient baths, is below street level; there is substantially-sized museum there describing life and Roman times and earlier. I was particularly taken by the half-size figures of the inhabitants, from Mesolithic (middle stone age) to Roman times, dressed in period clothing, which started out as rudimentary furred animal skins, and evolved through tanned leather (Neolithic) to increasingly sophisticated woven cloth (bronze age and later).

I didn’t have too much time to absorb this, because the two days kept me quite busy preparing, presenting and interacting with the 25 counselling trainers who were present. They represented a wide variety of theoretical orientations (a pleasant and stimulating variation on the mostly person-centred audiences I’m used to), counselling modalities, types of training course, personalities, etc.

I was helping Sue and Kaye Richards cover the first two (of 5) days. Sue and Kaye led off with an introduction to the week and the project. I did my Setting up Outcome-Process Monitoring/Introduction to Quantitative Research presentation, which I have presented enough times that it now works pretty well. The trainers really liked the format; and that really pleased me.

Multiple Training Needs. However, we immediately ran into a fundamental contradiction about the RDI project: Our grant is supposed to focus on training them in how to teach research more effectively, but the trainers themselves are hungry for more research training. As a result they kept wanting to move to the PhD level of discussion rather than the diploma (and masters) levels. This led to very interesting and challenging discussions, which periodically had to be directed back to the Matter at Hand. But really, much more is needed.

Qualitative Evaluation and Systematic Case Studies. The second day (today) turned out to more challenging for me, because I had two different inputs, both less honed than the Outcome Monitoring one. I stayed up until 2am completely revising both of them (including parallel Powerpoint and Word lecture note formats, as is my practice). In the end, the morning session on Qualitative Evaluation methods turned out quite well, but the temptation to pick my brains about a variety of qualitative research methods topics proved to be irresistible for the audience, so we spent quite a bit of time on that.

By this afternoon they had all the pieces they needed for Systematic Case Studies a la Robert/HSCED. I had made a valiant attempt to simplify HSCED (Hermeneutic Single Case Efficacy Design) to something approximating the diploma level; however, I did not entirely succeed: it became clear that this was way too complicated for the target audience, and many of the trainers struggled in places. As a result, I’ve spent a good part of this trip home revising the presentation while it is still fresh in my mind. I’m posting a version of the revised lecture notes as an entry on this blog.

Simplifying HSCED: The key is cut enough complicated bits to make it digestible, while still retaining enough of systematicness to make it worth doing. In the end, I think that it is a process of successive approximations from diploma through masters to PhD levels. At the diploma level, only one or two quantitative measures are used; the Affirmative and Skeptic processes and specific arguments are dropped in favour of a less systematic use of the data. The assembly and presentation of the rich case record is emphasized. And so on.

At the end of the day, before Sue whisked me away to the train station for the journey home, it became clear that these first two days had largely succeeded. There was a satisfying round of applause for how far we’d come. I’ve also been very impressed by Sue’s organizational skills (she runs a huge number of different counselling skills courses), and her skill as a trainer. She always seemed to know just when it was time for the participants to stop and break up into small groups of two, three, or 10 to discuss their process, needs, goals, plans etc. I really appreciated her sensitivity to the group process and her flexibility. John McLeod arrived tonight to continue the Research Methods Relay Race through the week. I’m not sure I could have handled more than the two days, but it was certainly intense, fun and productive.

Summer Research Workshops? In the course of the past two days it has become totally evident that there is a huge need and appetite for more training in research methods for these counselling trainers. I think what is needed is a series of summer research workshops modelled on the Clarion and other Writers’ Workshops that over the past 20 years have been so successful in nurturing new generations of science fiction writers. Counselling, like science fiction, is a marginalized discipline, regarded by mainstream academics as not particularly respectable. The solution called for is an alternate structure to provide support and nurturance to help early and even mid-level practitioners develop skills and identify opportunities. If we don't support and nurture ourselves, no one else is really going to be there to do it for us! And this has been a start.

Tuesday, July 29, 2008

On Pre-Post Effect Size Statistics

Entry for 27 July 2008:

Jess Owen, of Gannon University, has written to the SPR list server with an interesting question:
I was wondering if anyone had a good reference or just general thoughts for adjusting the effect size for single group pre-post study?

Currently, I have found a consistent theme in the literature to use the pre-SD in the equation. However, even with the pre-SD, I am finding some pretty large effect sizes (e.g., > 2). I would like to think that the intervention made a big difference, but I am better sure that this is inflated given the use of only an experimental group.
This question has statistical, design, and substantive implications.

First, in narrow statistical terms, it depends on what kind of significance test was used: If the client pre-post scores aren’t paired, then an independent samples t-test is used to detect whether the difference is statistically significant, and one divides the difference of pre- and post test by the pooled standard deviation (the geometric mean of pre and post standard deviations). This is the situation that Jess Owen is referring to. However, where pre-post client scores can be paired, a more powerful statistical test is available: the dependent t-test, which takes advantage of the pre-post (or test-retest) correlation to reduce error – a long as the pre-post correlation is .5 or higher. In meta-analysis, the pre-post correlation is generally not available, so one has to resort to rules of thumb estimation procedures (e.g., Smith, Glass & Miller, 1980; if it’s a standardized inventory measure given at a 4-month interval, assume r = .5). I personally don’t like having to use these estimation procedures, which is one reason why I don’t use effect sizes based on dependent t-tests.

Second, methodologically, it depends on how you are thinking of the pre-test. For example, I like to conceptualize the pre-test as representing the population of clients not in therapy, while the post-test represents the population of clients who have had therapy. This is the logic of talking about therapy from the point of view helping client moving from one population to another, e.g., the average client moves from the 50th to the 85th percentile of the untreated population, which is another way of saying that they improved by about one standard deviation unit. In this way, also, it makes sense to use the straightforward standardized different metric described above.

Third, substantively, it appears that uncontrolled pre-post effect sizes do tend to run larger than controlled effects between the post test scores of treated and untreated clients. Lipsey and Wilson (1993) reported this in their meta-meta-analysis. However, it’s never been clear to me how much their results reflect the use of the ESs based on dependent t-tests, or whether pre-post effects are just bigger than controlled post-only effects. Fortunately, it turns out that I can use the person-centred/experiential (PCE) therapy meta-analysis results to shed some light on this question: In this data set, clients seen in PCE therapy change about 1.0 sd (=a very large effect), while control participants change about .2 sd (a small effect); as a result, the controlled standardized gain statistic (i.e., the difference between treated and untreated participants) is about .8 sd (a large effect). In other words, the pre-post ES is a wee bit bigger than the controlled ES, and this is important to be aware of. This is of course why no-treatment control designs are used in first place, but the data show that in general such controls don’t do much except make our studies look more scientific. However, there are always exceptions; for example, some types of clients probably improve on their own more than .2 sd, while untreated distressed couples may get worse!

As a result of all three of these considerations, I prefer to use a simple standardized difference as a basic effect size for therapy outcome research: It’s more conservative (generally) than an effect size based on the dependent t-test; it’s easier to think about in population terms; and it’s closer rather than further away from a controlled ES. A final note: Psychotherapy is a wonderful thing, and perfectly capable of producing extremely large effects, including one on the order of 2 or 3 sd or even larger!

Lipsey, M.W., & Wilson, D.B. (1993). The efficacy of psychological, educational, and behavioral treatment: Confirmation from meta-analysis. American Psychologist, 48, 1181-1209.

Smith, M.L., Glass, G.V., & Miller, T.I. (1980). The benefits of psychotherapy. Baltimore: The Johns Hopkins University Press.

Monday, July 21, 2008

Bothwell Castle and the David Livingston Centre

Entry for 19 July 2008:

We’ve been continuing to keep up our custom of Saturday Adventures whenever we’re in town. Last Saturday, for example, we visited the Museum of Scotland in Edinburgh, spending almost the whole time in the basement looking at old stuff: neolithic, bronze age, and Roman, with a smattering of early Christian artefacts.

For this week’s adventure, after a bit of research, we determined that we could easily visit Bothwell Castle by taking the train to Uddingston and walking about a mile from the train station. It was raining when we arrived (the weather has been most un-summerlike for the past couple of weeks), and our feet quickly got wet as we trekked down to the castle, but it stopped after a bit and by the time we arrived bits of blue sky were showing. Although it’s a ruin, Bothwell Castle towers imposingly on a bend in the River Clyde, red sandstone, cut from the same rock as the stone that clads Glasgow’s famous red sandstone tenement flats, like the one we live in. Unlike many of the castles we’ve visited, however, this one saw plenty of action in its time, changing hands repeatedly in the wars between England and Scotland in early 14th century. We have the castle visit thing down to an art by now: scope out the great hall & chapel, kitchen, buy a guidebook, talk to the guide, climb up and down the tower(s), etc. The old keep, or donjon, where the lord originally lived, is particularly impressive, even with only half of it remaining.

The guide recommended that we hike up the river a mile to the David Livingston Centre, which I’d seen written up in our Scottish Heritage book, but hadn’t quite put together with Bothwell Castle. It turned out to be a lovely afternoon for a walk up the River Clyde’s leafy banks, in and out of shade, cloud and sun, until we reached the large, sturdy foot-bridge between Bothwell and Blantyre. There, in the middle of Lanarkshire, in the old cotton mill town of Blantyre, is a museum and park dedicated to celebrating the life of the Scottish medical missionary, African adventurer, and 19th century abolitionist. I found him to be an inspiring example of living by one’s values and ideals.

We caught the train from Blantyre and were back in time for Kenneth’s 4pm dugeon & dragons sessions with his friends in Ohio. As with the Museum of Scotland the week before, we are likely to return to both of today’s destinations, and we have explored another little bit of the Glasgow area, backwards and forwards in time and space, like Dr Who's TARDIS, making the unfamiliar familiar, finding our way into a life here.

Friday, July 18, 2008

Leijssen & Elliott (2008). Integrative experiential psychotherapy in brief

This is an article that Mia and I had fun doing together. Actually, we started by getting a very nice dutch-language paper of hers translated into English. I always enjoy the clarity and groundedness of her writing, and I always learn something from her. So I kept including more and more bits of her work, and pretty soon, it ended up with so much of her work in it that she really needed to be first author, which I had no trouble with. Keith Tudor found it a bit strange that our example client had received 25 sessions of “short-term” therapy, because that didn’t seem very short to him, but it was pretty clear to me that this client covered a lot of ground in a relatively brief period of time, so that it was almost like 4 brief therapies, one right after another. One the things I learned from Mia in this paper was the idea/practice of the therapist offering to keep the client’s pain between sessions. I’ve since tried this with my clients in the Social Anxiety project, to good effect.

Reference: Leijssen, M., & Elliott, R. (2008). Integrative experiential psychotherapy in brief. In K. Tudor (Ed.), Brief Person-Centred Therapies (pp. 31-46). London: Sage.

Abstract. Contemporary experiential therapies integrate aspects of several different suborientations within the broad client-centered/experiential approach, with new theory, practice and research, supporting their use as brief treatments. In this chapter we provide an overview of some of the main elements of current experiential therapy, with special reference to its application as a brief therapy. We briefly summarize the main research data supporting the effectiveness of this approach, We work in a more orthodox client-centered way to facilitate the narrative construction of the client’s life. We also introduce focusing micro-processes to help the client develop a healthy internal self-relationship. Interpersonal work takes the lead when maladaptive interpersonal schemes are hindering the relational life of the client. In addition, we appreciate existential processes, especially when the client struggles with the givens of life. In this chapter, we offer several vignettes from a short-term psychotherapy to illustrate this integrative approach. The client in this case study reported the introduction of a time-limit at the start of the therapy as stimulating and hopeful.

Tuesday, July 15, 2008

Emotion-Focused Therapy: Level 3 Supervision Series 2008-09

Facilitated by Robert Elliott
Professor of Counselling, University of Strathclyde

Tuesdays, 6-9pm, 9 September, 2008 – 9 June, 2009
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 Emotion-Focused Therapy (EFT) for counsellors and psychotherapists (Diploma level or above) who have completed Level Two training in EFT. This 12-session series will meet every three or four weeks throughout the 2008-09 academic year, beginning in September. The format will primarily focus on supervision of recorded therapy sessions, supplemented as appropriate by viewing of archival video-recordings, brief lectures, experiential practice exercises in small groups, and discussion. Emphasis will be on putting EFT into practice and examining blocks to effective practice.

This series is scheduled for the following dates. Sessions will take place in Wood W614, except where otherwise indicated:
Autumn 2008:
9 September
7 October
28 October in W500
18 November in W502
16 December
Winter-Spring 2008:
20 January
17 February
17 March
7 April
28 April
19 May
9 June

• Enrolment is set for a maximum of 12.

• Tentative Course fee: Until 15 August: £345; after 15 August: £395.

• 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 ).

(version 15 July 2008)

Emotion-Focused Therapy: Level 2 Workshop Series

Facilitated by Robert Elliott
Professor of Counselling, University of Strathclyde

Wednesdays, 6-9pm, 10 September, 2008 – 27 May, 2009
Sir Henry Wood Building Room W312
Jordanhill Campus
University Of Strathclyde
(Sponsored by the Professional Development Unit, University of Strathclyde)

The Counselling Unit at the University of Strathclyde is offering further training in Emotion-Focused Therapy (EFT) for counsellors and psychotherapists (Diploma level or above) who have completed Level One training in EFT or the equivalent. This 14-session series will meet approximately every three weeks (see schedule for exceptions) throughout the 2007-08 academic year, beginning in September. The format will be a mixture of brief lectures, videos or demonstrations, experiential practice exercises in small groups, supervision of cases seen by course members, and discussion.

The specific topics to be covered are flexible based on participant interest, but will feature material not covered in the Level 1 course, such as
• Therapist experiential response modes
• Client modes of engagement
• Narrative Retelling of difficult/traumatic experiences
• Clearing a Space for overwhelming or chaotic experiences
• Relational Dialogue for Alliance difficulties
• Creation of Meaning for meaning protests

The Focusing and different forms of Chairwork will be particularly emphasized:
• Focusing with difficult or painful experiences
• Two chair enactment for Self-interruption splits
• Two chair conflict split work depression, anxiety and self-harm behavior
• Empty chair work for unfinished business

This series is scheduled for the following dates:

Autumn 2008:
10 September
1 October
22 October
19 November (note change in frequency)
10 December
Winter-Spring 2009:
14 January
4 February
25 February
18 March
1 April (note change in frequency)
22 April
6 May (note change in frequency)
27 May
10 June (note change in frequency)

• Enrolment is set for a maximum of 20.

• Course fee: Until 15 August: £395; after 15 August: £445

• 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 ).

(version: 15/07/08)

Relational Change Processes in Process-Experiential/Emotion-Focused Therapy

Paper presented Person-Centred/Experiential Therapy Conference,
Norwich, UK, July 2008

Relational Change Processes in Process-Experiential/Emotion-Focused Therapy
Robert Elliott
University of Strathclyde

I. Therapeutic Relation and the Change Process in PE-EFT
A. Two functions (from Rice & Greenberg)
1. Primary: Fosters change directly as a corrective relational experience
2. Secondary: Fosters change by facilitating emotion change processes

B. Therapeutic Relation as a Primary Change Process
1. Client enters therapy with Negative Other emotion schemes, e.g.:
Uncaring, judging, misunderstanding, phony, exploitive, abusive
2. Therapist violates these expectations by acting differently, often in the opposite manner: Caring, accepting, understanding, genuine, putting client’s needs first, present in a healing way
3. Provides client opportunity to revise interpersonal emotion schemes into positive ones (therapeutic reaction: Positive Other
4. Also promotes revising Self Emotion Schemes to complement new Other Emotion Schemes (therapeutic reaction: Positive Self)

C. Therapeutic Relation as a Secondary Change Process
1. Enables the client to trust the therapist and the therapeutic process enough to risk entering into the difficult, often painful emotional experiences that are change processes in themselves.
2. Emotions are source of agency: helps client find own direction

II. Reflections on Deference in Therapy
A. General considerations:
1. Definition of Deference: Submission to the judgment, wishes or opinion of another person
2. Can be negative/interferring or positive/facilitative

B. Complexities of Deference
1. Universality
2. Types
3. Nonlinear relational regulation processes
4. Paradoxical deference in PCT

C. Universality of Deference
1. All relationships involve some degree of mutual deference
2. In talking, we take turns giving the floor to each other
3. We expect the other to listen to us when we speak
4. We design our responses to be responsive to the other

D. Types of Deference
1. Content deference: Topic/issue/task/goal; Meaning, commentary
2. Process deference: How a topic/task/issue will be worked with
3. Content deference can allow process nondeference

E. Feedback Processes in Deference:
1. When we defer, we follow the other person
2. But this often reveals to both people that the direction proposed doesn’t work, so they reverse direction and go a different way
3. This argues against simple linear deference models
4. What we should worry about is when deference defeats the natural self-correcting process in therapy

F. Paradoxical Deference in Person-Centred Therapy
1. Client asks for guidance from therapist
2. Therapist declines to provide guidance
3. Client defers to therapist by withdrawing request for guidance
4. So: Nondirectivity doesn’t eliminate the power differential, and may risk being experienced as a power play in which the therapist withholds valuable information in order to retain power over the client

G. Paradoxical Deference in Person-Centred Therapy
1. Gloria is a counter-example: She doesn’t really defer: She continues to ask Rogers for direction and finally extracts an answer to her question from her reading of his responses to her:
Gloria: Example of Client Nondeference:
C49 But then there's also a conflict there because I am not really positive what I want to do. ... Like when I bring a man to the house. I am not sure I want to do that. If I feel guilty afterward, I must not have really wanted to.
T49 ... I'm not just sure which words you used - but ... you don’t like yourself or don't approve of it when you do something against yourself.
C50 Yes. You know, this is so different. Now this kind of thing we are talking about now, it isn't just knowing whether you want to do something or not. ... when I find myself doing something I don't feel comfortable with, I automatically say, "If you’re not comfortable Gloria, it’s not right. Something’s wrong." All right now. What I want to ask you is, how can I know which is the strongest? Because I do it, does that mean that’s the strongest? And yet, if I disapproved, that's just part of the thing that’s got to go along with it? You see, it sounds like you... I'm picking up a contradiction...
2. But: What about less resilient clients? How often do we silence their request for help in resolving their tasks?
-Example of Possible Deference by a client:
-Is this an example of a client celebrating his new-found power…
-Or: attempting to self-persuade that it is OK to give up his desire for guidance from the therapist?
-Socially Anxious client in Nondirective Therapy:
… sometimes I want to ask you [for] advice and say: ‘what would you do?’ but I know that is not the purpose of this… and has been hard to get used to sit here and coming up with solutions myself… but I’m starting to see… we have only met for four or five times, but I can see the benefits of doing that and sitting here and doing that… just speaking and thinking… because the solutions are all in my brain! but sometimes there is so much mess in my brain I can’t see them. I have never in my life would have thought this would work, just me talking and … because you are the only person in my life who doesn’t offer me advice (laugh) and that is bizarre! But I’m coming to realize that I don’t need you to advise… yeah it would be lovely for you to turn and say: ‘I think you should this and this’, but the actual fact is that this is far healthier than.”
III. More Differentiated View of Deference needed
A. Interfering Deference:
1. Being silenced from expressing important, pressing concerns or feelings
2. Going along with something that goes against our values
3. Allowing ourselves to be put down or lowered in value
4. Being exploited for an other’s benefit

B. Facilitating Deference (for both client and therapist:
1. Holding back for a bit to make space for the other to finish
2. Trusting the other that something painful or difficult can be helpful

C. Conclusion:
1. Vital not to abuse client’s trust
2. With this warning, critical point is to be clear about what kind of deference we are using.

Acknowledgements to Bill Stiles, Beth Freire for the transcripts and to Art Bohart for general inspiration.

Saturday, July 12, 2008

Report on PCE Therapy Conference Norwich 2008

Entry for 10 July 2008:

For one reason or another, at this year’s PCE conference, I ended up doing five presentations and being a discussant on one other session. “Why do you do this?” Diane asked me, when she found out what I’d let myself in for. At one level, this is just an expression of my crazy life here in the UK and at Strathclyde, but at another level, the real answer is relational: my friends and colleagues asked me to, and I was pleased to contribute as an expression of our friendship and shared work.

Press coverage for the Four Professors Joint Statement. A couple of weeks before the PCE conference, working from a press release drafted by Judy Moore and Mick, I proposed the Mick, Art Bohart, Bill Stiles and I put out a joint statement in conjunction with the conference, arguing that the idea that CBT is more effective than other therapies is a myth. After some feedback and revision to my original draft of the joint statement, the others signed on. The press release (which I have previously posted as an entry on this blog) went out to the media a couple days before the conference, and just as I was arriving at the conference on Sunday afternoon, my mobile phone was ringing with someone form BBC Radio 5Live wanting to know if I’d be willing to speak on the morning sport talk program at 7am the following morning. I was dead tired and hadn’t yet finished the meta-analysis talk that Beth and I were to give first thing the next morning; however, I agreed to meet the University of East Anglia’s PR person at their sound studio to do this. Fortunately, for me in my sleep-deprived condition, the final game at Wimbledon turned out to be so exciting that they cancelled me (“It was one of the games of the century”, said the producer, trying to let me down gently), and I was able to get some sleep that night.

However, over the course of the next two days it appeared that our joint statement had made an impact, showing up in the Daily Mail under a lurid headline, as well as in the Independent and elsewhere. Gratifyingly, the most accurate account appeared in the Glasgow Herald, or at least in the on-line version, which was minus the large photos of JK Rowling and other celebrities giving testimony to the wonders of CBT. For reasons now obscure to me, I’d left Mick’s name stay first on the press release, even though I’d written most of it; this meant that he got the lion’s share of credit in Daily Mail and Independent stories, for which I discovered I was quite grateful. The news articles turned out to be rather thin in content, which was really our fault for emphasizing the logical argument rather than the meta-analysis data on which the claims were based.

As for the rest of the conference, here are some personal high points:

1. PCE Meta-analysis. The conference saw the roll out of the new, integrated version of the PCE outcome meta-analysis (with Beth), now with 77 new studies. We had a great turnout for this and an enthusiastic response, especially when the audience learned that we’d managed to demonstrate equivalence between CBT and “pure” Person-Centred therapy. More work remains to finetune the analysis, examine subgroups of clients and write-up various reports on it, but for now we have a nice feeling of accomplishment.

2. Workshop on PE-EFT tasks. This featured Systematic Evocative Unfolding (Jeanne), Focusing (me), and Two Chair Dialogue (Les). Again, turnout was quite good, especially given that there were 12 tracks running in parallel. I played a key moment from my first social anxiety client’s therapy, illustrating the power of focusing with this type of client presenting problem. Unfortunately, the nonnative English speakers couldn’t understand her Glaswegian Scots way of talking.

3. Social Anxiety panel. Mick and I came up with the idea of studying social anxiety two years ago, at the last PCE conference, in Potdam, Germany, so it felt very appropriate for us to be able to report on the project at Norwich. The panel featured examples from the clients being seen by Beth, Mick and I (Brian introduced and Tracey moderated; unfortunately, Lorna couldn’t make it for the session). Again, there were a lot of people in the audience, and it was lovely to for so many members of the team to be able to present. This time, I stayed up late the night before making a transcript of the 4-minute segment of Two Chair Work from my client, illustrating her social anxiety-critic process. I ran the transcript under the video, scrolling through a long, thin Word window by hand. In the discussion period, Pete Sanders accused us of harming clients by giving them a psychiatric diagnosis and developing theory and practice formulations specific to social anxiety.

4. PE-EFT in Australia. For Les, Jeanne, Rhonda and I, one of the most interesting and heartening developments at the conference was the presence of a very visible (by virtue of their energy and enthusiasm) Australian group of PE-EFT therapists centred around La Trobe University (where my family and I visited for 6 weeks in 1999). Melissa Harte, Zoe Krupka and Stan Korosi were at PCE Norwich representing a group of PE-EFT therapists trained by George Wills, whom Les and I met 11 years ago at the PCE conference in Lisbon. They presented an ambitious series of workshops emphasizing their innovative work on PE-EFT models of training and supervision. I missed Melissa’s talk, but the live demonstration of task-focused PE-EFT supervision was useful, powerful and thought provoking. Les and I were then asked to join an open discussion of the presentations we’d seen. Curiously, this discussion had a bigger turn out than the sessions we were supposed to be discussing, which meant that most of the people there hadn’t seen the sessions being discussed. I am certainly going to have to think about testing something like their “in mode” supervision approach out in the EFT-3 supervision group this fall; I will try to find time to write about their list of PE-EFT supervision tasks in a later entry. George should be proud of what his group have been able to accomplish!

5. Relationship Panel. However, the most fun I had at the conference occurred in the panel Beth put together with Art Bohart, Bill Stiles and me. By this time we are really getting to be the Old Same Crew. The topic was, loosely, “Client Deference, Corrective Experience, and Emotional Processing”. I had outlined most of my talk during an earlier keynote speech during the conference, working it into a set of Powerpoint slides the previous evening. The topic felt like a minefield, running right through the central faultline in the PCE movement, so I was fairly nervous about my presentation.

To further complicate matters, the room was pretty packed; several prominent nondirectivists were present; Bill and Art had decided to talk about the Gloria-Rogers film (because they are working on a book chapter using it as material); and Gloria’s daughter Pamela Burry (at the conference to talk about her new PCCS book on the subject) was in the audience. I was speaking last, after Art; Beth and Bill had both loaded their talks onto my laptop to reduce swap-over issues with the projector. As it happened, both Beth and Bill used transcripts with examples of deference-related processes in them: Beth’s from one of her Social Anxiety project clients, Art’s from the Gloria-Rogers film. While Art was talking (without Powerpoint), I unplugged the projector lead cord to avoid distracting the audience with the end of Bill’s talk, then suddenly realized that this would allow me to make a few last-minute revisions to my talk. I quickly copies the relevant transcript slides from Beth’s and Bill’s talks, highlighted the deference-related passages and finished by adding some transition language, just as Art was finishing. I plugged the projector cable back in and was off.

In the talk I put forward the propositions that deference is not necessarily bad; that we need to be much more differentiated in our thinking about deference; that nondirectivity can itself paradoxically generate client deference; and that the critical thing is to differentiate harmful and facilitative deference. This felt like walking into the lion’s den, and I was aware of how anxious I was as I started talking. However, the talk turned out to have a big impact on various of the people there, including Pete Sanders, who startled himself by agreeing with everything I’d said, and Beth. Even Lisbeth Somerbeck, one of the strongest of advocates for nondirectivity, owned that her ability to maintain this stance with hospitalized clients was made possible by the support of social workers who provided practical guidance for clients.

6. IPEPPT Practice-Based Research Panel. Nele Stinckens, one of my KU Leuven colleagues has developed a passion for practice-based research and implementing systematic case studies in therapy training. This year, she organized a session with Alberto Zucconi and me to report on our progress in implementing aspects of the IPEPPT (International Project on the Effectiveness of Psychotherapy and Psychotherapy Training). This was in the last timeslot of the conference, a terrible time to present, but we did have a reasonable group of hardy souls in attendence. As I got ready to present, the cumulative weight of the month’s presentations finally hit me like a lead weight, and I felt a moment of dizziness, as it all caught up with me. Then I pulled myself together and went on with this final presentation, once more into the breach, and I presented the research protocol Julie Folkes-Skinner and I are using for the Diploma course evaluation study.

At the end of it, I felt I’d well and truly earned the next couple of days off.

CBT superiority is a myth: The Four Professors Joint Statement

Joint Statement Issued by Professors Mick Cooper and Robert Elliott (both University of Strathclyde), William B Stiles (Miami University) and Art Bohart (Saybrook Graduate School)

The government, the public and even many health officials have been sold a version of the scientific evidence that is not based in fact, but is instead based on a logical error. This is how it works: 1) More academic researchers subscribe to a CBT approach than any other. 2) These researchers get more research grants and publish more studies on the effectiveness of CBT. 3) This greater number of studies is used to imply that CBT is more effective.

This is a classic example of the logical fallacy known as ‘argument from ignorance’ ie the absence of evidence is taken as evidence of absence.

Although CBT advocates rarely make this claim so boldly, their continual emphasis on the amount of evidence is misunderstood by the public, other health care workers, and government officials, a misunderstanding that they allow to stand without correction. The result is a widespread belief that no one takes responsibility for. In other words, a myth.

This situation has direct negative consequences for other well-developed psychotherapies, such as person-centred and psychodynamic, which have smaller evidence bases than CBT. These approaches are themselves supported by substantial, although smaller, bodies of research. The accumulated scientific evidence clearly points to three facts: 1) People show large changes over the course of psychotherapy, changes that are generally maintained after the end of therapy. 2) People who get therapy show substantially more change than people who don’t get therapy, regardless of the type of therapy they get. 3) When established therapies are compared to one another in scientifically valid studies, the most common result is that both therapies are equally effective. A case in point is person-centred and related therapies (PCTs): In a meta-analysis of more than 80 studies to be presented by Robert Elliott and Beth Freire at the Norwich conference, PCTs were shown to be as effective as other forms of psychotherapy, including CBT.

In view of these and other data, it is scientifically irresponsible to continue to imply and act as though CBTs are more effective, as has been done in justifying the expenditure of £173m to train CBT therapists throughout England. Such claims harm the public by restricting patient choice and discourage some psychologically distressed people from seeking treatment. We urge our CBT colleagues and government officials to refrain from acting on this harmful myth and to broaden the scope of the Improving Access to Psychological Treatments (IAPT) project to include other effective forms of psychotherapy and counselling.

7 July 2008
PCE Conference
University of East Anglia, Norwich, UK

Friday, July 11, 2008

Reflections on the 2008 EFT Level 1 Training

Entry for 10 July 2008:

Trying New things. We experimented a bit with this year’s Level 1 EFT training: After helping Les with the Level 1 in Galway two months ago, I wanted to try increasing the amount of chair work, moving it up by a day from last year. Also I want to see what it would feel like to do Systematic Evocative Unfolding after chair work. Another new practice was having the participants self organize into small groups to work together most of the week. I want to see if this will help the students who go on to EFT-2 to get into chair work more effectively.

In the event it did feel like a good idea to spend more time on chairwork, adding energy and depth, and the small groups appeared to work out generally. However, Unfolding got slighted to a certain extent on the last day. Time will tell whether the changes will translate into helping EFT-2 participants more readily “get over the hump” and into more and better Two chair and Empty chair work.

Next time I think it may be a good idea to put Unfolding back in before Two Chairwork. Probably it will make sense to run chairwork from Day 2 afternoon through Day 4 morning.

Task Tracking Questions. An interesting development was the identification and labelling of another important kind of PE-EFT therapist response, the Task Tracking Question (TTQ), for example, “Where are you with your sense of being pulled in two directions?” (for Two Chair dialogue for conflict splits) or, “Where are you with the thing that happened last week? Does it still feel puzzling to you?” (for Unfolding). TTQs are a type of State Check, e.g., “We need to stop in a couple of minutes. Where are you now?” Given that tasks are driven by salient and highly specific client states of distress, TTQs assess whether a task as task is still live for the client, and how far the client has progressed through the tasks, by asking about the distressing experience from which the task derives. They are helpful particularly because therapists often cannot tell these things, which means that they will be less able to facilitate client task resolution efforts, and may even impede their progress.

In the end, Jeanne and I really enjoyed working with this group of participants, who were eager to learn, took the training seriously, and seem less concerned about deviating from nondirectivity than previous groups had. In general, it feels like things are moving forward for PE-EFT training in Scotland. Jeanne and I have already scheduled the next EFT-1 training, for 13-16 July 2009.

Update: Leuven, Barcelona, EFT-1 & Norwich

Entry for 10 July 2008:

On the train back from the Norwich PCE 2008 conference.

What an intense past several weeks it has been! In fact, it’s really been a full month since I last had the time to look up and really reflect on what it happening. (That was on the train coming back from the last ERG meeting in London.) Since then, it seems I have been constantly on the run:

First, to Belgium to present a case study from the Social Anxiety Project at the Flemish Person-Centred/Experiential Association in Leuven.

I came home for a day, and then Diane, Kenneth and I were off to Barcelona for the annual international conference of the Society for Psychotherapy Research. This began with me receiving the Lifetime Distinguished Research Career Award. I posted a press release-type statement on this on the blog at the time, along with the poem I wrote for the occasion. As the poem indicates, this was huge for me, and gave me a real sense of satisfaction. Fortunately, we’re only allowed to do one first-authored presentation at SPR, and the two sessions I was discussant for were on the same day as my HSCED presentation, so the rest of the conference was fairly light. This meant that I was able to get in some sight-seeing with Diane and Kenneth on the Friday, when we took the train down the coast to the ancient Roman city of Tarraca, now known as Tarragona, where we spent the day visiting the ruins of the colloseum, circus (chariot race track) and Forum; the slow pace of life in Tarragona was a relief after the bustle of Barcelona. The next day my Australian colleague Margot Schofield, and I also visited the Gaudi’s fantastical, visionary cathedral, Familia Sagrada. I found his art nouveau, organic style to be a more exuberant expression of the sentiments behind Glasgow’s Charles Rennie McIntosh’s building and design work, but on a much grander, more fantastical scale.

The week after SPR was spent doing admin, seeing my research clients, and saying goodbye to my colleague Tracey. In the midst of this, my 15-year-old nephew Luke arrived for a visit. To provide him and Kenneth a Neolithic Experience, we took the two of them to Cairnpapple Hill, south of Linlithgow, overlooking much a central Scotland. There we tried to decipher 3000 years of ritual space (post holes for great wooden posts) and burials. The latter consisted of cairns on top of cairns, finally ending with a set of early Christian graves strategically placed to break the ritual circle. We clambered over the site, climbing down into the large cairn/dome reconstructed on top of several earlier burial cairns. The guide docent told us about the various visitors to the site, including druids and seekers of ley lines. The taxi driver had told us there was a stone circle nearby, but when we asked the guide, she pointed it out to us on the next hill, disdainfully noting that it had had been put up as a prank by the farmer’s sons.

Then the EFT-1 training was upon us. Jeanne Watson arrived with her partner Derek, and we worked flat out through Thursday, revising the materials and generally trying to stay one step ahead of the course. Thursday night we went down to the Star Folk Club to hear my favorite Canadian folksinger, James Keelaghan, give a lovely show, complete with Hillcrest Mine, a song that I once spent 5 years trying to track down after I heard it on the radio on a Canadian folk music program. For our Saturday Adventure, we took the ferry to Great Cumbrae, which we walked most of the way around while being rained on and blown to bits. This gave Luke an authentic Scottish Experience (he is probably grateful for his return to the baking heat of California). A high point was a stop we made at the Cathedral of the Islands, the smallest cathedral in the UK, a cute, miniature church (originally built as a chapel), with all the usual cathedral-type things (e.g., Lady Chapel), but on a smaller scale. We dropped by the tea room, and eventually persuaded the church warden to give us a bit of tour, so that I could determine its appropriateness for retreats and training weekends.

After that, I was off again, this time to Norwich for the 2008 PCE (Person-Centred Experiential therapy) conference, a very busy, intense time, which I’ll write about separately.

The cumulative effect off all this is one of exhaustion. I can hardly wait to get back to Glasgow and fall into my bed tonight. I was so eager to get away, that I caught an earlier train from Norwich and am now wending my way circuitously through central England via Peterborough (where I got off the train and immediately reboarded after checking the train schedules), Grantham, mostly distinguished by the large number of intercity trains that speed through at a great rate of speed on their way to and from London. After raining all week, the day started out in Norwich this morning in a glorious mix of cloud and sun and a cool breeze; now of course it is increasingly clouding over as we head north toward Scotland. I will have two more changes of train: In York and Edinburgh, before I reach Glasgow, but I am very relieved just to be on my way home, and am looking forward to a couple of days off from rushing around giving and preparing talks.