Sunday, March 29, 2009

Person-Centred-Experiential (PCE) Therapy for Social Anxiety (SA) following the Process-Experiential Model (3/09)

Entry for 30 March 2009:

As part of our planning for our next Social Anxiety study, I’m meeting with a couple of prominent Scottish CBT types this week to discuss a CBT comparison condition. As part of my preparation for the meeting, I put together the following summary of where I understand us to have gotten up to in describing a comprehensive PCE therapy for Social Anxiety.

A. Theoretical model: PCE Understanding of Social Anxiety:
1. Particularly interested in generalized SA/Avoidant Personality difficulties
•Commonly accompanied with clinical depression

2. Driven by emotion processes:
•Key emotions: primary maladaptive (overgeneralized) shame and fear
•Organized by core emotion schemes of self as socially defective (e.g., “rubbish”, “daft”, “not nice to look at”) and others as harshly judging/rejecting

3. Causal factors:
•Often grounded in early rejection/abuse by primary caregivers
•Results in harsh, shaming internal critic (introject of early rejection/abuse)
•Maladaptive shame/fear motivate social withdrawal/avoidance and emotional avoidance
•Recent life events (e.g., loss, rejection, conflict) activate core emotion schemes, lead to exacerbation of SA difficulties, interfering with life functioning, precipitating a SA episode or crisis

B. Treatment Model: Change Processes/Phases of therapy:
1. Establishing PCE working relationship
•Sessions 1 -3
•Offering adequate structure to allay initial client SA related to being therapy
•Communicating genuine empathy and unconditional caring
•Fostering mutual involvement in therapeutic goals/tasks

2. General exploration and initial narrative work
•Sessions 2 – 4
•Exploring nature and history of SA
•Making meaning
•Explicating and constructing life narrative

3. Initial exploration of key SA processes
•Sessions 3 – 8
•Systematic evocative unfolding of SA episodes
•Two chair work on SA and related self-criticism process

4. Strengthening the self
•Sessions 6 – 10
•Empathic affirmation/validation of sense of social defectiveness and desire for change
•Working on emotion regulation: clearing an internal space free of anxiety; experiential focusing on positive aspects of self; two chair dialog for self-soothing)

5. Work on changing core SA processes:
•Sessions 9 – 16
•Work on changing emotion with emotion and altering core self/other schemes: via two-chair work between emotional and SA critic aspects of self, and empty chair work with imagined rejecting/abusive significant others

6. Consolidation of changes
•Sessions 17 – 20 with decreasing frequency
•Additional narrative and other closure work as needed

Folk Clubs: Star & Partick

Entry for 27 March 2009:

This year, we’ve been going to the Star Folk Club a fair amount, attending the Thursday evening concerts at St. Andrews-in-the-Square (a 1750 grand Baroque era church modelled after St. Martin’s-in-the-Fields in London). Last night was a highly enjoyable evening, featuring a talented Scottish singer-guitarist duo named Doghouse Roses, whose repertoire features a lot of American or American-style music, as well as Pentangle-influenced songs. By this time, we’ve begun to treated as regulars, and Diane has been going up to and talking with the performers during the break.

This past Thursday, the host plugged a concert by a local Scottish group called Cruachan, in Partick on the following night. This intrigued us, so when we got home, I googled them.

What I got instead was an Irish celtic metal (i.e., a fusion of heavy metal and folk) group of the same name, with lots of fancy albums with complicated artwork, arthurian mysticism, website, Facebook page etc. Hmm… that didn’t sound right. After digging further, I finally found our Scottish Cruachan, consisting of a trio of older guys, looking somewhat white and a bit grizzled. The Irish Cruachan apparently takes its name from the capital of the ancient Irish kingdom of Connacht; the Scottish version claims to have selected its name by sticking a pin randomly into a map of Scotland.

Further efforts turned up the fact that they were playing at the Partick Folk Club, in its new venue in St. Peter’s Church Hall, just around the corner from a Catholic church of the same name at the head of Partick common, about 15 minutes walk from our flat. Partick Folk Club is hosted by Mick West, a fine traditional singer whom we’ve heard several times at the Star and have seen on Scottish television. This club only meets once a month and we’d obviously managed to missed it consistently for 2 years, so this seemed like a good opportunity to explore a new folk club. (It turned out that we’d been to a couple of previous events put on by them, but never a regular club event.)

We arrived about 8, found our way somewhat circuitously through a back way, and came into a classic church hall, although the mirror ball in the ceiling above the dance floor did seem a bit different. The place was already fairly full. Norel, a recent acquaintance from the Star Folk Club and a fellow expat (from Australia), waved to us and we squeezed in at her table.

It’s interesting to observe similarities and differences in folk club culture: The Star is well organized, tables and chairs arranged in orderly rows, audience attentive and well-behaved. The opening act gets half an hour, followed by main act doing 45 – 60 minutes; then there is an interval, during which raffle tickets are sold, often but not always followed by one or two brief “floor acts”, i.e., club members who get up and sing one or two numbers. Then there is a drawing for prizes, a few announcements, and the main act comes back for another 45 – 60 minutes.

The Partick Folk Club has a slightly different order of march, but feels much looser and slightly chaotic and funky. Instead of an opening act, Mick West opened things up by singing a song or two himself, then introduced a couple of club regulars, including a little old lady who sang a rather risque’ song about losing her “thingamajig”.

After about 20 minutes of “floor acts”, Mick introduced the main act. Cruachan turned out to be three retired guys, Nigel Munro, a mandolin player, John Malcolm, a singer and guitarist, and Jim Shearer on vocals, harmonica whistles and bodhran. Jim reminded us strongly of Dave Mearns, so much so that at one point I expected him to produce toy badgers (but these turned out to be egg-shaker percussion things). He told terrible jokes (sample: “I recently went to the marriage of a telly and a satellite dish: The wedding was lousy, but reception was incredible!”) They played a wide range of material, from different parts of Scotland as well as a lot of Irish and American material.

During the first half, we’d noticed that Mick West kept disappearing. Once the interval came, we had some clue about why, as he and his partner brought out a large pot of soup (vegetarian minestrone, he announced), followed by bread, coffee cups and spoons. Mick’s soup is apparently a long-standing tradition at the Partick Folk Club, and was very tasty.

There followed raffle tickets sales, two more brief floor acts, a rowdy and somewhat disorganized drawing for prizes, and then Cruachan for another 45 minutes. As the evening went on it seemed to tilt increasingly toward American roots music (for example, one of the floor acts, another older lady, after singing another risque’ song, did “Summertime” from Gerschwin’s Porgy and Bess). And Cruachan also dipped increasingly into the American catalog, especially bluegrass and country music.

As we walked home, we reflected on the evening: the popularity of American roots music here, the funky church hall space, the community of regulars who packed the place and knew so many of the songs, Mick West’s pleasure in welcoming people and hosting the evening, the soup, and the fellow who played the lowland pipes for us (a mellow, oboe-like instrument powered by a bellows). Here’s another little world within Glasgow, very local and grounded in some way I don't understand yet to its deeper history. This was glimpse of the past but connected to the present, unique but somehow universal.

Sunday, March 22, 2009

Nation, by Terry Pratchett

Entry for 21 March 2009:

I’ve been reading Terry Pratchett books since I discovered them as British imports in Canada in 1992 when I was on sabbatical at York University. I began by reading the first of Diskworld books, The Colour of Magic, to my oldest son, Brendan, who was 10 at the time. (Incidentally, we just watched the movie version of the first two books last week.) After that, I read them in sequence, first to Brendan until he was 17 (up to about The Last Continent, he reckons), and then to Kenneth until he graduated from high school. In the meantime, Kenneth got to hear Pratchett’s non-Diskworld children’s books, the Bromeliad Trilogy and the Johnny Maxwell books. The last Pratchett book I read to Kenneth was either Hat full of Sky or Thud!. Since then, I’ve had to read them to myself, which is not quite the same, but still nice, because it reminds me of my kids.

For his most recent book, Pratchett has temporarily set aside the Diskworld in favor of a young adult, slightly alternate history book, entitled Nation. I’m not sure where this book sprang from in Pratchett’s fevered imagination, but it is clearly a South Seas adventure tale, complete with nautical mutiny, buried treasure, and cannibals, part Treasure Island, part Robinson Crusoe, part King Solomon’s Mines, undoubtedly inspired by the author’s childhood reading experiences. (It resembles Gaiman’s The Graveyard Book in this harking back to earlier favorite books, but doesn’t follow its originals so closely.) However, it also updates these earlier models by reflecting current events (the 2004 Indian Ocean Tsunami) and current interests in multi-culturalism and non-western perspectives.

It locates all this in the context of a double coming of age story, tracking a couple of teenagers, a well-to-do English girl and a native boy. The cultural differences and consequent misunderstandings between the pair provide plenty of opportunity for Pratchett to comment ironically on Western civilisation. However, his main interest is to show how these young people deal with traumatic loss and seek to rebuild their lives under drastically-altered circumstances. One of the book’s themes is thus trauma and recovery, and the first half of the novel deals with this poignantly and honestly. At the same time, the two protagonists have to deal with difficult real-life situations. This is the adventure story aspect of the book, in which two very bright and resourceful young people come up with imaginative solutions to the dangerous situations they find themselves in; in this time-honored way, the book serves as a model or inspiration for today’s young people to behave in similarly inspired ways.

At a deeper level, however, the book is centrally and most consistenly about how we all have to differentiate ourselves from our respective cultural traditions while still preserving continuity with the past. Which voices of parents, grandparents, peers, ancestors do we ignore because they are no longer relevant, which ones do we simply follow, and which ones do we listen to and make our own by modifying or adapting them in the current situation? This is a universal developmental challenge, and Pratchett does a lovely job of portraying how these cultural voices live in us, even in the absence of external others to remind us and to reinforce these views. As we well know from therapy, it is in this inner realm of conflicting aspects of self or voices that the most important developmental work occurs.

In short, this multi-layered book ranks with Terry Pratchett’s best, most profound examinations of the nature of the human spirit. Over the past 25 years he has gone consistently further into the deeper, more complex aspects of human psychology, repaying our continuing interest in successive installments of his oeuvre.

SPR-UK Ravenscar 2009 Meeting

Entry for 16/22 March, 2009:

Last weekend we went to the latest conference of the UK Chapter of SPR, the Society for Psychotherapy Research. SPR-UK has been struggling a bit to maintain itself over the past few years, and last year the annual conference had to be cancelled because of lack of interest. This year was difficult also, with many people hesitating or withdrawing because their employers were no longer willing pay their way; however, we did manage to put together a small meeting with about 20 participants, about the size of some of the Ohio SPR meetings (put together in the early 00's by Bill Stiles, Tim Anderson, me and our students). Nevertheless, the level of presentations and discussion was quite good, the scenery stunning, and the food excellent.

Having talked myself into doing 4 presentations, the pace of work was unrelenting. I started off with a presentation of Beth and my PCE meta-analysis, now well-honed. A bit more difficult was the workshop on research training that Sue Wheeler and I were set to do, but which I ended up doing on my own when Sue couldn’t make it in time due to a prior commitment. Fortunately, Sue sent a very helpful set of notes, which I followed. Particularly useful were the following questions, which the three participants explored:
-What has been your best research training experience? What made it the best?
-What has been your most unhelpful training experience?
These questions (which are really Change Interview questions applied to research training) produced some very useful comments, emphasizing the relational aspects of research training and the value of learning in collaborative research teams.

In fact, the experience left me thinking that it would be really interesting and useful to do a larger study on the topic of helpful and unhelpful factors in psychotherapy/counselling research training. If I could just find the time… maybe this could be a component of the next phase of the Researcher Development Initiative project that I'm involved with (see Blog entry:

After the first day of the two-day conference, I stayed up late trying to put together my presentations for day 2. I fell asleep halfway through the first of these, a paper outlining the experiential approach to research training; however, I was able to finish it the next morning in time for the presentation.

I managed to throw together enough bits and pieces to be able to give the final paper, a preliminary report on our Rasch analyses of the SCL90R, utilizing data from the Aberdeen group, but it was not one of my better presentations, and I was relieved when it was done.

The UK SPR group appears to be resolved to make another try at organizing a larger conference, and even to meet again at Ravenscar, isolated though it is. This was Thomas Schröder’s first local area chapter conference as president and I enjoyed his enthusiasm and positive energy. We don’t know exactly how things will unfold; the UK chapter has gotten pretty small, work demands have increased, making running a small scientific organization increasingly a leisure-time activity; also, money for conferences has become increasingly scarce. The openness, flexibility, colleagiality, and even the level of the presentations all indicate that there is a place for SPR in the UK counselling/psychotherapy research scene, even alongside the obvious success of the BACP annual research conference. The latter is much better funded and organized, but feels a bit too regimented, lacks flexibility in type of presentation, and ends up feeling not as open or inclusive. I keep thinking that the ideal would be something that incorporated the best qualities of both conferences. In the meantime, there appears to be new blood and new energy in the UK Chapter of SPR, and the BACP research conference is still evolving, so there is hope that we will end up with two premier events for promoting and encouraging the development of research on psychotherapy and counselling in the UK.

Saturday, March 21, 2009

Running on the Vernal Equinox

Entry for 20 March 2009:

The kind of week it was: Four papers in 2 days at the UK chapter meeting of SPR down near Scarborough, followed by teaching on Tuesday and Wednesday, meetings on Thursday, more teaching on Friday and clients sandwiched in between. Running had been squeezed out by all this activity as has been happening too much lately, so finally, late on Friday, not long before sunset, I managed to get out for a long run along the canal.

I tracked the sinking sun, first from the top of Clevedon Hill, then once I’d reached the canal, as I ran along the path. As the canal rose past the Maryhill Lock Flight, the late sun glowed, an orange ball over Glasgow, on the first day of Spring, gradually sinking into the layer of cloud in the west. I’d lost sight of it by the time I’d reached the Nolly Brig, behind Firhill Stadium. (For quite some time, I’ve been wondering about the significance of the name of this bridge, but recently, someone told me that when she was growing up, “nolly” was the word that she and the other children in the area had used to refer to the canal.)

As I ran back, although the sun had fallen below the cloud, there was still a pink glow, and high in the sky the contrail from a jet still shown white, the tiny point at its head glinting in sun. The balance has shifted from dark to light, Spring has finally come, even in the Roman calendar. The world moves forward as the days quickly lengthen.

Wednesday, March 18, 2009

The Graveyard Book, by Neil Gaiman

Entry for 14 March 2009:

When my brother Willy and I were kids, our dad read The Jungle Book aloud to us, not the cute Disney version, but Rudyard Kipling’s original, a darker coming of age story about a feral child raised by wolves. The book unfolded, over time, in a series of episodes, punctuated by other stories, including most memorably Riki-tiki-tavi, the brave mongoose, and the white seal, who lived in a secret island in the Northern Pacific. All the stories in the Jungle Book’s two volumes involved outsiders finding their way in a hostile world, with the support of unexpected others. But it was the extended story arc of the Mowgli stories that carried the most weight. For some reason, I think it was the fact that we’d somehow misplaced volume 2, I never got around to reading these innocent/wise stories to my own kids, an omission that I still regret.

So when Neil Gaiman produced his own modern version of the classic Kipling story last year, I pricked up my ears and instead of waiting for it to come out in paperback, I sprang for the hardback version. And when I finished it, regretful that there wasn't more, I passed it on to Diane, who having read the first couple of chapters, wanted to know why I had recommended it. After all, an updated version of a classic 19th century animal adventure story, played as contemporary urban horror set in an abandoned graveyard, seems a highly unlikely premise for a modern young adult classic, which has just won the highest prize in American children’s literature, the Newberry Award.

So what is it that I so savoured in The Graveyard Book? Well, of course there is the sheer audacity of the concept, and the pleasure following the changes that Gaiman (author of the Sandman series of graphic novels, Coraline, and so on) has rung on Kipling’s original. Thus the wolf pack becomes the ghosts who inhabit the graveyard; Sheer Khan, the rogue tiger, becomes the killer Jack Frost; Bagheera, the black leopard and Mowgli’s protector and mentor, becomes Silas, a standard of horror fiction inverted into a kind of guardian angel; the apes become ghouls; and so on.

The hero, christened Nobody Owens by his ghost parents, features in a series of episodic narratives, spaced two years apart, as we watch him grow from 2 to 16. And although the genre is ostensibly horror, with all the trappings, and although there is a nicely done, terrifying climax to it all, the overall tone is one of innocence, by turns vulnerable, sweet, tender, naïve, wide-eyed, confused, and ultimately determined.

I think that the actual power of the book, however, is in its universality: It doesn’t matter whether you are being raised by wolves or ghosts or your own parents, life is filled with certain harsh realities: life and death, actions and consequences, facing the mystery of our origins (and all origins are mysterious no matter how well documented), figuring out who we are and how we will define ourselves for ourselves and for the world, separation and loss, and leaving those we love behind. All of us are constantly surrounded by our animal natures, our evolutionary heritage, represented by the Jungle; and in the same way, we are surrounded and live in the midst of the ghosts of those who have gone before us, the monsters of our human insecurity, selfishness and cruelty. Kipling uses Nature as a screen on which to project these archetypal aspects of what it means to be human; Gaiman uses the Supernatural for exactly the same purpose. Gaiman’s ghosts come from many different centuries, from Roman to Victorian times, providing an apt metaphor for the rich layering of history that we live within, and that lives within us, in our buildings, our laws, our belief systems and our language. These express themselves as the cultural/human universals, Jung’s archetypes, imprinted in us via the existential givens of our unfolding lives.

What I’d like to do now is to go back and read again, after the intervening 50 years, Kipling’s original Jungle Book stories.

Tuesday, March 17, 2009

Dekeyser & Elliott (2009): Chapter on Embodied Empathy Published

Entry for 13 March 2009:

Background. Four years ago I got asked to do a chapter on empathy for a book being edited by Jean Decety and William Ickes. (I first met Bill Ickes about 8 years ago when he came to Toledo to give a colloquium on his social psychology research on empathic accuracy, and subsequently ran into him at the University of Ghent in Belgium, where he was on sabbatical and I visiting during my 2-year parttime stint at Leuven.) Mathias Dekeyser was (and still is) a PhD student at KU Leuven, whom I co-supervise with Mia Leijssen, and who has an interest in empathy, so I invited him work on it with me and to be first author. He agreed, and the two of us put our interests together: his were in more general forms of empathy such as the empathy clients have for their therapist and in embodied empathy; mine were in metaphors for empathy and process-outcome research on empathy as a predictor of outcome. Now the chapter has appeared in a book entitled The Social Neuroscience of Empathy which also includes chapters by Decety and Ickes (the editors); Watson & Geenberg; Bozarth; Hatfield; the Feshbachs; and many others from a variety of disciplines. I'm looking forward to getting my own copy!

Summary. In this chapter, we focus on the dual interpersonal and bodily nature of therapeutic empathy: It is deeply social and interpersonal in that it is founded on everyday, bidirectional forms of empathy that make communication and psychological contact possible; it is bodily in that is it grounded in both the brain and in immediate bodily experience. This perspective leads us to examine not only how therapist understand and misunderstand clients, but also how clients understand and misunderstand their therapists, with implications for addressing severe communication problems in psychosis. This dialogical, body-oriented view offers a richer, more complete understanding of empathy, highlighting client agency and providing important leads for therapy and therapy training. These leads include new emerging directions for both practice, including methods for working with clients with severe communication difficulties (i.e., Prouty’s Pre-therapy); and for training, including using body-based metaphors to help students learn deeper empathic responding and training therapists to draw on their immediate bodily experience as a powerful source of empathy. In addition, we review evidence supporting the connection between therapist empathy to client posttherapy outcome.

Reference: Dekeyser, M., & Elliott, R. (2009). Empathy in Psychotherapy: Dialogue and Embodied Understanding. In J. Decety & W. Ickes (Eds.), The Social Neuroscience of Empathy. Cambridge, MA: MIT Press.

Thursday, March 12, 2009

Narrative and External Validity in Hermeneutic Single Case Efficacy Design

Entry for 12 March 2009:

Note. The good news was that this week, after many years’ delay, the paper on the adjudicated version of the HSCED method was finally accepted for Psychotherapy Research by Clara Hill. The bad news was that she made us cut another 10+ pages from it, including the abridged version of the judges’ opinions that we’d sweated over last January and a cool bit of the Discussion that she didn’t think fit that well with the rest. She’s probably right about it not fitting that well, but I think it’s nice enough and of general interest enough to post here as a blog entry, because it’s where I really develop the idea of a narrative approach to HSCED. And because it’s about the method in general rather than about the particular case, it makes sense out of context. So here is another outtake from “An Adjudicated Hermeneutic Single Case Efficacy Design Study of Experiential Therapy for Panic/Phobia”:

In the course of carrying out this study, we (and our audiences) struggled with the large amount of often-contradictory information generated by the HSCED method. As a result, we began to develop a more narrative view of HSCED. It now seems to us that making causal inferences in general is fundamentally a narrative process. That is, explaining something that has happened, such as the outcome of a client’s therapy, involves constructing a story about how and why it came about. HSCED is therefore a narrative research method. As we now see it, the function of the Affirmative and Skeptic teams is to create persuasive narratives that express a particular view of the data. In addition, the judges each construct their own narratives as they seek to make sense of the case from their own theoretical perspective. These competing narratives are part of a dialectic process that serves to clarify our understanding of whether and how the client changed and what brought any changes about. The goal is not necessarily to construct a single master narrative to bind together all the other narratives, but rather to highlight the main plausible, coherent accounts and the remaining ambiguities. Systematic data collection, argumentation and judging processes offer reasonable methods for eliminating error and estimating where the weight of the evidence falls.

Viewing HSCED as a narrative research method also helps us to think about the perennial issue of generalizing from single cases (cf. Stiles, 1994). It now seems to us that a good narrative provides two pillars for inferring generalizability: First, it supplies orienting contextual information (moderator variables) that helps us judge the relevance and applicability of the results to other, similar cases. In particular, it is important that the formulation include what we think it was that the client brought to therapy that made change possible, as we have done for George. Second, the description of the sequence of primary change processes tells us what in the therapy was relevant to change, that is, the active mediator variables. This allows us to reframe the Kiesler (1966)/Paul (1967) specificity “litany” for single case research: “When a client with these problems, those resources and this history experiences these in-therapy change processes, then this kind of change is possible/likely.” Thus, effective affirmative researcher-constructed narratives and judges’ opinions should include views about what the client brought to therapy that was relevant to his/her successful therapy. (Skeptic teams might similarly try to account for the apparent failure of the therapy.) Establishing this for a single case shows what is possible; in legal terms, it establishes a precedent. Identifying the same factors in multiple similar cases through replication increases the likelihood the same relationships will hold in future similar cases, as well as clarifying further conditions under which this is likely or unlikely to be the case (cf. Sidman, 1960).

Thus, along with Fishman (1999), Bohart and Boyd (1997), Miller (2004) and Stiles (2007), we are proposing a science of single cases, using the quasi-judicial methods illustrated here. Such single case causal studies can be done in standalone fashion as was done here, but they can (and should) also be carried out within group designs to help researchers understand their results, essentially filling in the “black box” in a randomized clinical trial. To those familiar with Sidman’s (1960) classic work in behavioral single case experimental design, this may be seen as coming full circle, but with a broader range of methods that apply to a wide range of therapy approaches.

Furthermore, what do we mean by “therapy” when we make the inference that therapy was a major influence on client change? Surely we are not referring only to the therapist’s interventions but presumably mean the partnership of both people working together. Therefore, “therapy” here refers not only to the opportunities that the therapist offers the client, but also the opportunities the client offers the therapist, and also how client and therapist make use of those opportunities within therapy. Although the driving questions used here in HSCED are phrased in terms that sound like old-fashioned linear causality, it does not take the method long to uncover multiple sets of complex bidirectional causal processes in which client and therapist offer each other opportunities to work together productively within the context of the client’s larger life, which itself continually interacts with therapy process and outcome, with both immediate and delayed effects on the client’s problems and life functioning. From the point of view of HSCED, we now believe that it is enough for therapy (and the therapist) to play an important, but by no means exclusive, role in the client’s continuing change process. Interpretive single case methods such as HSCED offer the possibility of beginning to specify such complex, nonlinear interactive processes.


Bohart, A.C., & Boyd, G. (Dec., 1997). Clients' construction of the therapy process: A qualitative analysis. Poster presented at meeting of North American Chapter of the Society for Psychotherapy Research.

Fishman, D.B. (1999). The case for pragmatic psychology. New York: New York University Press.

Kiesler, D.J. (1966). Some myths of psychotherapy research and the search for a paradigm. Psychological Bulletin, 65, 110-136.

Miller, R.B. (2004). Facing Human Suffering: Psychology and Psychotherapy as Moral Engagement. Washington, DC: APA.

Paul, G.L. (1967). Strategy of outcome research in psychotherapy. Journal of Consulting Psychology, 31, 109-118.

Sidman, M. (1960). Tactics of scientific research. New York: Basic.

Stiles, W.B. (1994). What do you know once you’ve heard a story? Paper presented at meeting of Society for Psychotherapy Research, York, England.

Stiles, W. B. (2007). Theory-building case studies of counselling and psychotherapy. Counselling and Psychotherapy Research, 7, 122-127.

Sunday, March 08, 2009

The Continuing Saturday Adventures

Entry for 7 March 2009:

It’s our custom whenever possible to go off somewhere every Saturday to explore some aspect of Scotland. Since the New Year, we’ve had seven of these Saturday Adventures.

A couple of times we’ve just explored a bit of Glasgow, such as the area around the Glasgow School of Art, above Sauchiehall Street; or the east end around the Barras Market, where we discovered the charming Irish Catholic church of St. Alphonsus, filled with statues of various saints, peaceful with the late afternoon sun shining in.

One two other occasions, we’ve taken train journeys to places not far from Glasgow: For one, we spent an intriguing day in Paisley (“Why would you want to do that?” asked my fellow tutor Alison when I told her), where we loved the Gothic grandeur of Paisley Cathedral, saw the ancient celtic cross kept there, had interesting conversations with one of the docents, with the lady in the nicely-stocked gift shop, and with the minister (who was getting ready to perform a wedding for someone he didn't really seem to know). We had lunch in a little Chinese place in the Paisley Mall, which was a little community in itself, family members bustling around and talking with the regulars. Finally, we spent a couple of hours in the charming Paisley Museum, a small municipal museum filled with odd bits and a very nice exhibit on the history of Paisley print (which didn’t come from Paisley at all but was made famous by the cheap knock-offs produced by the local textile industry).

Another one of our train journeys took us to Dunblane, just north of Stirling, where we spent the afternoon exploring Dunblane Cathedral, whose roof was removed not long after it was finished so that its nave was exposed to the elements for 400 years before finally being re-roofed at the end of the 19th century. There we had long talks the docent about the history of the place and the local community. We were especially impressed by the stained glass windows, particularly the unusual modern ones in the choir, full of angels, animals, and depictions of forces of nature.

A couple weeks ago, Diane finally got her UK driving license, after months of lessons. (Much to her surprise: she had been convinced she would fail…) Since then, we’ve been able to visit places that require a car. The first of these was Chatelherault, a regional country park, 20 miles east of Glasgow, surrounding an old hunting lodge, on the River Avon, a tributary of the Clyde. The rebuilt hunting lodge features dizzying, uneven floors, and there is a ruined castle across the river from the lodge. However, the most impressive thing there, we thought, were the ancient, gnarled cadzo oaks, some of them estimated to be 600-800 years old.

Then, last weekend, we drove to Carmunnock, a small village on the southern boundary of the Glasgow, featuring lots of neatly restored, white, 200- and 300-old houses. We happened upon the Kirk just as their warden arrived to run off the leaflet for the next day’s service, and were treated to in impromptu tour of the place, including guardhouse (built 200 years ago to watch out for grave-robbers!), crypt, and choir loft.Carmunnock Kirk features galleries on three sides around the pulpit, which dominates the church in classic Presbyterian fashion. A particularly interesting aspect is that the three galleries each have a separate outside stairway.

Finally, we’ve been meaning to get back to Edinburgh for a while, so yesterday when the weather turned dreich in Glasgow, we gave up the prospect of the walk through Govan in the pouring rain in favour of a day trip museuming in Edinburgh, which is usually drier (and colder) than Glasgow. We got off at Haymarket station and headed for the Scottish Museum of Modern Art. However, on the way on the way up Palmerston Place we got sidetracked by the Episcopal cathedral church for the Edinburgh/Lothian diocese, St. Mary’s. (Yes, it has the same name as the church we go to in Glasgow, which is also a cathedral.) Despite sharing a name, Edinburgh’s St. Mary’s is a very different structure, much larger, really a dark, neo-gothic church built in the late 19th century, following a fairly classic English cathedral plan, complete with chapter house, Lady chapel, clerestory etc.

Back on track, we finally made it to the modern art museum, where we were most impressed by the large outdoor work entitled “Landform”, which is exactly what the name indicates: a large out-door, swirling earthen structure covered with grass. The earthworks are maybe 8 feet high, terraced with multiple paths, and partially encircle a couple of comma-shaped ponds. They feel like the remains of ancient hillfort or one of Ohio’s serpent mounds. When we arrived they stood there, empty and mysterious, forlorn in the gray day, but as we came out to leave, they have become inhabited by running children and parents and thus seemed more playful than mysterious. We went across the street to the Dean Gallery, where the highlight is a room full of surrealist art, Magritte, Dali, Valraux, etc. I’ve always had a soft spot for surrealism. (Chalk that up to growing up in a household where dreams were taken seriously and science fiction magazines and books were scattered around liberally.)

And so the Saturday Adventures continue, and with each one we take into ourselves another bit of Scotland as something familiar and part of who we are and where we’ve been. Even when we return to something we’ve been before, it becomes more deeply written into us, as we see new aspects of it or see it in a different season, under different conditions, or even in a different mood. In a dialectically constructive manner, we change it (in the image we build in ourselves and even imperceptibly by our passing through it, touching the people we encounter there even briefly) and we are changed by it, growing and deepening. It is a kind of liturgy of travel and acquaintance.

Tuesday, March 03, 2009

HPCE ERG, Part 8: So Near and Yet so Far

Entry for 24 February 2009:

Although we have almost finished drafting the Humanistic-Person-Centred-Experiential competences, the most recent meeting turned out to be quite rough going, as the Expert Reference Group bogged down in disagreements over relatively minor wording changes, before finally confronting the divisions that have dogged us from the beginning. The result was not particularly pretty, but is a painful reality that we will nevertheless have to live with. The following is a collection of my views and personal opinions about what happened and where the project is at the moment.

1. Trouble ahead. On the way down from Glasgow, I reviewed the Specific Competences. We’d agreed at the end of the last meeting to add some sections on specific types of relational work. As agreed, a section on Relational Depth (following Mearns & Cooper) had been drafted, but this had met with objections from the group that it wasn’t different enough from the relational parts of the Basic Competences. (This is because it’s generally defined as an integration and higher level of the facilitative conditions, which are in the Basic competences.) Vanja and Tony had also drafted a couple of new sections of Specific Competences. These were labelled “Working with the ‘Here and Now’” and “Working at Relational Depth”. We’d seen part of an earlier draft of this material, to which several of us had objected because it was full of psychodynamic language like “transference” and “unconscious processes”. I’d suggested that these be rewritten in neutral language, and Vanja and Tony had done a good job of this. However, there were now conceptual problems with the new proposed sections, one of which was that the previous material was now gone from the section labelled “Relational Depth” and had been replaced by psychodynamic-based material on complex, multi-level developmental theory and application, having virtually nothing to do with Relational Depth as the person-centred world knows it. A similar situation held for the new “Here and Now” section. Hmm, I thought, this is a bit strange…

As usual, I arrived a bit after the meeting started, but earlier than usual, thanks to the new train service from Glasgow, which has cut travel time by half an hour. Tony had an LCD projector set up and was editing the document as we talked, so we could all see. Andy took us through one last review of the Basic Competences, and we made a couple of minor changes. Then, with Andy warning us that there was “mud ahead”, we dug into the Specific Competences, working over and trying to fine tune the sections we’d worked on last time. For reasons that weren’t clear, we found ourselves getting bogged down on relatively minor wording issues, going in circles; something wasn’t right.

2. Ability to work with the immediate therapeutic relationship. Finally, after lunch, we reached the proposed new sections on relational work. Both of these sections had labels that didn’t fit their material. The label for the section “Working with the ‘Here and Now’” might have focused on classical Gestalt field theory and dialogical practice-type material, but was predominated by the language translating transference and unconscious processes into more neutral terms. Although this material was consistent with psychodynamic theory and practice, I think most of all of us recognized it from our own practice when we engage in long-term therapeutic work with clients with fragile or borderline processes, and it really did feel appropriate to incorporate this material, which finally brought in the more interpersonal-dialogical parts of the larger HPCE family, such as contemporary dialogical Gestalt therapy and the approach developed by Germain Lietaer (a member of our ERG) and other PCE therapists in the Dutch and German-speaking countries. This section was therefore renamed as Ability to work with the immediate therapeutic relationship, with an initial Knowledge of relational processes section.

3. The ground shifts under us. Finally, we tackled the section labelled “Relational Depth”, and this is where things began to get really tough. Many of us began to have real problems with this material, for multiple reasons: First, as I said above, it didn’t correspond to person-centred formulations of Relational Depth, so it was seriously mislabelled. Second, it was redundant with previous sections, leaving us wondering why the material couldn’t just be redistributed elsewhere, or taken as read from what was already there. Third, it was really difficult to get a handle on exactly what the main point was. When we pushed Vanja, who represents UKCP, she talked about developmental theory and research, Stern and Winnicott, and working with multi-level, complex processes. “Working with Complicated Developmental Processes?”, some of us said, trying to be helpful, but this didn’t seem to fit either.

Maybe I was slower on the uptake that the rest of the group, but someplace in here, it became clear to me that Steve and Tony had done a 180 degree turn on this and had already decided to include this section, no matter what. Somehow, they had substantially altered their positions since our last meeting, and the project had come loose from its scientific moorings in systematic outcome research (randomized clinical trials and their treatment manuals). Later, I was told that they had been called into another meeting with Lord Alderdyce and Peter Fonagy, and this time had had the whole HPCE framework, all that we have been working on for the past year, threatened, if they didn’t accede in some ways to UKCP’s demands for more explicit representation. Now, basic developmental research was being cited as a basis for inclusion of an approach in the HPCE framework, in the absence of a treatment manual.

After we had gone in circles for a while, I said, “Well, it looks like this is a matter of producing something that the humanistic and integrative folks will accept as themselves being included in this framework, yes?” When this was met with agreement, I went on: “Then, the real question is whether these folks will accept this material being redistributed elsewhere in the framework or whether they will insist on having a specifically labelled section that they can point to as their own. Which is it?” And Vanja stated that they must have their own section.

4. The need to maintain conceptual elegance. This meant that we are now in a position of having to do damage control. As a result of political pressure put on the HPCE ERG, what feels like a foreign body has been thrust into the framework, compromising its empirical and conceptual integrity. Now the question becomes one of finding a way of including it in such a way that it can do the least harm to the overall framework. Certainly, translating psychoanalytic concepts into neutral language is a first step and a big help. But there’s potentially a real loss for the Specific Competences section if adding this material makes it into a conceptual jumble. The framework has been developing an elegant framework for the Specific Competences that organizes them as specialized therapeutic work within different domains of experiencing:
A. Ability to [Carry out Specialized] Work with Emotions
1. Ability to help clients to access and express emotions
2. Ability to help clients articulate emotions
B. Ability to [Carry out Specialized] Work with Meaning
1. Ability to help clients reflect on and articulate their personal meanings
2. Ability to help clients change emotional meanings
C. Ability to help clients explore and reflect on Puzzling or Difficult Experiences
D. Ability to make use of methods that encourage Active Expression

To which it now makes sense to add:
E. Ability to [Carry out Specialized] Work with Relational Processes,
Which we’ve agreed will have under it:
1. Knowledge of Relational Processes
2. Ability to work with the immediate therapeutic relationship

In addition, it is being proposed to add further new sections, roughly titled:
3. Ability to work with developmental processes [in the relationship]
4. Ability to maintain a non-directive stance [in the relationship]

It’s easy to see that these two new proposed sections strain the elegance of the underlying taxonomy of types of therapeutic work according to domains of experiencing: emotions, meaning (i.e., cognition/symbolic representation), puzzling/difficult experiences (i.e., perceptual-situation), active expression (bodily/action tendency) and relational aspects of experiencing. The only way of integrating them in a reasonably coherent manner is to include them under the umbrella of Relational Processes. Otherwise this section of the framework loses a structure that would enable users to keep them clearly in mind, which has important implications for teaching and measurement.

5. The problem of transference interpretation. A later, more careful examination of the proposed language for the contested new section reveals that transference interpretation has crept into the framework, in the guise of some rather recondite language: “An ability to help draw the client’s attention to strategies which they use to manage areas of difficulty in their relationships and which are currently out of their awareness, based on the ways that these can be identified in the relationship between therapist and client.” For many of us in the person-centered-experiential world, the use of transference interpretation, by whatever name, would prove to be a bridge too far: (a) Because it elevates the therapist clearly into the expert role; (b) because it pulls the client out of their immediate experiencing; and (c) because the empirical literature indicates that the impact of such interpretations is mixed at best and in some instances has been shown to be counter-productive. I certainly hope that this material is removed or substantially altered at the next iteration.

6. Moral issue: The therapies left behind. As we journeyed back to Glasgow after our long, difficult day, I found myself feeling increasingly troubled at a moral level. We had been given a set of ground rules, which, after substantial argument, we had agreed to in order for the project to go forward. We had then spent a lot of time reviewing the scientific evidence in order to provide a fair reading of it. This difficult process had resulted in several humanistic approaches not being including, except indirectly via their representation in Process-Experiential therapy. These include Gestalt therapy, Psychodrama, Focusing, and Pre-therapy. All of these forms of HPCE therapy have some systematic outcome research to support them, including RCTs. Now, a specific form of psychodynamic humanistic therapy with none of the required systematic outcome research, has been forced into the framework via a political process, while the other HPCE therapies with more evidence languish in the dark.

Truth be told, I don’t blame Steve and Tony for capitulating; if faced with the choice between a framework with some stuff that doesn’t belong in it and no framework at all, I’m pretty sure I’d rather have a compromised framework. No, it’s the sheer inequity that leaves a bad taste in my mouth, but more than that, I find it deeply painful in a moral sense. What about Catherine, our carer representative whose son was helped by Pre-therapy and who has faithfully taken part in the process? What about the substantial UK practitioner bases of Gestalt and Psychodrama therapists? In the end, I find myself less troubled by the imposition of the psychodynamic humanistic relational work in the Specific Competences section, where it appears that it can be reasonably contained, than by the omission of other, more evidence-based HPCE therapies. Where is the justice in that? Or is it the case that, as the character Death says in the Diskworld books, “IN THE END, THERE IS NO JUSTICE, THERE IS JUST ME”?