Entry for 25 April 2008:
One of Carl Rogers’ many contributions to psychotherapy research was his creation of the first psychotherapy research clinic at the University of Chicago in the 1940’s. (John McLeod, 2002, in a lovely article in the first issue of Person-Centered and Experiential Psychotherapies, wrote about Rogers’ research program in this research clinic, at the Chicago Counselling Center, attempting to characterize what made it so productive.)
This idea of the research clinic, which has been passed down from researcher to researcher since Rogers’ time, is a powerful one. As I have written previously, I encountered this firsthand in 1984-85, during the year we spent on sabbatical at the University of Sheffield, working with David Shapiro and his team in the Social and Applied Psychology Unit. Empowered by what I saw, I went back to Toledo afterwards and set up my own research clinic, which later evolved into the Center for the Study of Experiential Psychotherapy (CSEP). Les Greenberg at York University subsequently picked up the idea, as did John McLeod at the University of Abertay, etc. Eventually, two colleagues at Toledo set up their own competing CBT research clinic, modelled after CSEP. The point I am trying to make is that the idea of the research clinic is a meme, that is, a viral concept, i.e., a catchy idea.
What is the content of the Research Clinic meme? Essentially this: (1) It is possible and desirable to set up and run within one’s academic organization a clinic for delivering psychotherapy within one or more research protocols. (2) Such an internal clinic is serious about both its research and its psychotherapy provision and tries to balance these as much as possible, while putting client welfare first. (3) As Cook and Campbell (1979) noted, creating your own organization (i.e., research clinic) is often the only way to get the degree of control over data collection and assignment of clients to therapy (e.g., randomization) needed for addressing many scientific questions. (4) Although research clinics require resources of various kinds, the key steps are: (a) get the support of administrators; (b) collect a group of people around the idea of setting up and running it; (d) declare publicly that one is doing so; and (e) just do it.
Our research clinic here at Strathclyde opened last November, under the able coordination of Brian Rodgers. This has turned out to be somewhat more challenging to set up than the research clinic at Toledo was, because we didn’t have the infrastructure of a pre-existing training clinic to build on and rely upon. But the group of us were able eventually to pull the different pieces together, and we are continuing to build and fine tune.
Currently, we have 16 clients in therapy, four clients about to begin, and five clients on our waiting list (and expected to be picked up in the next couple of weeks). Brian has set up a useful system for scheduling rooms, tracking clients through the protocol, and monitoring their progress using the Personal Questionnaire as a signal alarm procedure (following Mike Lambert’s method developed for the Outcome Questionnaire).
Once up and running, a research clinic begins to produce its own energy. We have now reached the point where members of our research team are carrying out Change Interviews, and the excitement has begun to build, as it is becoming increasingly clear that powerful, useful data are emerging. We see our clients changing on our quantitative and qualitative instruments and we are starting to learn from them firsthand what it feels like to be met with a strong person-centred relationship. The Research Clinic is not just a catchy idea; it is also a place for helping clients and doing useful science at one and the same time, a place where science and practice truly come together!
Tuesday, April 29, 2008
Tuesday, April 22, 2008
Teaching Professional Practice: Science Fiction, Therapy and Research
Entry for 22 April 2008:
I have been reading the magazine Fantasy & Science Fiction since I was a teenager. Soon after my dad stopped subscribing to it in the early 1970’s, I took out my own subscription, later filling in the missing year or two from various sources. I now have an almost complete set (missing 2 issues if I remember correctly), going back to 1949, the year before I was born. (They are stored in plastic containers in my basement in Toledo.) F&SF is thus practically contemporaneous with my life, and it is my firm intention to continue getting it and reading it until one of us goes defunct.
In the January 2008 issue, there is a book review by one of their regular reviewers, James Sallis, of a biography of the famous SF illustrator-writer couple Ed and Carol Emshwiller. (His iconic paperback cover illustrations populated our house when I was growing up in the 1950’s; her recent fiction regularly appears in F&SF, and often examines gender and related issues in an allegorical manner unlike any other writer I know of working in the field today.)
Sallis concludes his review with the following quotation: “Interviewers frequently ask why, after forty-some years of writing, I remain drawn to teaching it. The answer, I tell them, is contained in the question. All too easily and soon one becomes professionalized, focusing on the mechanics, the production, the practicalities. Teaching makes me remember why this is so important to me, why I have worked so long and so hard at it, why I started doing it in the first place. So does this book.” (p. 39)
When I read this, it really rang true for me. I did not set out to be a teacher: First, I wanted to be a therapist, then a researcher. But helping opening the door to therapy and research for my students grew on me, gradually, over many years, at first feeling like an imposition; then moving to acceptance; then developing a real interest in the craft and discipline of teaching these subjects; and finally, in the past decade, growing into a passion. It feels fitting that I have come to work in a Faculty of Education, because that is where I am now in my work and life. In my ongoing inventory of what is important to me, teaching is key. I still very much like to write and do research, but teaching still feels like a growing edge for me, even more than writing and research. Because, as James Sallis writes, teaching takes me back to my starting place, to what drives me as a therapist and a researcher.
I have been reading the magazine Fantasy & Science Fiction since I was a teenager. Soon after my dad stopped subscribing to it in the early 1970’s, I took out my own subscription, later filling in the missing year or two from various sources. I now have an almost complete set (missing 2 issues if I remember correctly), going back to 1949, the year before I was born. (They are stored in plastic containers in my basement in Toledo.) F&SF is thus practically contemporaneous with my life, and it is my firm intention to continue getting it and reading it until one of us goes defunct.
In the January 2008 issue, there is a book review by one of their regular reviewers, James Sallis, of a biography of the famous SF illustrator-writer couple Ed and Carol Emshwiller. (His iconic paperback cover illustrations populated our house when I was growing up in the 1950’s; her recent fiction regularly appears in F&SF, and often examines gender and related issues in an allegorical manner unlike any other writer I know of working in the field today.)
Sallis concludes his review with the following quotation: “Interviewers frequently ask why, after forty-some years of writing, I remain drawn to teaching it. The answer, I tell them, is contained in the question. All too easily and soon one becomes professionalized, focusing on the mechanics, the production, the practicalities. Teaching makes me remember why this is so important to me, why I have worked so long and so hard at it, why I started doing it in the first place. So does this book.” (p. 39)
When I read this, it really rang true for me. I did not set out to be a teacher: First, I wanted to be a therapist, then a researcher. But helping opening the door to therapy and research for my students grew on me, gradually, over many years, at first feeling like an imposition; then moving to acceptance; then developing a real interest in the craft and discipline of teaching these subjects; and finally, in the past decade, growing into a passion. It feels fitting that I have come to work in a Faculty of Education, because that is where I am now in my work and life. In my ongoing inventory of what is important to me, teaching is key. I still very much like to write and do research, but teaching still feels like a growing edge for me, even more than writing and research. Because, as James Sallis writes, teaching takes me back to my starting place, to what drives me as a therapist and a researcher.
Sunday, April 20, 2008
A Saturday in Glasgow
Entry for 19 April 2008:
It’s been windy and cool but mostly dry this week, with the wind unusually out of the east for the past couple of days, producing unexpected drafts, such as the one that led Nikky, one of our secretaries, to tape the bottom of the window by her desk with bubble wrap. This is turning out to be a classic Scottish weather pattern: high pressure holding off the rain, but bringing cold winds with it.
After managing to get 9 hours of sleep last night, I went out for a 7-mile run along the canal, this morning, making it as far as the British Waterway operations central, which is almost to Speirs wharf, north of the city centre. It’s been months since I’ve managed to work up to this distance, my life has been so crazy, and it felt good to finally get back to this level.
Today’s Saturday Adventure turned out to be Retail Therapy: We set off for Staples looking for a filing cabinet, and ended up at the IKEA in Braehead, which was mobbed with people taking advantage of their 21% off 21st birthday sale. No suitable filing cabinets there either, but we found blue bolster covers for our guest bed, after a year of looking for them to come back into stock.
I’m in transition in my job, having decided a couple of weeks ago that I would no longer “follow other people onto the train.” This has been highly stressful and difficult, as various relationships and commitments have had to be and are still being renegotiated, but it has been liberating. The result of this is a process of taking stock of what my priorities are. For example, it’s become clear to me that one of those priorities has become the Research Clinic, which is now producing really nice therapy and lovely data. It certainly needs continued efforts to realize its potential and improve its operations, but enough of its promise is already being realized to see what a wonderful thing it is. A Saturday – even a cold, windy one -- provides the working distance to see this more clearly.
It’s been windy and cool but mostly dry this week, with the wind unusually out of the east for the past couple of days, producing unexpected drafts, such as the one that led Nikky, one of our secretaries, to tape the bottom of the window by her desk with bubble wrap. This is turning out to be a classic Scottish weather pattern: high pressure holding off the rain, but bringing cold winds with it.
After managing to get 9 hours of sleep last night, I went out for a 7-mile run along the canal, this morning, making it as far as the British Waterway operations central, which is almost to Speirs wharf, north of the city centre. It’s been months since I’ve managed to work up to this distance, my life has been so crazy, and it felt good to finally get back to this level.
Today’s Saturday Adventure turned out to be Retail Therapy: We set off for Staples looking for a filing cabinet, and ended up at the IKEA in Braehead, which was mobbed with people taking advantage of their 21% off 21st birthday sale. No suitable filing cabinets there either, but we found blue bolster covers for our guest bed, after a year of looking for them to come back into stock.
I’m in transition in my job, having decided a couple of weeks ago that I would no longer “follow other people onto the train.” This has been highly stressful and difficult, as various relationships and commitments have had to be and are still being renegotiated, but it has been liberating. The result of this is a process of taking stock of what my priorities are. For example, it’s become clear to me that one of those priorities has become the Research Clinic, which is now producing really nice therapy and lovely data. It certainly needs continued efforts to realize its potential and improve its operations, but enough of its promise is already being realized to see what a wonderful thing it is. A Saturday – even a cold, windy one -- provides the working distance to see this more clearly.
Wednesday, April 16, 2008
Psychodrama Trainers Conference in Bearsden
Entry for 16 April 2008:
I gave three conference presentations in the first week of April, which meant that I missed a bunch of email that I still haven’t had a chance to get to. The most colourful experience was presenting to a group of psychodrama trainers on a sunday morning at a Catholic Seminary in a northern suburb of Glasgow. I was very impressed with their wisdom about group processes and the lovely way they decided the theme of next year's conference by physically getting up in the middle of the group and having people who agreed with them gather around them. In the space of 10 minutes 8 proposals emerged from 50 people; people gathered around their favorite proposals, then the groups negotiated, merged, dissolved and reformed until there were only 2 left, at which point a count was made, and everyone involved cheered the "winner"! The process was both charming and efficient.
I loved the way they embodied what they were talking about. Celia Scanlan, who it turns out lives near me in Hyndland, organized the conference, so when they wanted to express their appreciation to her, they asked her to stand in the middle of the group. She then invited her helpers to stand with her, and, noting that some of them were unable to be there, she immediately deputized other people to stand in for them, so that all the helpers were represented. After this, she had to leave the closing session for a bit to drop me off, but before doing so, she asked Michael Weiser, to “be” her. I said, “You mean, to represent you?”, to which she replied, “No, to actually be me!”. I found this creativity, flexibility and embodiment to be both entertaining and inspiring.
I gave three conference presentations in the first week of April, which meant that I missed a bunch of email that I still haven’t had a chance to get to. The most colourful experience was presenting to a group of psychodrama trainers on a sunday morning at a Catholic Seminary in a northern suburb of Glasgow. I was very impressed with their wisdom about group processes and the lovely way they decided the theme of next year's conference by physically getting up in the middle of the group and having people who agreed with them gather around them. In the space of 10 minutes 8 proposals emerged from 50 people; people gathered around their favorite proposals, then the groups negotiated, merged, dissolved and reformed until there were only 2 left, at which point a count was made, and everyone involved cheered the "winner"! The process was both charming and efficient.
I loved the way they embodied what they were talking about. Celia Scanlan, who it turns out lives near me in Hyndland, organized the conference, so when they wanted to express their appreciation to her, they asked her to stand in the middle of the group. She then invited her helpers to stand with her, and, noting that some of them were unable to be there, she immediately deputized other people to stand in for them, so that all the helpers were represented. After this, she had to leave the closing session for a bit to drop me off, but before doing so, she asked Michael Weiser, to “be” her. I said, “You mean, to represent you?”, to which she replied, “No, to actually be me!”. I found this creativity, flexibility and embodiment to be both entertaining and inspiring.
Tuesday, April 08, 2008
BPS Dubliin Presentation: Client’s Accounts of Emotion Processes in First Sessions of Therapy
Entry for 4 April 2008:
Full reference: R. Elliott. (April, 2008). Emotion Processes in First Sessions of Process-Experiential Therapy: An Interpretive Discourse Analysis of Clients’ Accounts of Significant Events. Paper presented at conference of the British Psychological Society, Dublin, Ireland.
Jutta Schnellbacher and I gave an earlier version of this paper at the Society for Psychotherapy Research conference last June. This time, without Jutta to present her parallel analyses of relational processes, I decided to concentrate on emotion processes. Last time, I presented only one of the five domains that I’d analyzed; this time I decided to go for broke and present the entire analysis, all five domains. This involved staying up rather later than I had anticipated the night before the presentation, but I think that the resulting presentation gave the audience a much more complete picture of the variety and depth of analyses that are possible with this method for really digging down in one’s data. The following is a text conversation of my powerpoint slides.
I. Introduction
A. First Sessions as Locus for Studying Key Client Experiences
1. Clients typically bring to first session of therapy salient concerns about:
-Nature of the therapy relationship they are entering
-Their emotions
2. These are key processes in Process-Experiential/ Emotion-Focused Therapy
3. Initial sessions = excellent site to study these
4. Here focus on emotion processes; Jutta Schnellbacher of KU Leuven did parallel analysis of relational talk
B. Helpful Aspects of Therapy (HAT) Form (Llewelyn, 1988)
1. Widely used for collecting client post-session accounts of significant therapy events
2. Asks client to describe most helpful or important event in session, including:
-What made it helpful
-How helpful (9-point scale)
-Other helpful or hindering events in session
3. Typically produces relatively thin research protocols of brief but information-dense statements
4. Sometimes difficult to analyze properly
5. Example: Client 6, Session 1 HAT:
-Helpful: Being able to vent without having anything negative be said.
-Slightly Helpful: 6; Where?: from middle to end; How long? 20 to 30 mins.
-Hindering: Nervousness (mine) at first. Nervousness talking to someone I didn’t know about things that have happened in the past and present. Slightly Hindering: 4
C. Qualitative Data Analysis Practices
1. Generic approach to qualitative data analysis:
-Set of common analytic practices that different analytic approaches draw on (Elliott & Timulak, 2006)
-Types of Practices: Pre-analysis; Translation; Categorization; Integration; Credibility checks
-Translation practices: Data Summary, Explicating Implicit Meaning, Interpretation Unconscious Meaning, Process Description
D. Interpretive Discourse Analysis
1. Emphasizes Explication and Interpretation practices
2. Deeper reading of the data than is typical for standard ÅgdescriptiveÅh qualitative analysis (e.g., GTA)
3. Requires theoretical framework that provides basis for interpretation of aspects of experience of out informantsÅf experience (e.g., psychodynamic or feminist theory):
4. Process-experiential emotion theory
5. Lakoff-Johnson metaphor theory
II. Method
-Parallel analyses of relational & emotion talk
-Series of steps:
A. Step 1. Highlight relevant talk that points to:
-Position of self or therapist in relationship
-Experiences of own emotions
1. Example: Client 6, Session 1 (Highlighted)
-Helpful: Being able to vent without having anything negative be said.
-Slightly Helpful: 6; Where?: from middle to end; How long? 20 to 30 mins.
-Hindering: Nervousness (mine) at first. Nervousness talking to someone I didn’t know about things that have happened in the past and present.
-Slightly Hindering: 4
Key: Relational talk; Emotion talk
B. Step 2: Interpreting the Text
1. Read HAT texts closely for explicit and implicit meaning
2. Dialogue with the data: Ask:
-Relational Talk: What is the client telling/ revealing about their understanding of their and the therapist’s position in the relationship?
-Emotion Talk: What is the client telling/ revealing about their experience of their emotions?
3. Example of Emotion Talk Analysis:
Text: "Being able to vent without having anything negative be said"
Analysis: Read as description of:
-Emotion regulation process: heat/steam metaphor (Lakoff & Johnson)
-Action tendency(emotion as source of action/wish/need): Express/vent/get emotion out in the open
-Consequence of emotion expression or work: lack of negative interpersonal consequences
-Folk concept of problematic emotion process: In general, emotional expression is interpersonally risky -- a rule noted by virtue of an exception being remarked upon here
-Folk concepts of helpful processes re: emotions:
-(a) "It is helpful to express emotions" "Venting metaphor";
-(b) "The therapist’s acceptance/non-negative response to emotional expression is helpful”
C. Step 3: Developed general analytic framework (domain structure)
-Emerged from the analysis
-Rough correspondence to key elements of Process-Experiential emotion theory
I. Type of mention or nonmention
II. Type of emotion
III. Emotion regulation processes
IV. Emotion Scheme elements
V. Folk emotion theory concepts
D. Step 4: Open Coding within Domains
1. Within each domain, classified different different types of emotion talk (ÅgdomainsÅh)
2. Often used subdomains
3. Constructed categories within domains/subdomains (= Open Coding)
III. Results:
Domain I: Type of mention or nonmention
A. When clients didn’t talk about their experience of their emotions in their accounts:
1. No event description at all (n=5)
2. Emotion not mentioned or implied (n=13)
3. Report of therapistÅfs understanding of clientÅfs emotions (n=1)
B. When clients did talk about their emotions: n= 40 (74% of 54 event descriptions)
1. Talked about only in abstract or general terms (no specific emotions or emotion scheme elements) (n=5)
2. Remaining events (n = 35) involved additional information about emotions (described in further analyses)
Domain II: Type of Emotion
A. Distressing emotions re: Client’s life/ problems (n= 22 clients)
1. Anxiety/Fear: (10)
-Nervous/anxious (4); Overwhelmed (2); Fear (4)
2. Sadness/Depression/emotional pain: (12)
-Sadness/hurt/isolation (8); Depression (5); Emotional pain (1)
3. Dislike/disappointment/frustration/anger (5)
-Anger/hate (2); Confused/frustrated (1); Dislike (1); Disappointed (mild) (1)
B. Positive (attachment) emotions re: Relationship with therapist (21)
1. Relieved/relaxed/refreshed/comfortable/less overwhelmed/ unguarded: (9)
2. Secure/safe/trusting/grateful: (7)
3. Generally Good: (7)
-Hopeful (3); Globally positive: It feels good (4)
4. Understood/Validated/in rapport with therapist: (5)
-Understood (3); Validated/affirmed/cared for (1); Sense of rapport with therapist (1)
C. Other emotions: (2)
-Surprise (1); Avoidant comfort (1)
Domain III: Emotion regulation processes
A. Soothing/Containing/distancing (n=16)
1. Relational soothing (5):
a. being listened to/understood (2)
b. being (re)assured (1)
c. being validated/affirmed (1)
d. sense of rapport (1)
-160: To confirm a “rapport” with the therapist-that the likelihood is strong that progress and “personal” revelations will result over time
2. Venting/expressing (4):
-06: venting
3. Distancing/“extracting” uncomfortable emotion (3):
-24: Being able to “empty” all my feelings. I can put all my feelings aside and feel safe and comfortable doing it.
4. Focusing on positive aspects (1):
-67: Focusing on the positive aspects of my life. Getting positive reinforcement from my therapist.
5. Planning strategy for controlling emotions (2):
-143: When I talked about knowing that I have to take control of my own feelings (writing a journal).
6. Dissolving sources of distress (1):
-63: Dissolving some reasons for sadness.
B. Hindering Loss of regulation/unhelpful accessing (3):
1. Difficult realization (1):
-39: Realizing how frightened I am to be an adult [help neutral]
2. Stuck in distressing feelings (1):
-147: what do you do for a child trapped in a closet, alone fearing for her life?… but my feelings got “stuck” there
3. Continuing confusion/frustration (1):
-54: I was confused throughout the whole session, frustrated.
Domain IV. Emotion Scheme elements
-Emotion Scheme Model; Elliott et al., 2004
A. Perceptual-situational: [referent of emotion]
1. Life situation (14)
-51: I have been on the outside of the World looking in. She made a direct connection to my feelings of isolation and understood it.
2. Therapy context:
-11: She’s trying to understand what I’m going through and this makes me feel secure.
3. Research context:
-52: The pre-session form I filled out stated my problems in print this surprised me.
B. Bodily-Expressive: [How emotion is experienced or expressed in the body] (7)
1. Decreased bodily tension (3)
-14: Relaxing, cool, relieved
2. Crying (3)
-21: I don’t like to cry.
3. Panic sensations:
-147: I spoke about feeling trapped in my body, scared, fear not being able to breathe,
C. Verbal-Symbolic: [What the person thinks, says to themselves in accompaniment with the emotion; how they picture or classify self]
1. Cognitive/thinking errors (1):
2. Powerful mental image (2):
3. Verbalized thoughts (2)
-165: I don’t believe anyone would/should stand by me during my months of depression
4. Internal emotion attribution: Seeing self as responsible for one’s own emotions:
D. Action tendency [Actions, wishes, needs generated by and thus seeming to come from the emotion] (14)
1. Express/vent/get out in the open: (8)
2. Open self to other, let guard down (2)
3. Be free, move out into the world/contemplate possible action: (3)
4. Withdraw: (1)
E. Action tendency: toward [Actions, wishes, needs generated in response to or back toward the emotion] (12)
1. Approach/accessing:
a. Searching (for) emotions: (2)
b. Insight/realization/awareness of an emotion process: (5)
2. Distancing/containing: (6)
a. Setting aside/emptying/extracting emotions/pushing emotions away: (3)
b. Hiding emotions from others: (2)
F. Consequences of emotional expression or work (7):
1. Absence of expected negative response from other (2)
2. Relief (4)
3. Get stuck/stay with painful experience (1)
-147: ...what do you do for a child trapped in a closet, alone fearing for her life? …but my feelings got “stuck” there.
Domain V: Folk Concepts for Emotions
A. Problematic/Hindering aspects/processes re: emotions (7):
1. Emotion expression can be problematic (3)
a. Emotional expression is interpersonally risky (2)
b. Expressing distressing emotions burdens others (1)
2. Emotional experiencing can be problematic (4):
a. Uncontrolled/stuck emotions cause problems (2)
b. Being confused and frustrated is not helpful (1)
c. Unwanted emotional pain is unhelpful(1)
3. Hiding or pushing away emotions can cause you problems:
B. Folk theories of helpful processes re: emotions:
1. Managing/containing emotions can be helpful (5):
a. Distance from distressing/overwhelming emotions can be helpful (1)
b. Controlling one’s emotions can be helpful (1)
c. Emotions are things that can the removed or separated from other things (2)
d. Focusing on the positive can be helpful (1)
2. Approaching/accessing emotions can be helpful (10):
a. It is helpful to express emotions (venting) (8)
b. Emotions are hidden things to be carefully sought after (1)
c. It is helpful to sort out true emotions from false ones (1)
d. Emotion access can be life-changing (1)
3. Understanding emotions can be helpful (6)
a. Feeling unblamed for distressing emotions can be helpful (1)
4. The therapeutic relationship is important for helping clients work with their emotions (7):
a. The therapist’s acceptance of emotional expression is helpful (1)
b. Being able to trust/have rapport with the therapist is helpful (3)
c. The therapist’s non-negative response to one’s emotions is helpful (3)
C. Causal concepts involving emotions: (9)
1. Emotions are normal, common effects caused by events (6)
-30: It feels good having another human being understand my experiences
2. Emotions can be causes of symptomatic behavior: (2)
-39: It made me feel like crying.
3. Emotions have reasons: (1)
-63: Dissolving some reasons for sadness. I found that there were reasons you were depressed.
IV. Conclusions:
1. At first, it appeared that emotion processes were not particularly prevalent in session 1 HATs
2. However, by learning to look carefully at implicit meaning, found substantial emotion talk, in about 75% of accounts
3. Types of emotion talk in session 1 HAT were quite complex, covering the range of PE-EFT emotion theory, and in addition explicating clients’ folk theories about emotion and emotion work
4. Emotion processes and relational processes turned out to be more closely connected than we had anticipated.
5. Types of emotion reveal balance between
-Distressing emotions about clients’ lives and problems brought into first sessions and
-Attachment-related emotions emerging in early alliance formation
-Illustrates the central work vs. relationship dialectic in therapy, played out by on the stage of human emotions
6. The method and findings appear to be promising and merit further exploration
7. Raises many unanswered questions:
-Specific to Emotion-focused Therapy?
-Specific to first sessions?
-How do relational and emotion process connect to each other?
-Gender differences in how men and women describe significant events in general, and emotion more specifically?
-Relationships between types of HAT emotion talk and alliance; therapy incompletion; outcome, etc.?
Full reference: R. Elliott. (April, 2008). Emotion Processes in First Sessions of Process-Experiential Therapy: An Interpretive Discourse Analysis of Clients’ Accounts of Significant Events. Paper presented at conference of the British Psychological Society, Dublin, Ireland.
Jutta Schnellbacher and I gave an earlier version of this paper at the Society for Psychotherapy Research conference last June. This time, without Jutta to present her parallel analyses of relational processes, I decided to concentrate on emotion processes. Last time, I presented only one of the five domains that I’d analyzed; this time I decided to go for broke and present the entire analysis, all five domains. This involved staying up rather later than I had anticipated the night before the presentation, but I think that the resulting presentation gave the audience a much more complete picture of the variety and depth of analyses that are possible with this method for really digging down in one’s data. The following is a text conversation of my powerpoint slides.
I. Introduction
A. First Sessions as Locus for Studying Key Client Experiences
1. Clients typically bring to first session of therapy salient concerns about:
-Nature of the therapy relationship they are entering
-Their emotions
2. These are key processes in Process-Experiential/ Emotion-Focused Therapy
3. Initial sessions = excellent site to study these
4. Here focus on emotion processes; Jutta Schnellbacher of KU Leuven did parallel analysis of relational talk
B. Helpful Aspects of Therapy (HAT) Form (Llewelyn, 1988)
1. Widely used for collecting client post-session accounts of significant therapy events
2. Asks client to describe most helpful or important event in session, including:
-What made it helpful
-How helpful (9-point scale)
-Other helpful or hindering events in session
3. Typically produces relatively thin research protocols of brief but information-dense statements
4. Sometimes difficult to analyze properly
5. Example: Client 6, Session 1 HAT:
-Helpful: Being able to vent without having anything negative be said.
-Slightly Helpful: 6; Where?: from middle to end; How long? 20 to 30 mins.
-Hindering: Nervousness (mine) at first. Nervousness talking to someone I didn’t know about things that have happened in the past and present. Slightly Hindering: 4
C. Qualitative Data Analysis Practices
1. Generic approach to qualitative data analysis:
-Set of common analytic practices that different analytic approaches draw on (Elliott & Timulak, 2006)
-Types of Practices: Pre-analysis; Translation; Categorization; Integration; Credibility checks
-Translation practices: Data Summary, Explicating Implicit Meaning, Interpretation Unconscious Meaning, Process Description
D. Interpretive Discourse Analysis
1. Emphasizes Explication and Interpretation practices
2. Deeper reading of the data than is typical for standard ÅgdescriptiveÅh qualitative analysis (e.g., GTA)
3. Requires theoretical framework that provides basis for interpretation of aspects of experience of out informantsÅf experience (e.g., psychodynamic or feminist theory):
4. Process-experiential emotion theory
5. Lakoff-Johnson metaphor theory
II. Method
-Parallel analyses of relational & emotion talk
-Series of steps:
A. Step 1. Highlight relevant talk that points to:
-Position of self or therapist in relationship
-Experiences of own emotions
1. Example: Client 6, Session 1 (Highlighted)
-Helpful: Being able to vent without having anything negative be said.
-Slightly Helpful: 6; Where?: from middle to end; How long? 20 to 30 mins.
-Hindering: Nervousness (mine) at first. Nervousness talking to someone I didn’t know about things that have happened in the past and present.
-Slightly Hindering: 4
Key: Relational talk; Emotion talk
B. Step 2: Interpreting the Text
1. Read HAT texts closely for explicit and implicit meaning
2. Dialogue with the data: Ask:
-Relational Talk: What is the client telling/ revealing about their understanding of their and the therapist’s position in the relationship?
-Emotion Talk: What is the client telling/ revealing about their experience of their emotions?
3. Example of Emotion Talk Analysis:
Text: "Being able to vent without having anything negative be said"
Analysis: Read as description of:
-Emotion regulation process: heat/steam metaphor (Lakoff & Johnson)
-Action tendency(emotion as source of action/wish/need): Express/vent/get emotion out in the open
-Consequence of emotion expression or work: lack of negative interpersonal consequences
-Folk concept of problematic emotion process: In general, emotional expression is interpersonally risky -- a rule noted by virtue of an exception being remarked upon here
-Folk concepts of helpful processes re: emotions:
-(a) "It is helpful to express emotions" "Venting metaphor";
-(b) "The therapist’s acceptance/non-negative response to emotional expression is helpful”
C. Step 3: Developed general analytic framework (domain structure)
-Emerged from the analysis
-Rough correspondence to key elements of Process-Experiential emotion theory
I. Type of mention or nonmention
II. Type of emotion
III. Emotion regulation processes
IV. Emotion Scheme elements
V. Folk emotion theory concepts
D. Step 4: Open Coding within Domains
1. Within each domain, classified different different types of emotion talk (ÅgdomainsÅh)
2. Often used subdomains
3. Constructed categories within domains/subdomains (= Open Coding)
III. Results:
Domain I: Type of mention or nonmention
A. When clients didn’t talk about their experience of their emotions in their accounts:
1. No event description at all (n=5)
2. Emotion not mentioned or implied (n=13)
3. Report of therapistÅfs understanding of clientÅfs emotions (n=1)
B. When clients did talk about their emotions: n= 40 (74% of 54 event descriptions)
1. Talked about only in abstract or general terms (no specific emotions or emotion scheme elements) (n=5)
2. Remaining events (n = 35) involved additional information about emotions (described in further analyses)
Domain II: Type of Emotion
A. Distressing emotions re: Client’s life/ problems (n= 22 clients)
1. Anxiety/Fear: (10)
-Nervous/anxious (4); Overwhelmed (2); Fear (4)
2. Sadness/Depression/emotional pain: (12)
-Sadness/hurt/isolation (8); Depression (5); Emotional pain (1)
3. Dislike/disappointment/frustration/anger (5)
-Anger/hate (2); Confused/frustrated (1); Dislike (1); Disappointed (mild) (1)
B. Positive (attachment) emotions re: Relationship with therapist (21)
1. Relieved/relaxed/refreshed/comfortable/less overwhelmed/ unguarded: (9)
2. Secure/safe/trusting/grateful: (7)
3. Generally Good: (7)
-Hopeful (3); Globally positive: It feels good (4)
4. Understood/Validated/in rapport with therapist: (5)
-Understood (3); Validated/affirmed/cared for (1); Sense of rapport with therapist (1)
C. Other emotions: (2)
-Surprise (1); Avoidant comfort (1)
Domain III: Emotion regulation processes
A. Soothing/Containing/distancing (n=16)
1. Relational soothing (5):
a. being listened to/understood (2)
b. being (re)assured (1)
c. being validated/affirmed (1)
d. sense of rapport (1)
-160: To confirm a “rapport” with the therapist-that the likelihood is strong that progress and “personal” revelations will result over time
2. Venting/expressing (4):
-06: venting
3. Distancing/“extracting” uncomfortable emotion (3):
-24: Being able to “empty” all my feelings. I can put all my feelings aside and feel safe and comfortable doing it.
4. Focusing on positive aspects (1):
-67: Focusing on the positive aspects of my life. Getting positive reinforcement from my therapist.
5. Planning strategy for controlling emotions (2):
-143: When I talked about knowing that I have to take control of my own feelings (writing a journal).
6. Dissolving sources of distress (1):
-63: Dissolving some reasons for sadness.
B. Hindering Loss of regulation/unhelpful accessing (3):
1. Difficult realization (1):
-39: Realizing how frightened I am to be an adult [help neutral]
2. Stuck in distressing feelings (1):
-147: what do you do for a child trapped in a closet, alone fearing for her life?… but my feelings got “stuck” there
3. Continuing confusion/frustration (1):
-54: I was confused throughout the whole session, frustrated.
Domain IV. Emotion Scheme elements
-Emotion Scheme Model; Elliott et al., 2004
A. Perceptual-situational: [referent of emotion]
1. Life situation (14)
-51: I have been on the outside of the World looking in. She made a direct connection to my feelings of isolation and understood it.
2. Therapy context:
-11: She’s trying to understand what I’m going through and this makes me feel secure.
3. Research context:
-52: The pre-session form I filled out stated my problems in print this surprised me.
B. Bodily-Expressive: [How emotion is experienced or expressed in the body] (7)
1. Decreased bodily tension (3)
-14: Relaxing, cool, relieved
2. Crying (3)
-21: I don’t like to cry.
3. Panic sensations:
-147: I spoke about feeling trapped in my body, scared, fear not being able to breathe,
C. Verbal-Symbolic: [What the person thinks, says to themselves in accompaniment with the emotion; how they picture or classify self]
1. Cognitive/thinking errors (1):
2. Powerful mental image (2):
3. Verbalized thoughts (2)
-165: I don’t believe anyone would/should stand by me during my months of depression
4. Internal emotion attribution: Seeing self as responsible for one’s own emotions:
D. Action tendency [Actions, wishes, needs generated by and thus seeming to come from the emotion] (14)
1. Express/vent/get out in the open: (8)
2. Open self to other, let guard down (2)
3. Be free, move out into the world/contemplate possible action: (3)
4. Withdraw: (1)
E. Action tendency: toward [Actions, wishes, needs generated in response to or back toward the emotion] (12)
1. Approach/accessing:
a. Searching (for) emotions: (2)
b. Insight/realization/awareness of an emotion process: (5)
2. Distancing/containing: (6)
a. Setting aside/emptying/extracting emotions/pushing emotions away: (3)
b. Hiding emotions from others: (2)
F. Consequences of emotional expression or work (7):
1. Absence of expected negative response from other (2)
2. Relief (4)
3. Get stuck/stay with painful experience (1)
-147: ...what do you do for a child trapped in a closet, alone fearing for her life? …but my feelings got “stuck” there.
Domain V: Folk Concepts for Emotions
A. Problematic/Hindering aspects/processes re: emotions (7):
1. Emotion expression can be problematic (3)
a. Emotional expression is interpersonally risky (2)
b. Expressing distressing emotions burdens others (1)
2. Emotional experiencing can be problematic (4):
a. Uncontrolled/stuck emotions cause problems (2)
b. Being confused and frustrated is not helpful (1)
c. Unwanted emotional pain is unhelpful(1)
3. Hiding or pushing away emotions can cause you problems:
B. Folk theories of helpful processes re: emotions:
1. Managing/containing emotions can be helpful (5):
a. Distance from distressing/overwhelming emotions can be helpful (1)
b. Controlling one’s emotions can be helpful (1)
c. Emotions are things that can the removed or separated from other things (2)
d. Focusing on the positive can be helpful (1)
2. Approaching/accessing emotions can be helpful (10):
a. It is helpful to express emotions (venting) (8)
b. Emotions are hidden things to be carefully sought after (1)
c. It is helpful to sort out true emotions from false ones (1)
d. Emotion access can be life-changing (1)
3. Understanding emotions can be helpful (6)
a. Feeling unblamed for distressing emotions can be helpful (1)
4. The therapeutic relationship is important for helping clients work with their emotions (7):
a. The therapist’s acceptance of emotional expression is helpful (1)
b. Being able to trust/have rapport with the therapist is helpful (3)
c. The therapist’s non-negative response to one’s emotions is helpful (3)
C. Causal concepts involving emotions: (9)
1. Emotions are normal, common effects caused by events (6)
-30: It feels good having another human being understand my experiences
2. Emotions can be causes of symptomatic behavior: (2)
-39: It made me feel like crying.
3. Emotions have reasons: (1)
-63: Dissolving some reasons for sadness. I found that there were reasons you were depressed.
IV. Conclusions:
1. At first, it appeared that emotion processes were not particularly prevalent in session 1 HATs
2. However, by learning to look carefully at implicit meaning, found substantial emotion talk, in about 75% of accounts
3. Types of emotion talk in session 1 HAT were quite complex, covering the range of PE-EFT emotion theory, and in addition explicating clients’ folk theories about emotion and emotion work
4. Emotion processes and relational processes turned out to be more closely connected than we had anticipated.
5. Types of emotion reveal balance between
-Distressing emotions about clients’ lives and problems brought into first sessions and
-Attachment-related emotions emerging in early alliance formation
-Illustrates the central work vs. relationship dialectic in therapy, played out by on the stage of human emotions
6. The method and findings appear to be promising and merit further exploration
7. Raises many unanswered questions:
-Specific to Emotion-focused Therapy?
-Specific to first sessions?
-How do relational and emotion process connect to each other?
-Gender differences in how men and women describe significant events in general, and emotion more specifically?
-Relationships between types of HAT emotion talk and alliance; therapy incompletion; outcome, etc.?
Individualized Reliable Change using the Personal Questionnaire
Entry for 1 April 2008:
Reliable change is defined as change beyond the error of measurement on the instrument being used to assess outcome. It is calculated by a formula popularized by Neil Jacobson in the 1980’s, and based on the outcome measure’s reliability and standard deviation. This yields a Reliable Change Index (RCI), which tells how much client change on a measure is enough to conclude that the client has really changed.
The trickiest thing about calculating RCI is figuring out which estimate of reliability to use.
1. First, it should be reliability that is relevant to the question addressed, i.e., change across time, that is test-retest reliability. Internal reliabilities (among items, commonly calculated using Cronbach alphas) are sometimes used, but this is cheating, especially given that internal reliabilities are usually larger.
2. This leaves open the question of what kind of test-reliability estimate is best to use. Pre-post correlations comparing client pre-therapy scores to their post-therapy scores aren’t ideal because the whole point of therapy is to help the client to change their normal trajectory. If therapy were perfect in addressing client problems, highly distressed clients would change more and less distressed clients would change less (simply because they have less room to change); this would yield a zero pre-post correlation. Therefore, change over a period outside of therapy is generally preferred, i.e., the correlation between client intake and client pre-therapy scores (there is usually a delay between intake and starting therapy).
3. Of course, all of this leaves aside the very really possibility that clients differ in the consistency of their scores over time, with some clients being more consistent than others. It is perfectly obvious from tracking client weekly change that clients vary widely in this: Some clients show a consistent downward slope, while others’ scores bounce up and down wildly. Using weekly change measures, such as the Personal Questionnaire, provides an interesting alternative strategy for estimating temporal consistency: time series analysis or ARIMA (i.e., Autoregressive Integrated Moving Average; aren't you sorry you asked...) modelling, a method developed by economists to model changes in unemployment and so on. Here, we correlate each week’s score with that of the next week: time t with time t + 1 (i.e., session 1 with session 2, session 2 with session 3 and so on). This yields a what is called an autocorrelation (a correlation of a variable with itself, displaced in time).
In time series analysis, the non-random components of the time series are measured and modelled in order to carry out proper significance tests. These components include general change over time (referred to as “secular trend”), autocorrelation (after removing secular trend, if present, by calculating differences between successive scores), and autocorrelated error (carry-over of variability from one time to the next). This is one of the most technical, obscure research methods I know (and I’ve learned some doozies in my time…) However, for estimating consistency of weekly scores, I'm thinking a simple autocorrelation should do the trick.
As long as a client has at least 10 sessions or so (20+ is ideal), using autocorrelations would allow us to estimate RCI values on an individualized basis. For example, client PE-111, a client with a bridge phobia who I saw in the CSEP-1 (Centre for the Study of Experiential Psychotherapies Study 1) project, had a session-to-session (lag 1) autocorrelation of .37, and a standard deviation of .34. both values fairly low, but consistent with the high, fairly stable scores he showed over most of his therapy. These values yield RCI values of .75 points (on a 7-point scale) at a probability of p < .05 and of .5 points at a probability of p < .2. This means that this client would have to show at least half a point of change for us to be reasonably confident that he’d shown change over time (including from week-to-week), or three-quarters of a point for us to be almost certain that he had shown change. By contrast, for the client I am currently seeing our social anxiety research protocol, with a similar test-retest reliability and a standard deviation twice as large, the corresponding values are correspondingly larger: .99 and 1.50.
This is another example of how our conventional ways of calculating statistics are based on general assumptions that make relatively little sense when applied to individual clients, and point to the importance of individualized research methods.
Reliable change is defined as change beyond the error of measurement on the instrument being used to assess outcome. It is calculated by a formula popularized by Neil Jacobson in the 1980’s, and based on the outcome measure’s reliability and standard deviation. This yields a Reliable Change Index (RCI), which tells how much client change on a measure is enough to conclude that the client has really changed.
The trickiest thing about calculating RCI is figuring out which estimate of reliability to use.
1. First, it should be reliability that is relevant to the question addressed, i.e., change across time, that is test-retest reliability. Internal reliabilities (among items, commonly calculated using Cronbach alphas) are sometimes used, but this is cheating, especially given that internal reliabilities are usually larger.
2. This leaves open the question of what kind of test-reliability estimate is best to use. Pre-post correlations comparing client pre-therapy scores to their post-therapy scores aren’t ideal because the whole point of therapy is to help the client to change their normal trajectory. If therapy were perfect in addressing client problems, highly distressed clients would change more and less distressed clients would change less (simply because they have less room to change); this would yield a zero pre-post correlation. Therefore, change over a period outside of therapy is generally preferred, i.e., the correlation between client intake and client pre-therapy scores (there is usually a delay between intake and starting therapy).
3. Of course, all of this leaves aside the very really possibility that clients differ in the consistency of their scores over time, with some clients being more consistent than others. It is perfectly obvious from tracking client weekly change that clients vary widely in this: Some clients show a consistent downward slope, while others’ scores bounce up and down wildly. Using weekly change measures, such as the Personal Questionnaire, provides an interesting alternative strategy for estimating temporal consistency: time series analysis or ARIMA (i.e., Autoregressive Integrated Moving Average; aren't you sorry you asked...) modelling, a method developed by economists to model changes in unemployment and so on. Here, we correlate each week’s score with that of the next week: time t with time t + 1 (i.e., session 1 with session 2, session 2 with session 3 and so on). This yields a what is called an autocorrelation (a correlation of a variable with itself, displaced in time).
In time series analysis, the non-random components of the time series are measured and modelled in order to carry out proper significance tests. These components include general change over time (referred to as “secular trend”), autocorrelation (after removing secular trend, if present, by calculating differences between successive scores), and autocorrelated error (carry-over of variability from one time to the next). This is one of the most technical, obscure research methods I know (and I’ve learned some doozies in my time…) However, for estimating consistency of weekly scores, I'm thinking a simple autocorrelation should do the trick.
As long as a client has at least 10 sessions or so (20+ is ideal), using autocorrelations would allow us to estimate RCI values on an individualized basis. For example, client PE-111, a client with a bridge phobia who I saw in the CSEP-1 (Centre for the Study of Experiential Psychotherapies Study 1) project, had a session-to-session (lag 1) autocorrelation of .37, and a standard deviation of .34. both values fairly low, but consistent with the high, fairly stable scores he showed over most of his therapy. These values yield RCI values of .75 points (on a 7-point scale) at a probability of p < .05 and of .5 points at a probability of p < .2. This means that this client would have to show at least half a point of change for us to be reasonably confident that he’d shown change over time (including from week-to-week), or three-quarters of a point for us to be almost certain that he had shown change. By contrast, for the client I am currently seeing our social anxiety research protocol, with a similar test-retest reliability and a standard deviation twice as large, the corresponding values are correspondingly larger: .99 and 1.50.
This is another example of how our conventional ways of calculating statistics are based on general assumptions that make relatively little sense when applied to individual clients, and point to the importance of individualized research methods.
Saturday, April 05, 2008
Humanistic-Person-Centred-Experiential Therapy Expert Reference Group Meeting in London
Entry for 30 March 2008:
On Friday week before last a colleague and I flew down to London for the second installment of the expert reference group on what I will call for now “our kind of therapies”. This was the first official meeting, since the previous meeting at the end of January, which I previously described in this blog. At that time, after much discussion, the name we came up with was “Person-centred/Experiential”. When word of this particular branding reached the Humanistic and Integrative Psychotherapies Section (HIPS) of the UKCP (the UK Council of Psychotherapies), various people were most unhappy, resulting in my being grilled by Roger Cleminson at the UKCP Research Conference I presented at in early February. Then, a few days before the expert reference group meeting, we received a communication, from Vanja Orlans and Maria Gilbert from the Metanoia Institute in London, on behalf of UKCP, strongly objecting to our branding as too restrictive.
London City Airport. Our early morning flight into London City Airport, in East London ended with a harrowing, bumpy landing on its tiny runaway right next to the Thames. After we had braked to the stop just short of going into the river, our plane did a 180 degree turned and taxied briskly back along the runaway until we turned in to our gate, grateful that no one had decided to land on top of us.
Following Others onto the Train. After this nerve wracking but whacky arrival, we came out of the gate area into the terminal, whereupon my colleague started running for the escalator. I followed at pace, chasing after him onto what looked like an inter-terminal shuttle train, as is common in US airports. However, as soon as the doors had shut behind us and the trained started off, I looked up to see a sign saying that there was a £50 fine for travelling without a ticket on the train – now revealed to be the new Docklands Light Rail service. When I pointed this out to my colleague, he indicated that he thought I was over-reacting (a view apparently shared by the others at our later meeting at University College London); nevertheless, I wasn't comfortable with the situation and got off at the next stop to purchase a ticket, while he went on without me. (Ironically, when I got down to the ticket gate and saw the Oyster point, I realized that I had been legal after all, by virtue of my Oyster card.)
This incident has subsequently become a metaphor for me. Since I arrived at Strathclyde 18 months ago, I have following other people onto several trains: The Counselling Diploma course, the MSc course, the Social Anxiety project, chairing the Management Team, and most tellingly, the new Counselling Psychology course, whose research supervision load I have finally realized is totally unsustainable for me. Some of these and other trains are good ones for, for which I have the appropriate resources (tickets); others are not. From now on, I resolved, I will need to judge the nature and amount of work that I am going to take on.
Expert reference Group. So we arrived at the meeting on Friday morning to find that Vanja Orlans had been added to the Expert Reference Group (ERG), along with my old friend Germain Lietaer from KU Leuven in Belgium, and Andy Hill and Alison Brettle, the two folks who are going to go through the therapy manuals and extract the competencies.
Tony started by reviewing the process of the ERG for the newcomers, then we launched in the Matter of the Name: Vanja presented UKCP’s position, that “Person-Centred/Experiential” is too narrow and excludes most of her constituents, roughly 2500 therapists in the Humanistic and Integrative section of UKCP, including Gestalt therapists. Vanja had a difficult task, joining a group that had already started, in order to change its direction. She presented her case with some grace and passion. Finally, compromises were proposed and after much discussion we agreed to “Humanistic-Person-Centred-Experiential” therapy, a somewhat inelegant but practical compromise.
A Chainsaw for Stiles et al. After lunch, we, or rather Steve Pilling ran through my scoping document, organizing therapies for different client groups characterized by 2 or more controlled studies with something like a manual. The result was not pretty; it felt like Steve was a chainsaw cutting through the literature that Beth and I had been collecting. He casually dismissed the two enormous Stiles et al. studies, which I had characterized as “RCT equivalents”, using David Clarke’s argument that the data were too selective. That is, he claimed that therapists had selected their best outcome cases to submit, as if this was an established fact about the studies and as if this would somehow explain the lack of any differences among the person-centred, psychodynamic and CBt therapists in these studies. Apparently in his reference group this is what is considered to be reality, in spite of the fact that it would require an unparsimonous collection of factors operating differentially among the different groups of therapists. Apparently, they believe -- without any proof whatsoever -- that the CBT therapists submitted all their cases, while the person-centred therapists only submitted their successes! This is the kind of logic that in my experience follows from an unfalsifiable conviction that one's opinion must be correct, even in the face of contradictory evidence.
Steve and Tony admitted at lunch that RCT-associated therapy manuals are not really fit for purpose for identifying change processes; they indicated that this is a piece of methodological sloppiness that they are willing to live with, for the sake of being able to use the RCT data. Interestingly, a week later, at BPS in Dublin, Tony did admit that this logic is a “sleight of hand”, apparently hoping to charm the audience into buying the trick by coyly admitting to it. Hmm… this certainly sounds like a double standard to me. Accepting Stiles et al., as equivalent to an RCT seems like a lot less of a stretch than using therapy manuals used in RCTs as evidence for change processes.
The upshot of the application of Steve's chainsaw to the data set was not pretty. Nevertheless, Person-centred and PE-EFT were admitted to the list for extracting competencies from therapy manuals, for clients generally, but not for specific client problems. Again, I thought that this was weird, because of the PE-EFT depression evidence and also for having been recognized by the APA Division 12 Task Force. And they wouldn’t buy PE-EFT for trauma, because it wasn’t focused on PTSD. Catherine, our carer advocate on the ERG was most unhappy that Pre-therapy wasn’t admitted, but we will keep trying to find a way to include it with Person-Centred therapy. Gestalt was left up in the air, and really needs Beth and I to dig up some more RCTs.
Nevertheless, in spite of the less than satisfying handling of several clusters, we all ended up feeling as if we had made real progress over the day’s discussions, and that we had a basis for going forward.
On Friday week before last a colleague and I flew down to London for the second installment of the expert reference group on what I will call for now “our kind of therapies”. This was the first official meeting, since the previous meeting at the end of January, which I previously described in this blog. At that time, after much discussion, the name we came up with was “Person-centred/Experiential”. When word of this particular branding reached the Humanistic and Integrative Psychotherapies Section (HIPS) of the UKCP (the UK Council of Psychotherapies), various people were most unhappy, resulting in my being grilled by Roger Cleminson at the UKCP Research Conference I presented at in early February. Then, a few days before the expert reference group meeting, we received a communication, from Vanja Orlans and Maria Gilbert from the Metanoia Institute in London, on behalf of UKCP, strongly objecting to our branding as too restrictive.
London City Airport. Our early morning flight into London City Airport, in East London ended with a harrowing, bumpy landing on its tiny runaway right next to the Thames. After we had braked to the stop just short of going into the river, our plane did a 180 degree turned and taxied briskly back along the runaway until we turned in to our gate, grateful that no one had decided to land on top of us.
Following Others onto the Train. After this nerve wracking but whacky arrival, we came out of the gate area into the terminal, whereupon my colleague started running for the escalator. I followed at pace, chasing after him onto what looked like an inter-terminal shuttle train, as is common in US airports. However, as soon as the doors had shut behind us and the trained started off, I looked up to see a sign saying that there was a £50 fine for travelling without a ticket on the train – now revealed to be the new Docklands Light Rail service. When I pointed this out to my colleague, he indicated that he thought I was over-reacting (a view apparently shared by the others at our later meeting at University College London); nevertheless, I wasn't comfortable with the situation and got off at the next stop to purchase a ticket, while he went on without me. (Ironically, when I got down to the ticket gate and saw the Oyster point, I realized that I had been legal after all, by virtue of my Oyster card.)
This incident has subsequently become a metaphor for me. Since I arrived at Strathclyde 18 months ago, I have following other people onto several trains: The Counselling Diploma course, the MSc course, the Social Anxiety project, chairing the Management Team, and most tellingly, the new Counselling Psychology course, whose research supervision load I have finally realized is totally unsustainable for me. Some of these and other trains are good ones for, for which I have the appropriate resources (tickets); others are not. From now on, I resolved, I will need to judge the nature and amount of work that I am going to take on.
Expert reference Group. So we arrived at the meeting on Friday morning to find that Vanja Orlans had been added to the Expert Reference Group (ERG), along with my old friend Germain Lietaer from KU Leuven in Belgium, and Andy Hill and Alison Brettle, the two folks who are going to go through the therapy manuals and extract the competencies.
Tony started by reviewing the process of the ERG for the newcomers, then we launched in the Matter of the Name: Vanja presented UKCP’s position, that “Person-Centred/Experiential” is too narrow and excludes most of her constituents, roughly 2500 therapists in the Humanistic and Integrative section of UKCP, including Gestalt therapists. Vanja had a difficult task, joining a group that had already started, in order to change its direction. She presented her case with some grace and passion. Finally, compromises were proposed and after much discussion we agreed to “Humanistic-Person-Centred-Experiential” therapy, a somewhat inelegant but practical compromise.
A Chainsaw for Stiles et al. After lunch, we, or rather Steve Pilling ran through my scoping document, organizing therapies for different client groups characterized by 2 or more controlled studies with something like a manual. The result was not pretty; it felt like Steve was a chainsaw cutting through the literature that Beth and I had been collecting. He casually dismissed the two enormous Stiles et al. studies, which I had characterized as “RCT equivalents”, using David Clarke’s argument that the data were too selective. That is, he claimed that therapists had selected their best outcome cases to submit, as if this was an established fact about the studies and as if this would somehow explain the lack of any differences among the person-centred, psychodynamic and CBt therapists in these studies. Apparently in his reference group this is what is considered to be reality, in spite of the fact that it would require an unparsimonous collection of factors operating differentially among the different groups of therapists. Apparently, they believe -- without any proof whatsoever -- that the CBT therapists submitted all their cases, while the person-centred therapists only submitted their successes! This is the kind of logic that in my experience follows from an unfalsifiable conviction that one's opinion must be correct, even in the face of contradictory evidence.
Steve and Tony admitted at lunch that RCT-associated therapy manuals are not really fit for purpose for identifying change processes; they indicated that this is a piece of methodological sloppiness that they are willing to live with, for the sake of being able to use the RCT data. Interestingly, a week later, at BPS in Dublin, Tony did admit that this logic is a “sleight of hand”, apparently hoping to charm the audience into buying the trick by coyly admitting to it. Hmm… this certainly sounds like a double standard to me. Accepting Stiles et al., as equivalent to an RCT seems like a lot less of a stretch than using therapy manuals used in RCTs as evidence for change processes.
The upshot of the application of Steve's chainsaw to the data set was not pretty. Nevertheless, Person-centred and PE-EFT were admitted to the list for extracting competencies from therapy manuals, for clients generally, but not for specific client problems. Again, I thought that this was weird, because of the PE-EFT depression evidence and also for having been recognized by the APA Division 12 Task Force. And they wouldn’t buy PE-EFT for trauma, because it wasn’t focused on PTSD. Catherine, our carer advocate on the ERG was most unhappy that Pre-therapy wasn’t admitted, but we will keep trying to find a way to include it with Person-Centred therapy. Gestalt was left up in the air, and really needs Beth and I to dig up some more RCTs.
Nevertheless, in spite of the less than satisfying handling of several clusters, we all ended up feeling as if we had made real progress over the day’s discussions, and that we had a basis for going forward.
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