Elliott (2010). Psychotherapy Change Process Research: Realizing the Promise

Entry for 31 March 2010:

When I received the Distinguished Research Career Award from the Society for Psychotherapy Research in June 2008, it came with a catch: I had to produce a paper for SPR’s journal, Psychotherapy Research. Paulo Machado asked me in Barcelona shortly after I got the award, giving me what felt at the time like a generous deadline: Aug 1, 2009. I spent months wondering what I should write about; I even sounded Paulo and Clara out about using my long-neglected Adjudicated HSCED paper (Elliott et al., 2009) for this purpose, but was gently reminded that it had to be single-authored.

Somewhere around February or March 2009 I finally realized that the only logical thing was for me to write about Change Process Research (CPR), a topic close to my heart and one that has spanned my research career. By a strange piece of synchronicity, Madison, Wisconsin, provided a 30-year time loop encircling my interest in CPR: At the front end of the time loop, my scientific interest in CPR dates back to a fateful conversation that I had with Les Greenberg in 1977, as we drove to O’Hare Airport after that year’s SPR meeting in Madison, Wisconsin. At the other end of the time loop, I had given a plenary paper on CPR at the 2007 SPR meeting, which was once again in Madison. The Madison 2007 paper became the starting point for my senior career award paper.

Because my writing schedule is generally restricted these days to 20 minutes each morning, work on the paper proceed slowly, as the pressure from Paulo increased to produce the paper, as it turned out, earlier than the original deadline. April and May passed, with the paper being repeatedly pushed aside for other pressing writing projects, including final work on the adjudicated HSCED paper. I had promised Paulo something by the end of June; however, I arrived in Santiago de Chile in late June with only a fraction of the paper drafted.

Then I came down with the H1N1 or Swine Flu, which was pretty awful in itself, but turned out to be gift from heaven as far as my senior career CPR paper was concerned. First, I was quarantined in my hotel room for a week, so I had plenty of time to lay in bed with minimal distractions. Second, the doctor had given a timely dose of Tamiflu, which reduced the flu symptoms enough so that I actually had enough energy to work on the paper. As a result, I wrote most of the paper during the week after the Santiago SPR meeting.

The paper turned out to be a tour de force, a survey of the major approaches to CPR, featuring lots of references and examples. It felt big, and was an odd contrast to my situation at the time, living in the enforced role of an invalid while putting together a grand survey of the key approaches at the core of the most central focus of the psychotherapy research field. Nevertheless, thanks to the H1N1 virus, Tamiflu, and especially to Diane’s patient help, the paper got written and was submitted on the 3^rd of July.

See also January 18, 2010 entry on this blog for a previous excerpt from this article: Change Process Research on Relational Depth: The Added Paragraph

Reference:

Elliott, R. (2010). Psychotherapy Change Process Research: Realizing the Promise. Psychotherapy Research, 20, 123-135.

Abstract: Change process research (CPR) is the study of the processes by which change occurs in psychotherapy, and is a necessary complement to randomized clinical trials and other forms of efficacy research. In this article I describe and evaluate of four types of CPR. The first three are basic designs and include quantitative Process-Outcome, qualitative Helpful Factors, and micro-analytic Sequential Process; the fourth, the Significant Events approach, refers to methods such as Task Analysis and Comprehensive Process Analysis that integrate the first three. The strengths and weaknesses of each design are described and summarized using both causal and practical criteria, as part of an overall argument for systematic methodological pluralism.

Questions about EFT, Part 1 (Groningen, March 2010)

Entry from 6 March 2010:

I’ve been doing a lot of EFT training lately, and recently began asking participants to generate questions from skill practice sessions. On the last day of EFT Level 1b (= days 3 & 4 of Level 1) in Groningen last weekend, Jeanne Watson and I ran a long “Open Marker” skill practice session, in which participants were asked to first locate the client task and then to work with whatever it was. Afterwards, we asked them, “What questions do you have from the Open Marker Work Practice?” On this occasion, the participants came up with a particularly rich set of questions, which Anja typed into my computer so that everyone could see them. Finally, Jeanne and I tried to answer the questions, to the best of our ability, while Anja again recorded our answers. The following is an edited and elaborated version of those notes. (Many thanks to Jeanne Watson and Anja Rutten for their help in formulating and recording this material.)

A. On Two Chair Work:

1. How do you know when to suggest that my client switch chairs in 2 chair work?

(a) In general, when a request/demand/ultimatum is made, a place where in a regular two-person conversation you would naturally expect the other person to respond. You may feel this in your body.

(b) Jeanne points out an important time to change: When the client has expressed a primary adaptive feeling and the associated need, particularly when this is directed back to the other part. Then it’s important to see how the Critic responds to this, to see whether they are able to soften and begin negotiation. If not, then the client can go back to the Experiencer chair and talk about the experience of the critic not softening.

(c) It’s also useful to look at what the Critic (or Other in Empty Chair work) is doing, not just their content/words, thus move a bit beyond content in process. For example, acting dismissively, showing scorn in face, or sitting in a particular way, etc. The therapist can formulate this back to the client and help them heighten it (“Are you aware of look of scorn on your face? Can you do that some more?”).

(d) It’s also important to pay attention to the fact that clients sometimes change parts but not chairs, which can confuse things a lot. Pay attention to the manner and content of each part, so that you can hear if this happens then suggest that the client go over to the other chair and say it from that part.

(e) Finally, Jeanne notes that in 2 Chair Work, the two parts can sometimes get stuck in a pattern of ‘fight-fight’ that goes in circles and stays on the surface. Then, stopping the usual back and forward and helping the client to deepen one or the other part can be useful.

2. When you are working with 2 chairs and heightening Critic, how do you know when there is enough heightening?

(a) Remember that the Critic is your friend in the process, so often what we are doing is helping the client heighten their Critic until something “pops”. You can test this: Have the client try out a critical statement or repeat it, then switch and see what comes up in the Experiencer. If there is no response from Experiencing chair, then it is not enough. Also, you can use your own felt response as a test.

3. In Two chair work, when the client hesitates to switch chairs, when is it a good idea to address it and explore it with the client?

(a) It’s natural for clients to be hesitant about chair work, given that it is

so different from ordinary everyday processes. They generally think it’s crazy until they’ve tried it.

(b) At the same time, it’s always a good idea to pay attention to client hesitation in changing chairs, although once understood it is often OK to proceed anyway.

(b) Nevertheless, any serious hesitation requires therapeutic attention and exploration, and possibly alliance repair work.

4. What do I do with a collapsed Experiencer?

(a) Don’t panic! This is common and expectable part of working with conflict splits in depression, social anxiety etc.

(b) See Learning for a description of the Two Routes, via the critic or via the experiencer (sometimes both).

(c) Via the Critic: Ask: “What happened there? It looks like you were starting to do/say X, and then it just collapsed. That’s really interesting! Is that what happens?” Change chair task and look at how critic makes experiencer crumble by heightening the critic. Heightening critic can intensify the experience; for example, it may make the experiencer angry, so that they protest. It also is important to help the Critic see what s/he is doing to the experiencer.

(d) Via Experiencer: Client will be in a ‘collapsed experiencer’ state. Ask, “What is it like to experience that, what happens, can you stay with that?” Help the client deepen the Experiencer by responding empathically to the pain, then listen to experiencer in order to find their growth tendency and help them come up again, usually by asking them what they need/want, which helps them move toward action/self assertion. Clients with severe social anxiety may not have a strong enough sense of self, they may need help to build this.

5. A related question: What do you when the client in the chair of the harsh Critic displays tears/vulnerability? Do you stay with the strong criticism or the first sign of softening?

(a) It’s important to hear both things, to hear the critical message but also to ask what the tears are saying.

(b) It’s also important to find out if softening is in the Experiencer or Critic part.

(c) Remember to stay with the process and the client: The client is more important than the model.

B. Other Practice-oriented questions:

6. Can you change from one task to another and if so when?

(a) See Principle 5 in the Learning book for more on this issue. If a new, more central task emerges, it’s generally a good idea to switch to the more central task, e.g., from 2 chair to empty chair or vice versa.

(b) In addition, many different relationships can exist between different tasks, and markers often overlap. You can have tasks nested within tasks, such as doing a bit of Empty chair work within a Two Chair dialogue, or vice versa. Also, some tasks go nicely with others; for example, after the Meaning Bridge in Unfolding, it can make a lot of sense to switch to Two Chair Work to work on the broader issues, which typically involve a conflict between old and new ways of seeing things.

7. What do you do when you think the client is leaving something out/there is something missing?

There are really two different situations here:

(a) It’s easy if you think client knows it but isn’t saying it: Use empathic conjecture.

(b) However, it’s trickier if client really seems to be unaware of what you are seeing. Here there is a risk of ‘therapist cleverness’ disempowering the client, so you have to be very careful. Here are some suggestions for handling this situation:

•First, pay attention to your emotional attachment to your interpretation. Where is it coming from? Does it come from a need to feel clever? Does it come from a desire to help the client by giving them insight into their problems? Do I believe that insight is an important change process?

•Second, consider the advice that Laura Rice once gave me: Remind yourself that no matter how clever my interpretation is, the client’s own idiosyncratic self-understanding of what is going on will fit them better. The main problem with most therapist interpretations is that they are too simplistic.

•Third, take your interpretation and ask yourself: If I’m right about this, what would be in the client’s experience? Then offer an empathic conjecture about this experience. For example, with a transference link between the client’s experience of you and their parent, is there something about relating to me that feels familiar and old to them?

8. How do I help my client internalise/represent the work we have done with language or symbols?

(a) In general, make time to process the work at the end of the session, talking about what happened; eg, how harsh the critic is.

(b) It can be important for the client to remember/conceptualise some key words (like ‘handles’ in Focusing), to give sense of process they have come through. This often means distilling the key message, eg, with abused clients, ‘it wasn’t my fault’. Jeanne tells about a client who dreamed of a special creative place, which she came to understand as representing taking more care of self

(c) Offering awareness homework is also helpful here, suggesting that the client pay attention to a key feeling outside session. For example, Jeanne suggested at the end of the session to the client who had dreamed of the creative place, that her client try to ‘hold on to the memory of the place and the feeling she had experienced in there’.

(d) Jeanne points out that if there is real resolution, there is often no need to work at helping the client remember it, because work is done and they are already seeing and experiencing in a new way, which will establish itself.

(e) So internalizing work is probably most useful and common in work that is half way, where the client can see ‘light at the end of the tunnel’ but isn’t there yet. Helping the client symbolize what is and isn’t clear at this point makes a ‘placeholder’ for future work.

9. How do I learn more about all the different markers in the different tasks?

(a) Read Learning Emotion-Focused Therapy; (b) do EFT Level 2; (c) Practice, practice, practice!

10. Anything else you want to tell us?

The main roads by which we can help clients access their emotion schemes: (a) Paying attention to their body (Focusing); (b) accessing episodic memories (Unfolding; Empty Chair Work); (c) actively expressing the action tendency/need linked to the emotion scheme.

C. General Questions:

11. Does doing EFT change the way my body feels?

Yes, by becoming more self-aware of it. It may (a) hurt more, if pain has been ignored; (b) or there may be physical relief or a sense of space or a feeling of easing from resolving a problem.

12. How do I get more professionals around me to support my EFT work?

Network! Building your skill at EFT takes time and a network of fellow practitioners to support your developing practice. Set up an EFT study/intervision group in your area. Find an EFT-friendly supervisor. Take part in research on EFT, either on your own or as a part of a practitioner research network (PRN) or larger study.

13. What is the difference between EFT for couples and EFT for individuals, for example, regarding attachment?

(a) Attachment processes are vital to EFT-I (EFT for individuals), just as it is in EFT-C (EFT for couples). However, like Les Greenberg, we don’t see attachment as the only interpersonal process; there are also power and autonomy needs that need to be balanced and integrated in working with couples.

(b) Jeanne and I don’t do couples therapy training so we feel unable to fully answer this. However, we note that Les’ version of couples’ EFT work allows more space for work with individuals within the couple, especially once it’s become clear how each individual’s own issues help generate the couple’s problems. I can remember times in work with a couple when witnessing the other partner’s distress can genuinely touch the observer couple member. However, it’s also the case that the person who is working can feel guilty or exposed; and sometimes it is too painful or not safe to reveal deeply painful experiences to the other.

(c) I speculate that in EFT-C there is really one main task: To help the couple repair the attachment injury in the relationship; it just happens to be a very large task.

(d) Of course, healing the attachment injury will typically mean helping the couple address their individual injuries and the associated emotion schemes from their past that are involved in their recent partner injuries. This may require EFT-I.

Saturday Adventure in Balloch

13 March 2010:

We had briefly visited Balloch, at the southern end of Loch Lomond, in July 2006, when we were in the process of organizing our move here. At the time, we didn’t do much more than have lunch at an Italian restaurant and walk around Balloch Castle. At the time, it seemed a bit touristic, so we hadn’t been back.

However, when the weather suddenly turned sunny (though still a bit chilly at night) this week, we began looking at an outdoor excursion. So this morning we decided it was time to give Balloch another look. It’s extremely convenient to take the train from Hyndland directly to Balloch, which is what we did. We arrived in time to catch an early afternoon one-hour boat tour that essentially ran up to to Inchmurrin (St Mirin's Island) and back. It was a bright day of mixed sun and cloud. There is still snow on the hills and low mountains around Glasgow, which lend drama to the views around the city. From the boat, Ben Lomond was particularly impressive, looming in the distance across the loch that is named after it: snow-covered, its peak in the clouds while the sun glinted off brightly off its lower slopes. From time to time, the pilot pointed out the castles and refurbed great houses along its southern shores. There were about twenty of us on the little tour boat, mostly fairly hardy souls up for the cold wind on the observation deck. We had difficulty sitting still and kept going up and down the stairs between the observation deck, where we were chilled and attacked by the wind, and the cabin, which was warm but where the view wasn't as good.

On returning, we set off for Loch Lomond Shores; along the way we discovered the Maid of the Loch, a 1950’s lake steamer with side paddle wheels, sitting at dock next to the public slipway. It’s open to the public while it’s being restored, so we spent some time traipsing about it. Actually, it’s a bit sad, some of the staterooms full of old TV sets and used books from jumble sale fund-raising efforts. The most interesting thing was the engine room, dominated by the enormous crankshaft that turns the paddle wheels.

After this, the Loch Lomond Shores and aquarium turned out to be a medium-sized shopping mall cum tourist trap. However, there was also a pretty decent Scottish-cuisine restaurant, the Kilted Skirlie, where we ate a late, leisurely lunch while admiring the stunning view of Ben Lomond, watching the late afternoon light change its appearance. I had a new dish for me: chicken Bonnie Prince Charlie: a chicken breast on top, and under it layers of snow peas, a cross section of baked apple, bits of turnip, with skirlie (an oatmeal stuffing) as the bottom, all drenched in a sauce of drambuie and slivered almonds. Nice!

Finally, we took a walk around sculpture park next to the shopping mall, made of paths winding through the trees connecting various pieces, varying from an outdoor video installation of waterfalls mounted in a wooden beam(?) to a field of blank reflective stainless steels “labels” mounted on little metal polls stuck in the ground. My favorite piece is a curving retaining wall made of local quartz (the artist had help from a local “waller”, that is, a person skilled in building traditional walls).

And at the end of the day’s Adventure, we simply walked down to the train station and got on the train to go back to Hyndland, tired but satisfied from a lovely late winter day, filled with the promise of Spring, soon to arrive.

Saturday Adventure: Strathclyde Country Park

Entry for 3 March 2010:

After a long and welcome sleep, I finally get out for a longish run last Saturday morning. With all the cold weather we’ve been getting, it isn’t surprising that the canal was still pretty iced over. (Coldest winter in 30 years, said the newspaper headline last week, while displaying a photo from 1955, of people sledging across the ice on Loch Lomond to deliver the mail.) The swans live along the canal all year, so I am more amused than startled when I come up behind a couple of them, carefully striding along the ice with a curious back and forth wading motion, as they tranverse the sippery surface from one patch of ice-free water to the next, about 50 yards distant.

After returning home, I pull out our 25 Walks Around Glasgow book to identify a suitable destination for the day, which is rapidly disappearing underneath the Saturday morning dallying over break, paper, shower etc. Strathclyde Country Park looks doable, however, so we print off directions and information and are off.

Strathclyde Country Park is not the prettiest of the regional council parks in the Glasgow area, centring as it does around the large artificial Strathclyde Loch and primarily featuring a medium-size “theme park”. (I can’t tell exactly what the theme is, unless maybe it’s pirate ships.) This, however, is not our destination; instead, I have my heart set on a walk up the Calder Water.

But before that, we want to take in the ruins of the Roman bathhouse, which turns out to located next to the mouth of the Calder Water where it flows into the loch. The Roman bathhouse is a bit bigger than our local one in Bearsden, with two levels of warm room (tepidarium). Unfortunately, it is no longer sitting on its original site, having been moved up a bit to escape the rising waters of the loch when the latter was created. Nevertheless, the foundations and walls have been carefully reassembled and are quite evident. We happily roam over the site taking photos and imagining the Roman soldiers scraping off the mud from a day’s march south from the Antonine Wall in Glasgow, working their way up through the levels of heat to hottest (calidarium) before returning to jump into the cold plunge bath at the end.

I suddenly remember visiting the hotbaths at the Tassajara Hot Springs, south of Carmel Valley, as a child: My dad is initiating me into the ritual of the hot baths, and I am nervously easing myself into the bubbling, smelly hot water at his urging. He tells me to imagine all the toxins coming out through my pores into the water. After soaking a bit, he leads me to the cold plunge bath, telling me that this is necessary in order “close your pores” so as not to get chilled we emerge into the fresh air again. I’m even more wary of this than the hot bath, but I grit my teeth and jump in after him. It’s quite a shock, but afterwards I have a sense of triumph, and feel a bit more grown-up.

After several false starts and the discovery that my Glasgow walks book is out of date (the cute arched 19^th century “Roman Bridge” has been closed, presumably for health and safety reasons), we eventually locate the path. At the beginning it runs at some distance from the Calder Water, along the edge of Motherwell, past football pitches (i.e., soccer fields) and housing estates, but eventually the path veers off into the forest, and we gradually descend toward the Calder Water gorge. Before long, we come upon the enormous stone arches of a great viaduct spanning the gorge: This is the Orbiston Viaduct, over which the West Coast line passes on it way south from Glasgow. I have ridden over this viaduct many, many times, and when I happened to look out the window when we crossed it, shortly before reaching Motherwell, I always thought we were crossing the River Clyde rather than the Calder Water. Another connection made!

We take lots of photos of the viaduct, which is relatively easy to see with the trees still bare at this time of year. Then we continue up the Calder Water, finally descending to a path that runs right next to it. There is a roaring in the distance, and then we arrive at a large weir, where the water plunges dramatically. Above and below the weir, the water is quite calm, almost tranquil, but not here.

Walking further, we pass a man, with a dog, fishing on the other side of the river. Then the path bends away from the river and ascends, until we reach a pedestrian bridge that takes us over to the other side of the river, and we follow the path back down from whence we came, as the sun sinks lower in the west. Along the way pass the man and dog again; the man is digging for earthworms or grubs, then we pass under the Orbiston Viaduct again, red sandstone cliffs on either side and follow the path up to the cliffs. We also pass a clump of older men, with a large collection of bottles of various kinds of alcohol, standing around drinking. Diane is surprised and disturbed by this scene, but it is very familiar to me from runs along the canal in Glasgow, where there is usually a similar collection of sad, seedy-looking people hanging out near Ruchill. After we pass by, she remarks,“But they are so old! I thought it was just kids that did that.” “They’ve probably been drinking since they were kids,” I observe.

After this, we follow the path through the park and finally down to the main road and the parking lot. There is still enough light left for a trip to See Woo, the enormous big box Asian grocery where we buy 20 lbs of California sushi rice, a little bit of home to cook in our rice maker. It’s been another lovely Saturday Adventure, all the more welcome because I’ve been travelling so much lately that we’ve missed out on quite a few. For me, such days are a little bit of heaven, a blessing, part of the ever-growing web of our experience of Scotland.