Wednesday, December 31, 2008

Year’s End in Murray Creek

Entry for 30 December, 2008:

Murray Creek, second last day of year,
Daylight comes at seven;
We luxuriate in long early light.

Rising to run Murray Creek road,
Frost lingers on car and star thistle,
Mist rises, ghostly, lit by early sun.

Life slows, creek flows,
Gently, not yet in full spate,
Waiting for more winter rains.

Peace fills winter valley,
Slowly turning green;
Animals stir quietly, hardly seen.

Labyrinth waits, silent
Wet stones settling into earth,
Path littered with oak leaves.

Slow time hovers in the valley,
Pausing at year’s ending,
Land mending, work done, we rest.


Entry for 31 December 2008:

When I began keeping this blog 2 years and 4 months ago, it never occurred to me that I would ever get to 200 entries, let alone 300. However, interesting things kept happening and its function kept expanding, to include the politics of psychotherapy, therapy and research training, poetry, commentary on published articles and book chapters, and so on. And so, “by commodius vicus of recirculation” (to borrow a phrase from Joyce’s Finnegans Wake), I suddenly find myself at entry number 300, considering my starting point, the journey so far, and the future prospects.

My first entry, written 31 August 2006, but not posted until several days later, was entitled, “Arrival in New California”, and began as follows:
We have arrived safely in Scotland. As we flew into Glasgow yesterday, we suddenly noticed that there are hills and mountains all around, and of course the river Clyde broadening out toward the sea in the distance. It reminded us strongly of California in the winter, when everything is green. So we have decided that Scotland is our new California! A New California for our new life...

Journey through Old California. And of course, as I write this, we are in Old California, the place where I was born and lived my first 28 years. New Year’s Eve day dawned this morning, another clear, cool Northern California winter’s day, again frosty as it has been for the past several days. After breakfast and clearing out the lower house (my mom has stayed in the upper house since my dad died), we said goodbye to my mom until next August. Descending out of the foothills, just past Valley Springs, we encountered the fog that has blanketed the entire Central Valley, from Redding to Bakersfield, over the past day or two, leading to multi-car pile-ups on the major highways. San Andreas, as my mom noted, is “Above the fog and below the snow" Down in the great valley where I grew up, however, there’s been no wind lately and therefore nothing to blow away the fog, so here it sits.

Much of Northern California has so far had only about 5 inches of rain this season, on top of several years of drought, so there really isn’t much green yet as we pass Tracey and climb over the Altamont Pass. Diane marvels again at the sheer number of car and trucks, like us seemingly driving from nowhere to nowhere. American loves its cars, and California especially. Finally, near the top of the pass, the fog is beginning to burn off, and we are suddenly nearly blinded by the bright winter sun. This is the fourth time we’ve passed through here on this trip, and like the previous 3 trips the windmills of Altamont stand there, unturning, still, bereft of breeze, waitng in vain for a windy day. No, this isn’t really very Scottish afterall…

The Journey So Far

Why blog? This blog has provided me with an opportunity to meet a need I have to document, take note, express, create and reflect. Why do it in such a public way, I have been asked, and not as a diary or a private blog, shared only with a small circle of family and friends? This is as difficult to explain as it is true of my experience: The need in me that drives this blog is a need to express and communicate to others, or an Other. It is part of the same need that pushes me to write and publish articles, to present my work at conferences, and to write and read my poetry for audiences. It is a need to connect, to be heard, to make a difference in another’s experience, which is itself a need to be in contact and thereby to be real. This is an old and familiar part of me. To quote the comic strip, Calvin and Hobbes: “’I am significant!’, screamed the dust speck”. Scientific publications are great, and I’ve done lots of those (about 110 at last count), but they lack intimacy and immediacy, which is where the blog comes in.

Types of entries.
In general, entries fall on a spectrum from personal (typically labelled as “Personal experiences” or sometimes as “Poems and Dreams”) to professional (labelled variously as “*News”, “Articles”, “Research”, “Training Opportunities” etc), with some entries blending personal and professional content (e.g., some of the “Politics” entries). At some point, I started posting text versions of selected lectures and conference presentation and doing little commentary pieces when a new article was published. Over time, I would say, I’ve reduced the amount of personal content in relation to professional content, especially as the readership of the blog has increased to the point where it is likely that some of the readership is not necessarily friendly.

Rate of entries. At the beginning I wrote entries every day or two (highest number: 24 in September 2006; second highest number: 20: March 2007). At times, the rate of entries has slowed to a trickle (4 entries for Sept and October of 2008), but just when I thought I’d dried up, something in me would find the need to write something. Over the past year, I’ve produced on average one or two entries per week, which feels like a good number for this.

Blog Process. I do collect ideas for blog entries, although many are never written. At the end of each month, there are usually a couple unfinished entries, most of which will never be completed. I never compose directly in Blogger; instead, I draft entries first on my notebook computer, then copy them onto the Blog. I always revise entries before posting, sometimes extensively, so that posted versions are generally second drafts (but still contain typos and errors nevertheless). I occasionally go back and revise previously posted entries.

Reader comments invited. I think people find posting comments to this blog to the a bit of a pain, which is my theory for why there aren’t more comments posted. To begin with, you have to sign up for a Google account. Early on, I decided to moderate comments, after someone posted spam on the blog. That means you can’t post directly to my blog; instead, when you submit your comment, Blogger sends me an email message containing the comment and asking me if I want to publish or reject. I will publish any comment that is reasonably relevant and appropriate. Two recent comments that I rejected were ads, one for someone’s internet dating website and the other a dodgy-looking internet drug discount site pushing anti-anxiety medication! I think a lot of my serious readers have really interesting things to say but are too shy to post comments, so I would like to take this opportunity to encourage them to do so!

Future Prospects

What are my goals and resolutions for the 2009?

1. I’d like to continue doing 2 entries per week, along the same lines as before, continuing to mix personal and professional entries.
2. I certainly intend to continue documenting my views of developments in the politics of the helping professions in Scotland and the UK.
3. I plan to resume my “Saturday Adventure” entries of interesting sights around Scotland.
4. Although this blog is primarily a verbal medium, I’d like to include more photographs.
5. I’d like to write more about the social anxiety research we’re doing in the Research Clinic; I’ve had to be careful here because of confidentiality issues. Fortunately, as we accumulate more clients it becomes more possible to write generally about common, repeating clinical phenomena that are emerging in several different clients.
6. I’m hoping that new, unexpected and interesting things to write about will emerge. Part of the fun of doing this is the opportunity to follow new interesting developments!

For now, I wish you a peaceful and prosperous New Year.

Friday, December 26, 2008

Scottish Matrix Slights Person-Centred-Experiential Psychotherapies

Entry for 26 December 2008:

After some delay, the new template that is supposed to guide the delivery of psychological therapies for Scotland has been released, just in time for Christmas. The document is entitled, Mental Health in Scotland: A Guide to delivering evidence-based Psychological Therapies in Scotland: “The Matrix”, and was produced by NHS Education for Scotland (NES), drawing on inputs from experts. (I drafted the section on Social Anxiety/Social Phobia, which appears with some later additions by others.)

1. What is The Matrix?
To begin with, the stated purpose of the the Matrix document is, “to help NHS Boards:
• Deliver the range, volume and quality of Psychological Therapy required for the effective treatment of common mental health problems, and the achievement of ICP accreditation;
• Provide evidence-based psychological interventions in other key government priority areas; and
• Work towards reducing waiting times for Psychological Therapies in anticipation of future ‘referral to treatment’ targets,”
It does this by, among other things, ‘Summarising the most up-to-date advice on evidence-based interventions.’ In addition, there is the following qualitified disclaimer: “The Guidance is not intended to be prescriptive, but does offer guidance to local groups involved in the strategic planning and delivery of Psychological Therapies.”

The bulk of the document is a set of tables of recommended therapies organized into different common client presenting problems, for both adult and child populations.

2. How was The Matrix document constructed?
NHS Education Scotland assembled a collection of experts on different client presenting problems. I was asked to review the literature on social anxiety, presumably because there aren’t too many people working on it in Scotland. We were given a relatively short amount of time, less than 2 months, and encouraged where possible to rely on the NICE and SIGN guidelines, which are respectively the English and Scottish official summaries of research evidence and clinical recommendations for Evidence based practice. Since there are no published NICE or SIGN guidelines for Social Anxiety, I was on my own. Reviewing the literature on outcome for therapies for Social Anxiety/Social Phobia turned out to be interesting and useful for me, in spite of the lack of evidence for PCE therapies and the preponderance of CBT research. Interpolating from existing general effectiveness data and clinical reports, as well as our early outcome data from our Social Anxiety Protocol, I was able to return a level C rating for Psychodynamic and Humanistic-Person-Centred-Experiential therapies, that is, “No evidence to date but opinion suggests that this therapy might be helpful”. However, interesting as the experience was, it did confirm the misgivings that Steve Pilling had expressed to me about the Scottish equivalents of NICE being under-funded.

3. How does PCE therapy generally fare in The Matrix?
Given the approach of the Matrix (organizing guidelines by client present problems), the political climate (dominated by CBT), and current state of the scientific literature on PCE therapies (fairly scattered and focused on different research questions), it is not really surprising that Person-Centred therapy is mentioned exactly twice in the document, once one page 10, in a list of therapies commonly-practiced in Scotland, and again on page 40 in the Guideline for Social Anxiety/Social Phobia that I drafted, referred to above.

In other words, PCE therapies are virtually invisible. If NHS Boards follow the advice in the Matrix, they will not commission PCE therapists to provide services for any common group of clients.

There are many problems with the verdict of The Matrix document on PCE therapies: philosophical, political, scientific, practical etc. However, I want to focus on just one of these and just one client presenting problem:

4. The Matrix document fails to fairly summarize the existing scientific evidence on therapies for depression.
Mild-to-moderate is arguably to most common client presenting problem in practice settings. Actually, a mixture of depression and anxiety accompanied by various other issues is probably the most common, but Depression has become a kind of flagship diagnosis, an entry-point for new therapies vying for broader recognition.

This past September, SIGN (the Scottish Intercollegiate Guidelines Network, i.e., the Scottish equivalent of NICE) released its revised treatment guidelines for depression, on which The Matrix section on Depression appears to have been largely but not entirely based. Building on earlier work I’d done for the HPCE competence Expert Reference Group, I took the meta-analytic data that Beth Freire and I had collected and pulled out the depression studies, looking for patterns. As a result, I was able to derive the following recommendations that were missing from the draft SIGN Depression guidelines:
(1) Person-Centred/Experiential therapies in general for Mild to Moderate Depression: Evidence Level A: Highly Recommended
(2) Person-Centred Therapy for Mild to Moderate Depression: Level B: Recommended
(3) Process-Experiential/Emotion-Focused Therapy (PE-EFT) for Depression: Level A: Highly Recommended
(4) Person-Centred Therapy for Perinatal Depression: Level A: Highly Recommended
These recommendations are documented with citations to published RCT and meta-analytic data (the defining criteria for the different evidence levels) in a summary document. I sent my evidence document off to the SIGN folks, who thanked me for my input; I have heard nothing since then. For some reason, I never got around to posting this evidence document on this blog, so I remedying the situation by doing so now.

Meanwhile, the Depression section of The Matrix appears to have been added after the rest of the Matrix was developed, between the September and November draft versions, limiting the time for feedback on it. Moreover, in the November draft, it was clear that there were significant omissions, even when compared to the draft SIGN Guidelines. These omissions didn’t just involve PCE therapies: Psychodynamic therapy, Problem-solving therapy (for elderly depression clients), and generic Counselling had also been left out, as was much of the documentation for the recommendations. Accordingly, I sent off a proposed revision of the Depression Matrix recommendation to The Matrix folks. Unfortunately, this input and the associated scientific evidence are not reflected in the published version of The Matrix Depression recommendations, although the documentation has been added.

5. What should we do?
As a teenager, I remember reading in Arthur Koestler’s The Ghost in the Machine, something that has become one of my favorite quotations: “When in danger or in doubt, run in circles, scream and shout.” But is The Matrix verdict the End of the World As We Know It? The fight for recognition of PCE therapies is worldwide and involves scientific, political, educational and practical elements. One that we have learned over the past 15 years is that a single set-back isn’t the end. It’s damaging, as we have seen in Germany, where Person-Centred therapists have been fighting a rear-guard action against the government and the insurance industry for at least 10 years. These kinds of set-backs are bad for morale and can have serious negative consequences for practitioners working in an approach, such as losing their jobs.

However, conceding defeat would be worse and is not necessary; instead it is vital that HPCE therapists persevere and continue meet the challenges, using a variety of tactics. Here are some suggestions:

First, as noted, it is important not to give up, and not to take no for an answer. We can take heart from the fact that The Matrix Depression recommendations are already out of date, because they do not include the recent research evidence, which has so far been ignored by the relevant bodies. There is room for more negotiation.

Second, it seems to me that a useful next step is going to be political: Those of us who can vote (I can’t since I’m neither a British nor an EU citizen) need to contact their MSPs and to express concern about the scientific data left out of published version The Matrix. To do this, you will need to be in possession of the facts about the research (see accompanying summary of the depression research literature. The point here is that we don’t even have to attack The Matrix’s depression review on the basis of its standards, even though these aren’t particularly fair: By its own standards, HPCE therapies should be included in The Matrix at Level B or A (depending on the speicific knowledge claim you want to defend).

Third, we need to move ahead with more research on the use of HPCE therapies for depression, especially more RCTs. It appears that Michael King’s 2000) ground-breaking RCT comparing, Person-Centred, CBT and GP clinical management is now being discredited because Beck Depression Inventory scores were used rather than formal diagnostic interviews. We need to keep doing more and better research.

Fourth, it’s important for us to be in dialogue with our CBT brothers and sisters rather than attacking them. Most CBT folks that I’ve met are genuinely concerned first and foremost for client welfare and believe that scientific data can help us learn how to help our clients more effectively. We can make common cause with our CBT colleagues in helping government bodies more fairly evaluate the available research evidence.

Fifth, HPCE therapists need to make common cause with one another instead of fighting for their particular brand of HPCE therapy against the others. In Germany, Systemic therapy has recently been recognized by the government, on the basis of a broad, inclusive approach to the research data, while Person-Centred, Gestalt therapies, and Psychodrama languish because they refuse to cooperate with one another. We can no longer sustain this kind of divisive approach.

Additional Research Information on Person-Centred/Experiential (PCE) Therapy for Depression for SIGN Consultation

(Robert Elliott, version 2, 21 Sept 2008)
[Note: This is a consultation document prepared to provide input for the review process for the SIGN Guidelines on Mild-to-Moderate Depression. It is provided here as supporting documentation for the blog entry on the release of The Matrix guidelines documents on commissioning mental health services in Scotland.]

The purpose of this document is to provide additional evidence missing from the Draft SIGN Guideline for Non-pharmacological management of mild to moderate depression. Based on ongoing meta-analytic research being carried out at the University of Strathclyde (supported by a grant from the British Association for the Person-Centred Approach) we are proposing that the following information be added to the Guideline. Note that the draft guidelines refer only to generic counselling, without reference to the particular type of counselling. We summarize evidence specific to Person-centred/Experiential (PCE) therapy, including (a) general meta-analytic support for PCE therapies for depression, (b) strong RCT evidence for a particular form of PCE (Process-Experiential) to general clinical depression, and (c) strong RCT evidence for Person-centred therapy for a specific form of depression (postnatal). It is our view that this body of evidence warrants modification of the draft Guideline to include Person-Centred/Experiential therapy in its recommendations for psychosocial management of mild to moderate depression. I am happy to supply the supporting references cited in this document.

1. Person-Centred/Experiential therapies in general for Mild to Moderate Depression.
Meta-analytic evidence: A meta-analysis of 23 PCE therapy research studies (including 4 controlled and 16 comparative studies) reported large pre-post effect sizes and general and statistical equivalence to nonPCE therapies. The small number of controlled studies mostly involved small or unrepresentative samples. (An updated meta-analysis [Elliott & Freire, in preparation] includes 32 pre-post studies, 8 controlled studies, and 33 comparative outcome studies with comparable or more favourable results.) (Evidence level 1+)
(Grade of recommendation: A: Highly Recommended)

Elliott, R., Greenberg, L.S., & Lietaer, G. (2004). Research on Experiential Psychotherapies. In M.J. Lambert (Ed.), Bergin & Garfield‘s Handbook of psychotherapy and behavior change (5th ed.) (pp. 493-539), New York: Wiley.

2. Person-Centred Therapy for Mild to Moderate Depression:

(1) Extrapolated evidence: There is one large well-designed RCT with 62% diagnosed depressed clients, and pre-therapy depression measure scores typical of depressed samples, showing comparable outcomes to CBT across 2 randomized comparisons and one preference comparison. Another source of extrapolated evidence is research on Person-centred therapy for postnatal depression, reviewed in section 3 below. (1+ or 1++)
(2) Cohort study: In one large, unpublished analysis of depressed patients taken from a very large published naturalistic study, the depressed subgroup analysis finds no difference between Person-Centred, CBT and Psychodynamic therapies. (2++)
(Grade of recommendation: B: Recommended)

Elliott, R., Greenberg, L.S., & Lietaer, G. (2004). Research on Experiential Psychotherapies. In M.J. Lambert (Ed.), Bergin & Garfield‘s Handbook of psychotherapy and behavior change (5th ed.) (pp. 493-539), New York: Wiley.
King, M., Sibbald, B., Ward, E., Bower, P., Lloyd, M., Gabbay, M., & Byford, S. (2000). Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy and usual general practitioner care in the management of depression as well as mixed anxiety and depression in primary care. Health Technology Assessment, 4 (19). [Well-designed study with two embedded RCTs and one preference trial; 62% of clients met criteria for depression, but Beck Depression Inventory was used a primary outcome measure and mean pre-therapy scores were at levels typical of clinically depressed samples. Results for Person-Centred therapy were comparable to CBT.] (1+)
Stiles, W.B., Barkham, M., Mellor-Clark, J., Connell, J. (2007). An Addendum to "Effectiveness of Cognitive-Behavioural, Person-Centred, and Psychodynamic Therapies in UK Primary Care Routine Practice: Replication in a Larger Sample." Unpublished manuscript, Miami University, Ohio, USA. [Subsample analysis of larger published study (Stiles et al., 2007): Well-controlled naturalistic study in NHS primary care with large sample of clients identified as depressed by therapists; identical pretherapy scores with no difference in posttherapy outcomes among Person-centred, CBT and Psychodynamic.] (2++)
Stiles, W.B., Barkham, M., Mellor-Clark, J., Connell, J. (2007). Effectiveness of cognitive-Behavioural, person-centred, and psychodynamic therapies as practiced in UK primary care routine practice: replication in a larger sample. Psychological Medicine. Published online 10 September 2007. doi:10.1017/S0033291707001511.

3. Process-Experiential/Emotion-Focused Therapy (PE-EFT) for Depression:

Process-Experiential therapy (also known as Emotion-Focused Therapy) is an integrative form of Person-Centred therapy that incorporates other humanistic therapy techniques such as Gestalt Two Chair exercises into a treatment targetted for depression. There are three well-designed RCTs testing this approach, using medium-sized samples and conducted by two different research teams, comparing PE-EFT to other therapies in the treatment of Major Depressive Disorder. One of these studies found that PE-EFT had significantly better outcomes (including very low relapse rates) when compared to Person-Centred therapy. The other study found equivalent, and on some measures better, results than CBT. (1+ or 1 ++)
(Grade of recommendation: A)

Goldman, R. N., Greenberg, L. S., & Angus, L. (2006). The effects of adding emotion-focused interventions to the client-centered relationship conditions in the treatment of depressions. Psychotherapy Research, 16, 537-549. [Replication of Greenberg & Watson, 1998: Well-designed RCT with clinically depressed clients and medium-sized sample, comparing PE-EFT to Person-Centred therapy; outcomes were strongly and significantly better for PE-EFT.]
Greenberg, L.S., & Watson, J. (1998). Experiential therapy of depression: Differential effects of client-centered relationship conditions and process experiential interventions. Psychotherapy Research, 8, 210-224. [Well-designed RCT with clinically depressed clients and medium-sized sample, comparing PE-EFT to Person-Centred therapy; outcomes were slightly but not significantly better for PE-EFT.]
Watson, J.C., Gordon, L.B., Stermac, L., Kalogerakos, F., Steckley, P. (2003). Comparing the effectiveness of process-experiential with cognitive-behavioral psychotherapy in the treatment of depression. Journal of Consulting and Clinical Psychology, 71, 773-781. [Balanced researcher allegiance RCT comparing PE-EFT to CBT in clinically depressed sample; outcomes for PE-EFT were generally at least as good as CBT and on some measures were better.]

4. Person-Centred Therapy for Perinatal Depression:

Perinatal depression is currently excluded from the draft guideline; however, the current SIGN guideline for Postnatal depression and puerperal psychosis states, “Postnatal depression should be managed in the same way as depression at any other time, but with the additional considerations regarding the use of antidepressants when breast feeding and in pregnancy.” In other words, the major difference between the treatment of postpartum depression and depression more generally is that antidepressant medication should be used more cautiously. There are four reasonably well-designed RCTs for perinatal depression with medium to large sample sizes that show superiority to treatment as usual (3 studies) or no difference in comparison to CBT (2 studies) or short-term Psychodynamic therapy (1 study). We are proposing this important population be included in this guideline, on the basis of these studies; in addition, we suggest that this body of research is relevant to the effectiveness of Person-centred therapy with depression more generally. (Level of evidence: 1+ or 1++) (Grade of recommendation: specific to Perinatal depression: A; extrapolated to depression generally: B)

Cooper, P. J., Murray, L., Wilson, A., & Romaniuk, H. (2003). Controlled trial of the short- and long-term effect of psychological treatment of post-partum depression. British Journal of Psychiatry,182, 412-419 . [Well-designed RCT; Person-centred comparable outcome to CBT and Psychodynamic]
Holden, J.M., Sagovsky, R., & Cox, J.L. (1989). Counselling in a general practice
setting: Controlled study of health visitor intervention in treatment of postnatal depression. British Medical Journal, 298, 223-226. [Medium-sized RCT: Clients in Person-centred therapy had better outcomes than control clients]
Morrell CJ, Warner R, Slade P, Paley G, Dixon S, Walters SJ, Brugha T, Barkham M, Parry G, Nicholl J. (In Press). Clinical effectiveness of health visitor training in psychological interventions for postnatal women – a pragmatic cluster-randomised trial in primary care. British Medical Journal. [RCT; Person-centred similar outcome to CBT, better than treatment as usual]
Wickberg, B., & Hwang, C. P. (1996). Counselling of postnatal depression: A controlled study on a population based Swedish sample. Journal of Affective Disorders, 39, 209-216. [RCT; Person-centred much better than treatment as usual]

Monday, December 22, 2008

Winter Solstice 2008 in Toledo

Entry for 21/22 December 2008:

We arrived in Toledo without delay or mishap, which is always a relief; however, the weather has been formidable. Two days earlier, Toledo got 6 inches of snow, followed by freezing rain, so the roads and our driveway were a mess. After a quick bite at our favorite Chinese restaurant, we went home and crashed.

Officially, the winter solstice occurred about 7am the next morning. with a bit more than 9 hours of daylight Toledo, compared with 7 hours in Glasgow. We woke up to the howling wind. Winter had arrived. Or rather winter was here already, and we had arrived in Winter. By nightfall, the temperature had fallen to around 0 degrees Fahrenheit. None of your wimpy 0 Celsius; this was the real 0, bitterly cold, -18 degrees Celsius, with the icy wind gusting at 30 mph (50 kph), bringing the wind chill at times down to –25 degrees F (-32 C). It cut through my medium-weight coat like a knife. After two and half years of living in the temperate, Gulf-stream-warmed Scottish lowlands, we’ve lost our Midwestern winter conditioning, and I had neglected to take my serious winter coat out of deep storage.

Not without reason does “Glasgow” mean “dear green place”; but the American Midwest in the throes of winter is neither green nor dear. Instead, like C.S. Lewis’ Aslan, it is “not a tame beast” but is instead full of intense majesty: ice flung by the wind to rattle ominously against our bedroom windows; our car spinning out on the ice in a back street in our neighborhood so that we almost rang into a large tree (saved by bank of frozen snow!); snow blowing desolately across the highway as we drove to Cleveland to pick up Kenneth; and along the way sun glinting magically off the trees, still covered with ice from the earlier freezing rain. Kenneth went out to meet us as we arrived, huddled against the blast in his coat, the last person left in his dorm, waiting for his parents' return. It was so good to see him; he chattered at us all the way back to Toledo.

So we are in Winter now, but the snow and longer daylight makes everything feel lighter, less dark and heavy. I woke earlier again today (Monday), my head full of things to write about. It is lovely to be here in our other home, listenign to the wind blow outside, Kenneth sleeping next door in his old room, with Christmas once again almost upon us.

Saturday, December 20, 2008

Sleepless in Glasgow

Entry for 20 December 2008 (en route to USA):

I don’t usually have trouble sleeping, and I’ve been needing extra sleep for the past month as I recovered from the bug that laid me low. Even now, every time I end up a bit short on my sleep, the cough kicks in again, just to remind me that I’m still not completely well. So it was that as I got into bed last night after a very full and exhausting week, the last week in the run-up to my Christmas holiday, I fully expected to fall asleep without much effort.

Unfortunately, as soon as I turned off the light, I found myself wide awake. I tossed and turned for a good half an hour, then, remembering the standard advice, got up and read for an hour before trying again, finally falling asleep at 2am.

As I lay there, and even this morning, as I wait for our flight to Amsterdam, the first leg of our voyage back to Ohio, I am still puzzled by what happened last night. It can be looked at as a Problematic Reaction Point, so I could try to unpack my puzzling sleeplessness using Systematic Evocation Unfolding. However, last night it felt more like an Unclear Felt Sense, and I tried to Focus on it, with limited success. I suppose that Ann Weiser Cornell would say that I wasn’t able to be fully in presence with it, because I found myself feeling impatient with it: “For once you’re ready before a trip: you’ve done your essential email, you’re all packed, why can’t you sleep!” In retrospect, the Focusing was at least a partial success; it just didn’t help me fall asleep… and of course the impatience got in the way of sleeping also.

I did make some headway with the felt sense, though: It felt a bit like a caffeine-induced unsleepiness, but not exactly. Hmm… there was something like the feeling of excitement I used to get on Christmas eve, waiting for the next day to arrive, wishing I would just fall asleep to make the time go faster but being prevented from doing so by the very excitement to arrive there. So I was clearly excited to get out of the dark, big-city, still-after-2-and-a-half years-somewhat alien life here and back to the two-hours-of-light-more-a-day, suburban, easy familiarity of Toledo (and from there North California). And my kids and the rest of my family… and Christmas.

“Ridiculous!”, said something adult and impatient in me. “You’re not 7 years old, and you don’t really even want anything for Christmas this year. You’re going back a home that isn’t really a home anymore. Sure, you’re looking forward to seeing your kids and larger family again, but that’s not something to lose sleep over!” So I lay there tossing and turning, until I finally gave in to the sleeplessness and got up again. As I said, I was having difficulty being patient with myself, but the getting up was in a way a way of at least acknowledging the validity of the sleeplessness.

This morning I still find myself wondering about, and Unfolding, in a Focusing sort of way, the episode a bit: Some things that felt connected:

First, it has been an intense week, including two different intense processing sessions that revealed deep truths about my relationships with others and left me both drained and more fully appreciative of these situations and their sources. At some level, this feels quite important, although the implications need time to play out. But I’m left with a sense of excitement somewhere in me, about possibilities for new ways of being with others.

Second, there is sense of intellectual excitement over a new possible collaboration with a very diverse collection of colleagues from all over the University, around work on practical applications of Complexity Theory, something I’d looked into years earlier. Ernesto Estrada, recently arrived (about the same time as Lucia, but from Spain instead of Italy) to take up a new Chair of Complexity Science (cross-appointed in Math and Physics), is leading this effort. The developing project is helping me to think about the connection between significant therapy events and complexity theory, using Ernesto’s framework: internal structure (the person’s internal complexity of multiple voices or emotion schemes and modes of engagement); and external forces (the therapeutic framework, which provides a context that changes the equilibrium of the person’s internal organization). This has stimulated my scientific imagination, leaving me with a sense of excitement about the possibilities, not the least of which is the chance to interact with some of the best minds in this science-and-technology-oriented university, which I am coming to realize has a lot in common with Case Western Reserve University (Cleveland, Ohio), where my kids have gone to school.

Third, there is something bubbling away here about the RAE, or Research Assessment Exercise, the initial report for which was reported two days ago. The RAE happens every 7 years in British universities, and is a Big Deal. In addition to status, universities get more money from the government if they get higher RAE scores. I’ve got tons of publications (about 110 at last count), but they only look at the past 7 years, and it hasn’t really been clear exactly what the review panels have been looking for, so I don’t know if my individual submission will meet expectations or not (the individual results apparently will not be available for some time). I’ve been fairly nervous about this, because I was hired as part of an effort to improve the Education Faculty’s RAE ratings, and the Powers That Be will not be happy with me if I don’t do well. In fact, a couple of hours before I went to bed, I’d read our Vice Dean’s pessimistic assessment of our overall results, so that was definitely percolating in the background as I lay awake, a source of indeterminate worry.

Fourth, I realized that my body had a kind of unexercised untiredness, like it hadn’t been used enough. I’ve done very little running in the past two months; now with my energy coming back, it begins to feel like I’m missing the tiredness that comes from having run 3, 5, 6 or even 8 miles. So the unsleepiness also felt a bit like my body saying that it hadn’t been used enough. This didn’t help me sleep, so the impatient part that wanted sleep didn’t appreciate it at the time, but it’s an important message to hear and to do something about.

So no wonder I was having trouble sleeping… and one more thing: This morning, getting up on 5 hours of sleep, felt familiar in itself, comfortable, as if one is supposed to start one’s Christmas vacation tired, dozing on the plane, relieved just to be away from it all. It is the proper mode for travel, especially when you are going to be packed into a large tin can for many, many hours, waiting, suspended between here and there, now and then, waiting to arrive. Instead of Dramamine or alcohol, I have my tiredness to keep me company and temper the journey into a bearable, even enjoyable, time between.

Saturday, December 06, 2008

New Diploma Course Director Arrives

Entry for 5 December 2008:

As I’ve mentioned before, since Tracey Sander left last July, I’ve been Acting Course Director for our three Postgraduate Counselling Diploma courses, along with all my other duties. I’ve been able to survive this by virtue of a lot of help various people: Rachel in the Counselling Unit Office reminded me when things needed to be done, and nagged me when I forgot about them or when the email got buried in the 700 emails in my in-box. Alison Cumming picked up Tracey’s Personal and Professional Development group on the Monday Part-time course. Terry Daly helped the overseas students find placements and took on the monthly Deferrer’s group (for students from the last year or two who are still working on completing their requirements). Various members of the part-time teaching staff continued the pattern initiated by Tracey, of helping out with administrative tasks such as course timetabling and room booking.

For the past five months, some things got forgotten or left aside, while other things were not done with the style or grace with which they had been done before, but somehow we have managed to muddle through.

This week, however, to our great relief, our new course director, Lucia Berdondini, arrived. Lucia is highly focused, enthusiastic Italian woman with an easy smile and a direct but friendly manner. She was trained in Gestalt and Person-Centred therapies and lived in England for 13 years before going back to Florence 3 years ago. She found contemporary Italian politics and life no longer to her liking, and has been eager to return to the UK. She says that she has always wanted to live in Scotland. Although she is just beginning to learn what the job entails, it is a great relief to have her join us, and I for one am looking forward to having a new colleague to bounce ideas off of.

When she saw the ad for the course director position, she says she learned about the Counselling Unit not only from our regular website but also from this blog. I can only hope that the reality doesn’t prove to be too far off the mark from her experience. I don’t make any claims that my perceptions of reality, as represented here, match those of other people!

We invited her to come along to a large group session on the Monday Part-time course on her very first day at work, and she was very impressed with the quality of the interaction among the students she observed. It was a process she recognized entirely from the course she trained on and has taught on, and so I think it helped her feel at home here. And it is a great relief for me to have the company. Even though the early December days are short and the nights long (and this week cold and icy) we are doing our best to help her feel welcome. Welcome, Lucia!

Monday, December 01, 2008

Bracketing in Psychotherapy Research

Entry for 30 November 2008:

In the midst of the run-up to Thanksgiving, my old friend Connie Fischer contacted me for some help with a manuscript on “Bracketing” she was writing for Psychotherapy Research. Clara Hill was asking her for an example from therapy research. Since Connie’s area is psychological testing, she was a bit a stumped and wanted to know if I could provide her with an example. (Connie does wonderful stuff on humanistic approaches to psychological assessment, among other things.)

This was an interesting question for me, because of the short pieces I’ve written recently for the Applied Educational Research course website, on the Hermeneutic Circle and Sensitizing Categories (also posted on this blog). Bracketing is an interesting linguistic metaphor (brackets are what Americans call parentheses), and yet another take on issues of researchers’ prior understandings and what to do with these. While I don’t think that complete bracketing is possible, I do firmly believe that the attempt to bracket expectations and preferences for one’s data is an essential aspect of a responsible scientific process, because it helps open us up to what are informants are trying to tell us. In this sense, bracketing is close to my heart.

Accordingly, I sat right down and wrote the following example of bracketing in psychotherapy research for Connie:
For example, in their study of significant insight events in psychodynamic and cogntive-behavioral therapies, Elliott et al. (1994) attempted to bracket their expectations for what they would find: At the beginning of their study, the members of the research team wrote down what they thought they might find. They then literally stuck these expectations away during the conduct of the study, attempting to hear as clearly as possible what the data were telling them. In addition, at the end of the study, in order to capture their emergent expectations, they repeated this process, finally rating all the categories they had obtained for the extent to which they now realized they had expected these. They thus accomplished the double movement of both reflecting on their pre-understandings while also consciously striving to be open to their data. Beyond this, they were able to demonstrate the success of their bracketing, by showing that their actual findings differed from their expectations: that is, they had found things they hadn't expected and also failed to find other things that they had expected.
As for Connie’s take on bracketing and what she did with the example I sent her, we’ll all just have to wait for her paper, which will be coming out in Psychotherapy Research in 2009, as part of a special issued on research methods. Look for it!


Elliott, R., Shapiro, D.A., Firth-Cozens, J., Stiles, W.B., Hardy, G., Llewelyn, S.P, & Margison, F. (1994). Comprehensive process analysis of insight events in cognitive-behavioral and psychodynamic-interpersonal therapies. Journal of Counseling Psychology, 41, 449-463.