New Litany for Running

Entry for 27 September 2008:

While I‘m out running, I have a little litany or prayer that I have been doing for many years (since about the time I turned 50, actually). The basic form starts like this:

Lady of the Universe,
You hold all things in your hands,
You hold each of us in your hands;
I ask you to hold ____ in your hands.

In the blank, I insert the name of various people for whom I have some concern: a family member, a client, a colleague, one of my children, and usually myself. I then imagine this person surrounded by light.

Then I continue with the second part, which I usually reach in the last few minutes of my run:

Lady of the Universe,
I don’t know where I came from before I was born,
And I don’t know what will happen to me when I die.
As far as I know, I come from nothing,
And when I die, I go to nothing.

Therefore, every moment is a gift,
every day is a gift,
every month is a gift,
every year is a gift,
and my life, my ___ years are gift.

Over the years, this little litany has helped me face and acknowledge my fear of death, which has largely dissolved in the face of this “radical acceptance” (to use Ann Weiser Cornell’s memorable phrase).

However, in past few years, the meaning of the “I” in “I don’t know where I came from, etc” has shifted to something closer to: “the small, limited part of me that calls itself ‘I’ die”. And usually when I get to this part of the litany, something in me answers back that it doesn’t really buy this anymore.

This is because this something in me has really come to believe something closer to:

Lady of the Universe,
I know that I come out of all that has gone before me,
And that all this continues to live in me,
In the same way that I will still continue to live,
as part of the pattern everything around me,
Living in all those I’ve known
and touched in some way.

This is the gift of this day, this moment,
this year and this life,
and is to be treasured and rejoiced in … forever.

This is what feels true to me know, and what gives me a sense of peace and acceptance. So last Saturday, coming back from a long, nearly 8-mile run, on a lovely late September Glasgow morning, I decided that it is time for a new version of my Running Litany, along the lines suggested. I’m not sure I’ve got the words exactly right, but it’s a start, which I plan to try out over the next couple of weeks.

HPCE Expert Reference Group, Part 5

Entry for 19 September

1. Heisenberg’s Uncertainty Principle Applied to Blogged ERG Proceedings. Possibly the most closely followed of my blog entries has been the series of pieces I’ve written on the Skills for Health project Mick and I have been involved in since last January. The Humanistic-Person-Centred-Experiential Expert Reference Group (HPCE-ERG), as it has come to be called, has been controversial from the beginning. I have documented some of this, and of course in my early entries I have been fairly critical of the methods being used, and in particular the excessive reliance on RCTs as the ultimate arbiter of what would be included or not. Although I still have some misgivings, I’ve been impressed over time by the quality of the discussions and the opportunity for dialog, as well as what is beginning to emerge from the process.

The amusing thing is that it turns out that Tony Roth and Steve Pilling have been following these blog entries, so that the process of blog-observing the HPCE ERG meetings has altered them. At one point at the meeting this past Monday, Tony turned to Steve and told him to put down his chainsaw, a reference to a metaphor I used in my pieces on the March and June meetings. And at the end of the meeting, Tony said he was looking forward to hearing about the meeting in the blogosphere. So here I am, called back from my Blog Block by colleagues whom I’d criticized earlier, and I am left not wanting to disappoint them.

2. Steady progress on the competency framework. Thanks to Alison and Andy’s efforts, the HPCE competence framework is continuing to shape up. The overall, top-level framework, a one-page summary overview chart, looks to me to be in good shape, and the detailed list underneath it is progressing. We spent most of our time going over sections of the latter, trying to flesh it out more concretely, paying particular attention to theory-knowledge competence, which required spelling out what the essential elements of the theory are, and elements of the relational competence. For example, how do you describe what the therapist does to foster “collaborative contact”? Should “presence” be developed as a competence beyond or in addition to the three facilitative conditions? These discussions have been stimulating, fun, collaborative and illuminating.

3. Continued Scoping: Steve and I reported back to the group the results of our continued attempts to scope out data that might warrant including Gestalt and Psychodrama. Back in July, I made another attempt to pull something out of the Gestalt and Psychodrama literatures, which was the basis for a teleconference among Tony, Steve and I. Alas, our efforts were in vain; we are unable to find more than a single decent RCT for one client group for either of these approaches, and for now Gestalt and Psychodrama will continue to languish in the margins of the competence process, as what I am going to refer to below as Ghost Entries.

4. UKCP’s Dilemma: A Modest Proposal. Because of my aversion to flying within the UK, I again arrived 90 minutes into our latest meeting. I had missed a difficult discussion between Vanja Orlans, who again had been saddled with the thankless task of conveying to the group a Bill of Complaint from UKCP. Representatives of the latter had had another meeting with Lord Alderdice and Peter Fonagy, from my point of view trying to accomplish with lobbying what they didn’t have the data to support. By the time I got there, the difficult discussion was done and it was almost time for lunch. I felt somewhat guilty for having missed the experience, but also relieved. However, I did not entirely escape the controversy: Tony gave me a summary, and at the end of the day Vanja stayed on for a bit after, and she, Tony and I went over some of the arguments again. Vanja was frustrated with me for not having been there in the morning to support her position, but the problem was that I had by now gone over to the Dark Side and was prepared offer qualified support for the HPCE ERG project, warts and all.

I have very mixed feelings about the series of complaints that UKCP has lodged against the HPCE ERG process since it began. My very first impression was that they had been caught trying to pull a fast one at the very beginning, having persuaded the Skills for Health folks that Humanistic and Integrative Psychotherapy was a meaningful, conceptually coherent theoretical orientation on the same order as CBT or Psychodynamic psychotherapy. This struck me then and continues to strike me today as an attempt to dress up, in nice scientific and professional clothing, a political compromise by which a collection of humanistic and various other therapists banded together to increase their clout.

Historically, as I now understand it, a body of training, practice and philosophy has by now grown up around this compromise, and I have been impressed by the position that Vanja has put forward. Nevertheless, there are several problems with integrative psychotherapy as a basis for a competency framework: (1) The list of therapies involved is a long and variegated one (which includes Process-Experiential/Emotion-Focused Therapy as well as Cognitive Analytic Therapy), with little in common except that they don’t fit anywhere else. (2) The research basis for this group of therapies is fairly poor, so that it provides little grist for the ERG process Steve and Tony have set up. Even if Steve and Tony’s inclusion rules were relaxed somewhat, there still wouldn’t be much. (3) Unlike PE-EFT, this approach to integrative therapy runs beyond the confines of humanistic therapy, to psychodynamic approaches in particular; so it really cuts across theoretical modalities, creating an inherent difficulty for a modality-based competency approach, and threatening to break the process even if it were to be tried.

But where does this leave us? As I have come to understand it, what Vanja and her colleagues at Metanoia are trying to do with their formulation of a personalized integration approach is admirable, makes sense, and is a Good Thing. I did the same thing at the University of Toledo, but certainly without as much intellectual rigor: The idea is that each student should, through a careful, self-reflective process, develop their own personal integration, building on systematic exposure to multiple theoretical modalities. However, this doesn’t make sense to me as a basis for a competency framework; in fact, given the assumptions of the approach, it should be impossible, or at least seriously unwise, to do so.

Instead, if you are going to integrate humanistic with other therapies, the thing to do is to use multiple competence frameworks from which to draw one’s personal integration. When they are completed, the various competence frameworks now being developed will provide a valuable tool for this process. The ERG competence process is the not the enemy of Humanistic and Integrative Psychotherapy (HIPS), but its helpmate. In fact, this appears to be exactly what Lord Alderdice and Peter Fonagy have recommended to them. Let UKCP’s HIPS section proclaim superiority by owning all the frameworks!

5. Ghost Entries: More Modest Proposals. As noted, Focusing, Pre-therapy, Gestalt and Psychodrama all fall within the HPCE camp, but because of their lack of RCTs (or even, I would say, RCT-equivalents) and therapy manuals, they remain the equivalent of Brown Dwarfs in the evidence-based therapy firmament, their Dark Matter exerting a strong gravitational force, without the visibility they desire. In the emerging HPCE competence framework, they are the Ghost Entries in the Specific HPCE Adaptations column: their proper place is alongside PE-EFT, currently the sole visible inhabitant of that region of the framework.

Given that the Ghost Entries belong in the framework but currently lack the evidence base to qualify formally, what should they do? I have two suggestions:

(1) Jump-starting research. First, they need to start doing systematic, well-designed, focused research on key client populations. Below, I use Pre-therapy as an example of what I’m talking about. It is important to recognize the possibility that some of the ghost therapies are not going to turn out to be as effective for particular client groups as they might have hoped. The psychotherapy field of full of treatments that people swore worked but turned out not to really be effective, at least not without significant further adaptation.
(2) Open-Sourcing the ERG Process. Second, rather than bemoaning their exclusion from the competence framework, they should go ahead and actually create their own Ghost Entries for the framework (or if you prefer a more political metaphor, they should create shadow cabinets). That is, they should use the methods that Alison and Andy are using to generate the Specific HPCE Adaptation competences for Process-Experiential Therapy. Actually, these haven’t been done yet, but they will be in the next couple of months, but once they are drafted, they will provide a template for other specific adaptations, like Psychodrama, Gestalt, etc, to use. These Ghost or Shadow Competence HPCE Adaptation modules can be offered as a supplement to the official HPCE framework, and can also be used to support research, as in my first suggestion.

6. How to get Pre-Therapy on the Map. Every meeting, Catherine Clarke, our caregiver member, makes an impassioned plea for the inclusion of Pre-therapy. Pre-therapy, developed by Gary Prouty for work with clients who are out of contact because of a psychotic process, is another of our highly-promising Ghost Entries and one whose practice is spreading rapidly in the UK, but is presently excluded because it lacks a strong research base. Catherine has seen how effective Pre-therapy was for her son, and also how ineffective other approaches have been; she is also aware of the harm being done by over-medicating people living with psychotic processes, so she takes the omission of Pre-therapy personally. Every meeting we listen to her, and I say that the Pre-therapy folks need to start doing more research, but somehow this isn’t enough. At this week’s meeting, it was clear that she was feeling fairly discouraged, and so I said that I would offer some suggestions for a strategy forward. So here is what I am proposing to the Pre-therapy Network:

(1) Pretherapy practitioners need to form a Practitioner Research Network (PRN) to develop controlled collaborative research using a shared research protocol. No one is going to do this research for you; you will have to do it yourselves! Wendy Traynor has just spent the past year developing such a research protocol, and is willing to act as a consultant for the project. The Pre-therapy Network already exists and provides an existing basis for this kind of collaboration; it is exactly the kind of organizational structure that is needed to support a PRN.

(2) Study 1: After getting ethics approval (Wendy is about to submit her protocol to NHS Ethics) involves as many members of the network as possible to track one new client through a psychotic process using Pre-therapy, measuring process and outcome following Wendy’s protocol, using the HSCED method to analyze whether the client changed and whether therapy was responsible for the changes. Keep track of client outcome over the course of therapy, but evaluate intensively during episodes of psychotic process, so that Pre-therapy phases of therapy can be evaluated inside the longer course of therapy.

(3) This needs to be done from at least 5 – 10 clients, making a clinical case series of systematic case studies. Until you do this, you don’t have a clear sense of the generalizability of the results of the case study in Step 2 or of the older studies reviewed by Dekeyser et al. (2008)

(4) Study 2 is a controlled outcome study against Treatment as Usual, with randomization. This is can done using a cluster design: randomize pairs of clients in relevant agencies, one to receive treatment as usual, the other Pre-therapy.

(5) Study 3: A different group of pre-therapy researchers then replicates this study. Alternatively, you can use the infrastructure from the first set of studies to compare Pre-therapy to a different therapy, like CBT.

A similar stagewise process can be used for other therapies not currently included, but its important for them to focus on a key client group, such as depression or generalized anxiety, rather than doing scattershot studies that don’t cumulate.

The HPCE Expert Reference Group will continue to meet, for at least more meeting in November, and I'm looking forward to it already!

Blog Block

Entry for 16 September 2008:

I’ve found writing my blog increasingly difficult over the past few months. This blog started small, really at the request of my kids, who said to me two years ago, as we were leaving Toledo to move to Scotland, “Dad, you’ve got to start a blog, so we can keep up with what you and mom and doing!” So I started writing, for them, about our daily adventures fitting into our new life in Scotland, including our practice of Saturday Adventures. (To this day, my mom is my most faithful reader. Hi, Mom!)

Then, because a large part of the adventure and the strangeness was my work, I began to write out that as well. Somehow, word got out to my colleagues that I was keeping a blog (probably I told them), so some of them started reading the blog also. At some point, I told my students about the blog, so some of them started following it also, especially the entries about my adventures teaching, which were many and various. From time to time, a stranger, or an anonymous acquaintance posts a comment, when a search leads them to some relevant entry of mine. (Early on, I had to start moderating comments to prevent spammers form posting ads or garbage.) Finally, I began writing about the politics of Person-Centred/Experiential therapy in Scotland and the UK, and an even larger readership emerged.

Over time, however, with the accumulating, diverse audience and various things that came up, it has become increasingly complicated to write the blog. When I started to see clients, a year ago, a big portion of my creative energy got steered back to my client work, where I have, among other things, been developing ideas about working with social anxiety and couples work. Of course, it’s really difficult to write safe blogs about clinical work while protecting clients’ confidentiality, and it’s also possible one of my clients will read an entry about themselves or another client. So that had to go underground. Furthermore, not everyone has been happy about what I have written in the blog, and a couple of people have complained about what they read there. Blogs are supposed to be an informal, personal and spontaneous communication medium, but it’s so new that the social norms and etiquette are still emerging. The result was that some toes got stepped on, and more and more things haven’t felt safe to write about. With this, the blog has become less and less fun to do, because I have had to be more and more careful what I say. Instead of a creative outlet, I’ve felt squelched and have found it more and more difficult to write. One result is the safe little pieces about my publications, for example.

Hence, my relative silence over the past month, while various significant things have gone unmentioned: During our 4-week visit to the US, my mom fell and broke her foot while we were visiting her in Murray Creek. I flew to Boston for the Humanistic Psychology conference and American Psychological Association conference, where I received the Carl Rogers Award for Contributions to Humanistic Psychology and had a lovely, memorable visit with my famous, fun cousin Courtenay Harding. We moved Kenneth back to his dorm and said goodbye to Brendan and Mayumi as they prepared to leave Cleveland and move to Seattle, Washington. And we brought Diane’s mom, Gladys back to Glasgow with us for a two-week visit. Things started off intensely at work, which huge piles of work waiting for me, papers to grade, exam board, clients, students, ever-mounting pile of email, job interviews, courses starting in new configurations, various crises etc etc.

Part of the issue is that I’ve been run too ragged to write about it, but it is more than that: it wasn’t fun, and I didn’t have any long, unstructured trips during which to just sit and see what comes. I miss that. It's probably inevitable, but it does feel a bit like my running: If I'm too busy to carry on with it, then it means that my life is too busy and something needs to give, period!

How Do you Audit a Qualitative Analysis?

Entry for 15 September 2008:

Whenever I talk about qualitative data analysis, I make a point of arguing that auditing has become a standard of good practice in general and for supervision of students in particular. However, I am then asked for recommendations for how to carry out an audit of a qualitative analysis, and find that there is actually very little written on the procedure.

Here is an attempt to spell out the process qualitative analysis auditing:

1. Prepare complete analysis for auditing. First, the analysis must be presented in an auditable fashion. This involves assembling, in outline form, all the categories and, under each category, all the meaning units that fall under it. If one is using computer-based qualitative analysis management software, then the program much be capable of displaying categories and data in this fashion. (I could be wrong, but it’s not clear to me how to do this in the latest version of NVIVO; comments on how to do this would be appreciated.)

Once the analysis has been presented in this fashion, it is turned over to the auditor, who in many cases is the research supervisor. (In my view, this is a major component of the duties of the supervisor of a qualitative masters or doctoral dissertation.)

Auditing consists of two main activities, which I will refer to as Fine Tooth Combing (FTC) and Category Structure Checking (CSC). Ideally, the two activities are carried out in parallel, because each of them depends to a certain extent on the other. (This is yet another example of the inevitable Hermeneutic Circle.)

2. Fine-Tooth Combing (FTC) begins by reading all the examples under a particular category very carefully. It is possible to audit on the basis of a sample of 2 or 3 instances per category, but it is really better to have all the examples, which also helps with Category Structure Checking. My practice – particularly with large meaning units – is to mark (underline or highlight) the parts that fit the category. (This is because a given meaning unit may contain information for several different categories.)

I’m particularly interested in looking for bits that don't fit the category because they may belong somewhere else or may be askew from what is going on with the rest of the category. I’m also looking for subgroups of meaning units under the category that indicate the need to add a layer of subcategories, as when two closely-related but slightly different kinds of ideas are being expressed within a category. Then I check the labelling of the category to make sure it fits my felt sense of the meaning units under it (an example of David Rennie's concept of using your stomach or gut feeling in qualitative analysis); I’ll revise the category label as needed to make it fit. At other times, I will elaborate the description of the category to bring out the richness of the meaning units within it.

3. Category Structure Checking (CSC) goes on, as I said, in parallel to FTC, and I typically check for several things when I do this: First, I make sure the categories have a parallel structure so they look like different aspects of a related aspect. For example, it might be nice for all the category names to refer to activities, or properties, or be in gerund verb form. Second, I look for for redundant/overlapping categories, which would need to be collapsed and possibly reconceptualized. This is the essence of what is called the Constant Comparison method in Grounded Theory Analysis. Third, I check for situations where there are too many categories (i.e., more than about 4) at the same level and place in the analysis (see my Qualitative Analysis Secrets blog entry from November 2007). If I find subgroups (and I usually do), I will typically suggest subcategory names. Fourth, I check to see if there is a logical order or temporal flow to the categories, out of which a mini-narrative or sequence could be constructed to make the analysis more lively or descriptive of some sort of process.

If effect, then, I propose various revisions to the analysis; however, I regard all the suggestions I make in this process to be tentative alternatives to what the original analyst has done, so I try to make it clear to them that they are free to change anything back. For this reason, and also to make it clear where I’ve proposed changes to the analysis, I turn on Track Changes at the beginning of the audit review process. After all, the original analyst knows their data better than anyone else, since its their study and they generally did the interviews on which the analysis is based. For me, it's enough that the analyst hears another way of understanding at their data.

In addition to providing quality control on qualitative anlaysis and helping analysts stay true to the their data, this sort of auditing is a very useful training device, as it conveys several important principles of good qualitative analysis, lessons that are very difficult to convey any other way. I can harp all day about checking data against categories, or about domain structure, or about the Rule of Four, but until you see what these things look like in your data, I don’t think the idea really sinks in.