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sections, one of which was that the previous material was now gone from the section labelled “Relational Depth” and had been replaced by psychodynamic-based material on complex, multi-level developmental theory and application, having virtually nothing to do with Relational Depth as the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”?


Ken Evans said...

Dear Robert,
I am quite baffled has to why you persist in equating work with the transference with 'interpretation' and the elevation of the therapist to the role of the 'expert'. Traditionally this has been the case with psychoanlysis, but today contemporary relational psychoanlaysis takes a much more radical position advocating appropriate use of self disclosure, questioning the very notion of therapist neutrality and expertise and are even writing about'contact'.
Dialogical gestalt and many approaches to Integrative psychotherapy use the language of transference but have substantially transformed it. We long ago divorced from the psychoanalytic meanings but continue to use and deepen our understanding of the phenomenon within a thoroughly humanistic frame.In short we have not thrown the baby out with the bath water but made a principled integration.It is possible to decontaminate the language in order to gain access to aspects of meaning that do speak to the human condition. I am by nature ecumenical and have learned more from exploring the opposite polarity than staying entrenched within 'party lines'.

Robert Elliott said...

Obviously, I don't agree with this comment, and see no reason to continue using the term "transference" when (a) there are more useful ways of talking about the same phenomenon (e.g., "emotion scheme"), and (b) "transference" is a red flag for so many (but obviously not all) humanistic therapists. -Robert