Monday, April 13, 2009

HPCE ERG Part 9: Dialogue and Understanding

Entry for 9-12 April 2009:

The full moon shone through the clouds as I stepped out of the front door of my flat in Hyndland and walked down the hill to the train station. The Caledonian Sleeper carried me down to London, arriving at 6:15am, a bit earlier than I wanted. I sat at a café in Euston Station for an hour and a half, ate a bit of breakfast and reviewed the materials for the day’s meeting of the Humanistic Person-Centred-Experiential (HPCE) psychotherapy competences Expert Refernce Group (ERG).

This was an extra meeting, beyond the official end of the project’s funding, organized under special dispensation and with a change of venue (because of the Easter holiday). So it was that I found myself getting off the underground at the Finchley Road tube station about quarter to nine on Maundy Thursday, climbing the hill up Trinity Walk, and progressing along the road in search of the Anna Freud Centre. Just as I was beginning to think I’d made a wrong turn, Steve Pilling came walking jauntily down the street from the other direction, equally early for our 10am meeting.

Lead-up. Several things had happened since our previous meeting in late February: Steve and Tony had had another meeting with representatives from UKCP, who were asking for more changes, and in particular for additional representation and for the restoration of psychodynamic language like “transference” and “projective identification”. The issue of the name of the “Fourth Modality” had once again been raised; this had also been discussed at the Modality Working Group (the next stage of the competence development process), and the word on the street was that our ungainly working title (HPCE) was due for an overhaul.

After the previous ERG meeting (see HPCE ERG report 8), I was stricken by the injustice of including psychodynamically-sourced material from the humanistic-integrative approach in the absence of outcome data while failing to include material on Pre-therapy, as advocated by Catherine Clarke, our carer representative. As a result, I subsequently contacted sources to see if we could develop set draft set of Pre-therapy competences. These sources (I’m being deliberately mysterious here) kindly obliged and we had run the draft through 7 revisions by the beginning of the week of the meeting; these had by now been rebranded as psychological contact competences. In the meantime, Steve had phoned me the previous week to discuss the name issue and to try to convince me that Pre-therapy should not be included even though humanistic-integrative had been (with less outcome data). In addition, Tony and Andy had revised and distributed the Process-Experiential Specific Adaption section. Clearly, we had a full plate for the day.

After an hour’s wait, the others arrived, minus M and our BACP representatives Nancy Rowland and Sally Aldridge, who were away. Angela Kotter, whom I knew from previous contacts, joined us as an 11th hour addition of another representative from UKCP (ironic in the absence of both BACP reps); she was there to provide some support and to take some of the pressure off Vanja Orlans in the negotiations.

The core issue. At the heart of what we’ve struggled with all along are the large apparent discrepancies among the different suborientations in theory, practice and language. For example, many aspects of Process-Experiential practice (most outstandingly, the various forms of chair work) are unacceptable to Person-Centred therapists. Similarly, for reasons mysterious to us, many Humanistic-Integrative therapists feel deeply attached to psychodynamic language like “countertransference” and “unconscious communication”, which the Person-Centred and Process-Experiential therapists find beyond the pale, even when talking about the same clinical phenomena and forms of practice, such as when working with clients with chronic severe dysfunction like borderline/fragile process. These discrepancies have continually strained the conceptual and structural intregrity of the competence framework, as well as the patience and tolerance of the ERG members, and at times feelings have been intense and distrust has been rife.

Over the months, however, relationships among ERG members have developed and the group has learned to deal with its conflicts and to hear the similarities amid the differences, some of which are more apparent than real, while others cut deeper. Here’s how the work went:

1. Specific Approaches. We started out by reviewing the overall HPCE Competence map and in particular the structure of the Specific Competences, which had developed into the key venue for the inclusion of additional competence modules, including the psychodynamicly-flavoured relational work, the person-centred nondirectivity, and the proposed psychological contact work competences. How could such diverse and mutually exclusive material be combined within a single framework? To our surprise, Tony and Steve managed to finesse this one by proposing to label the modules in this section as “Approaches”, thus allowing the different suborientations to do their own thing without the requirement of being consistent with each other.

Later in the day, in the process of our general review of the work done so far, we relooked at the structure of this Specific Approaches section and reorganized the working with emotion and working with meaning sections into a single Working with Emotion and Emotional Meanings sections, making a nice sequence of Accessing Emotion => Articulating Emotion => Reflecting on and Developing Emotional Meanings.

2. Lexical allergies and language as identity. Another big item on our agenda was the issue of mutually-objectionable language, exemplified by terms such as “Actualising Tendency” (person-centred) and “Transference” (UKCP). Many years ago, Marv Goldfried described such terms as “X-rated language”, but in today’s permissive culture another metaphor is called for. I’ve been using the metaphor of a kind of lexical allergy, words that evoke a strong negative reaction in some people. In our case, the problem is not semantic, because we agree on the importance of concepts such as the natural tendency of organisms toward growth and adaptation, or key repeating interpersonal patterns. In some cases, some suborientations valorize certain concepts by giving them special names, like “transference” (humanistic-integrative) or “emotion schemes” (process-experiential), while other suborientations recognize the phenomenon but don’t choose to give it a special name; thus, the person-centred therapists choose not to name the phenomenon, even though they are happy to talk about characteristic and repeatedly-experienced elements of their clients’ core self-concept (as my colleague Beth Freire did last week when we compared notes on how we were thinking about our work with some of our Social Anxiety clients).

Instead, some of us reject certain terms because of their connotations. For example, person-centred and process-experiential therapists reject “transference” and “unconscious” because, like Carl Rogers before us, these terms are a Language of Oppression, representing a psychiatric power structure that we rebel against. Similarly, for process-experiential and humanistic-integrative therapists, apparently, “actualizing tendency” might be seen as a dewy-eyed naïve usage, suggesting a specific pre-formed blueprint; we want something more neutral and open, like “growth tendency” or more interactive and rich, like “dialectically constructive process” or "intersubjective multilevel complexity". Thus, the terms in questions are symbols of an identity that we reject.

Conversely, for various of us, specific key terms are signs of an identity that we espouse and embrace as defining who we are. To use another metaphor, as I did on Thursday, these terms are our native tongue; to make us give up these words is like forbidding people in Ireland and the Scottish Highlands from speaking Gaelic. That is, as people often forget, language is culture, and culture is identity.

How is this relevant to the work of the HPCE ERG? Well, the different suborientations that have been sparring with each other over the past year: person-centred, process-experiential, humanistic-integrative and pre-therapy are each a little culture. Each of these has its own language and points with pride to some aspect that makes it big or important: Person-centred to its history and tradition; process-experiential to its research and its process-differentiation; humanistic-integrative to the size of its practitioner base and the complexity of its theory; pre-therapy to social justice issues grounded in the neglect and mistreatment of severely distressed client populations.

This applies to the humanistic-integrative suborientation as much as the others: What UKCP’s Humanistic and Integrative Psychotherapies Section (HIPS), including Ken Evans -- who keeps sending me cranky emails and postings to this blog -- has been saying is that over the past 20-odd years they have developed their own culture of humanistic practice that incorporates key psychoanalytic terms and now have a substantial practitioner base. They say that they have redefined the psychoanalytic terms and cleansed them of their oppressive connotations, and for them I can only assume that this is true.

However, the terms still retain their toxicity for the rest of us. This is not because we are stuck-in-the-mud, but because we practice in a different culture, where those words mean something else.

Thus, we can argue back and forth as we have been doing about just how big the specific base of the humanistic-integrative suborientation is (it’s undoubtedly not as large as HIPS itself, which is made of quite diverse subgroups, including person-centred, gestalt, psychosynthesis etc), whether this is really a humanistic therapy if it uses all that psychoanalytic language, and why it has none of its own, focused outcome research (what is the impact on outcome using all the psychoanalytic language, even if you don’t actually act interpret your clients?). However, it is still its own developed culture, complete with key texts, language and practitioner base… and Steve and Tony have already agreed with The Powers That Be that humanistic-integrative therapy will be included, psychoanalytic language and lack of focused outcome research and all, and there you have it.

The real key is understanding the fact that the language issue was about our different cultures, and once we finally did that on Thursday, we were able to develop a compromise: We agreed to continue to emphasize ordinary language, generally acceptable versions of important concepts, while giving the technical, identity-based terms as examples, in brackets and quotations, such as “the assumption that people are motivated towards self-maintenance, psychological growth and development, and the realisation of their potential (e.g., “actualising tendency”)”.

Thus, much of our time was spent reviewing the existing framework for places where various of us had trouble with particular terms, going right back the Basic Competence section and following through the rest one more time.

3. Psychological contact competences. It appeared that everyone but Tony and Steve liked the idea of adding psychological contact competences, and we argued around in circles for quite a while about this. Steve had two main arguments against it: (a) the potential for controversy over what would be perceived as a claim to have an effective treatment for severe disorders such as schizophrenia and dementia, coupled with (b) the lack of research to back such a claim up. Steve argued on the basis of having had 20 years of experience with psychotic populations in community mental health settings, fearing the risk of falsely raised expectations might threaten the credibility of the whole framework. The discussion became quite heated as Catherine argued passionately for the need for an alternative to what she described as abusive medication policies.

Andy reminded us that we had previously talked about including psychological contact in the Basic Competences and wondered if something like this could go there, perhaps broadened a bit to include a wider spectrum of contact disturbances such as might be encountered short of but also including psychosis; these include being overmedicated, under the influence of alcohol or other substances, or just interpersonally unengaged. Afterall, psychological contact is the first of Carl Rogers’ six facilitative conditions. Finally, Tony proposed that Andy and he work from the draft I’d put forward to produce a new module on psychological contact to go early in the Basic Competence section, and to run it by the rest of the ERG via email. In spite of the difficult discussion, I ended up feeling quite hopeful that something would come of this. Of course, as always the devils are in the details, and some of the fine details about specific types of therapist responses in the draft are unlikely to survive intact, so we will have to see what the revision looks like. Nevertheless, at the very least we should be able to come out with something that addresses an important clinical issue, broadens the relevance of the competence framework, and acts as a pointer to the rapidly emerging area of Pre-therapy and contact work.

4. The Name issue. One of the final things the ERG tackled was what to call the competence framework that we’ve been working on for the past year. UKCP was now complaining that it wasn’t fair the framework should be named after two suborientation brand names (“person-centred” and “experiential”) while their brand name was left out. Of course, the PCE label was developed as an inclusive label by our professional organization (WAPCEPC, talk about an awkward name) 10 years ago, but it wasn’t UKCP's label and they don’t identify with it, so we were once again back to identity politics. On the other hand, no one was seriously proposing to go back the original title “Humanistic and Integrative”, because “Integrative” is just too large an umbrella (it includes Cognitive Analytic Therapy, Multi-modal therapy etc). And everyone agreed that “Person-Centred-Experiential-Humanistic-Integrative” was too long and clumsy. Really, the only viable label we are left with is one that no one really likes: “Humanistic”. This is a kind of lowest common denominator solution, a shoe that fits no one perfectly but one that almost all of us can wear like a kind of one-size-fits-all-of-us-with-mediumish-sized feet. Germain Lietaer did made a final plea against this, because the term is simply not used in Europe and has relatively few practitioners today in North America. He argued that our adopting “Humanistic” would limit the usefulness of the competence framework internationally. In the end, however, the competence framework must first work domestically in the UK, so we agreed to go forward with this spartan label. HPCE has now become H.

Finishing up and summing up. And so our long series of face-to-face meetings devoted to developing a set of humanistic competences finally has finally come to an end. The rest will have to be done by email and possibly teleconference. We didn’t get to the Process-Experiential therapy competences, but Andy, Tony and I will continue working on those over the next few weeks, before we send them out to Les Greenberg, Jeanne Watson, Rhonda Goldman and possibly Sandra Paivio for further review and comment.

Over the past year, the HPCE (now H) ERG evolved over a complicated and sometimes fractious process, and I’m sure that when it’s finally finished the result won’t totally satisfy anyone wholly. Interestingly, it seems to me that the most important thing about it is not the emerging framework itself but the opportunity for dialogue among folks representing the different points of view within the humanistic therapy world and also between us and Tony and Steve. We have come to understand and respect each others’ perspectives. It is clear that differences in practice and language remain and will continue to set us apart from one another; but it is even clearer that we need to continue to try to hear and understand each other in spite of (and also because of) those differences.


bonnie meekums said...

Hi Robert,

I found it very helpful to read this as I am on the group that is working on the NOS.

What resonated with me was the stuff about identity politics, and the way that these are enshrined in our language. Actually, I have been careful in my work on the NOS working group to avoid jargon as much as possible because I think this is divisive. Sometimes, practitioners work with very similar or identical processes and yet call it different things, as if the label were something that could be deemed to be 'true' on any level.

Actually, that is why although I belong to the UK Association for Humanistic Psychology Practitioners, I see my practice as integrative. It bugs me that psychoanalysis has in fact become more humanistic over time and seems not to want to acknowledge that this is a key influence, particularly the political implications of the client knows best (and the awful abuse of the therapist always knows best). UKAHPP does not rule out the existence of what some people call transference, not because it is espousing the UKCP view, but because this has always been part of some humanistic practices. The humanistic umbrella is indeed very broad and has more than one root. UKAHPP has managed though to embrace this diversity, somehow, whilst identifying key humanistic prinicples. I do not speak for UKAHPP in this - I am merely a member with no formal function.

I take issue with you that humanistic is a label that 'no-one really likes'. Who is this no-one? No-one powerful enough to sit on the ERG? Power is everywhere, and even those who try to fight power politics can find themselves in positions of power, listening to a limited range of voices. Not all voices were represented on the ERG. I find it interesting that humanistic is not a label used in (the rest of) Europe, and that these days it has largely disappeard from the USA. Why do you think this is? Could there be (and you are going to hate this) unconscious forces at work, silensing the rather embarrassingly 60's-like voices of the humanistic movement? After all, we have all moved on from love and peace and spontaneity (and sex!), haven't we? It was all so uncontrolled. Of course, I do not wish to argue here against boundaries and ethics - there was a lot wrong with the human potential movement (I caught the wave in 70s Britain), but I do wonder what is being silenced here.

I remain committed to humanistic practice because I think it is right - not in the sense of evidence based, but because it is right in the same way that not having sex with clients is right. The prinicples run at the heart of what it means to be human. I remain interested in understanding therapeutic processes as a researcher, but this is not all there is. I support the use of the label 'humanistic', and will strive to work towards the use of words that mean something to everybody rather than jargon that carries with it not just identity but power and mystification. I have a sense that this is going to be a difficult but worthwhile task.

Robert Elliott said...

Thanks for your very interesting comments, Bonnie! I tend to agree with you that for many of us some of our dispreference for the "humanistic" label is grounded in our not wanting to be associated with some of the worst abuses of the 1960's and '70's. Actually, I've never that much trouble with the label and have used it off and on. In fact, I belong to the Division of Humanistic Psychology of the American Psychological Association, and they gave me the Carol Rogers Award last year for my contributions to humanistic psychology. But some of my European and South American colleagues have a real problem with the label...