Stephen & Elliott (2011), “Developing the Adjudicated Case Study“

Entry for 3 March 2011:

Commentary on a Commentary: For the past several years Dan Fishman, editor of Pragmatic Case Studies in Psychotherapy, has been trying to get me to submit one of our HSCED studies to his online journal. For various reasons, we’ve been unable to accommodate him. However, last Fall he made me an offer I couldn’t refuse: the opportunity to write a commentary on two adjudicated case study projects, one from Ron Miller and his team, and the other from Art Bohart and colleagues. I asked Susan Stephen, one of my PhD students to work with me on this, because she has a special interest in the topic and is doing her PhD research on the HSCED method.

When the package of 10 articles arrived at the end of this past December, however, we realized that we’d gotten a bit more than we’d bargained for. There was a lot of material get through! However, we dived into the papers and were able to work our way through them. In the process, Susan got considerably ahead of me and ended up writing the bulk of the paper, so I was very pleased for her to be first author. Actually, I thought she did a great job, although I was able to earn my keep by adding several sections and contributing bits here and there, especially on the history. In the process I think we produced a very useful paper discussing issues about the implementation of adjudicated case study methods that we hadn’t seen discussed before. This paper, along with the rest of this issue of PCSP, now becomes required reading for everyone involved in HSCED and other adjudicated case study methods, or even just contemplating using this method.

Abstract: In this commentary we discuss Miller’s Panel of Psychological Inquiry (PPI) and Bohart’s Research Jury method approaches to the development of the adjudicated case study method, as represented by the papers assembled for this issue of Pragmatic Case Studies in Psychotherapy. In our view, the case studies presented here demonstrate the rapidly developing potential offered by this approach for psychotherapy research and reveal many parallels to recent research using the Hermeneutic Single Case Efficacy Design (HSCED) model. In our view, each of the three models has taken significant steps forward in adapting particular aspects of the legal process as viable psychotherapy research procedures. In this commentary we summarize the HSCED method, then take readers through the issues of the sources of the evidence used; ways in which that evidence is tested; claims, burden and standard of proof; and the handling of the adjudication process itself. We conclude with recommendations for further development of adjudicated case study methods.

Reference: Stephen, S., & Elliott, R. (2011). Developing the Adjudicated Case Study Method. Pragmatic Case Studies in Psychotherapy, 7(1), 230-241. Available online at: http://pcsp.libraries.rutgers.edu.

Saturday adventure to the Dean Gallery in Edinburgh

Went to see amazing exhibit of photographs by early 20th century German photographer August Sander: People of the twentieth century: A cross section of people, Farmers and merchants, composers and bankers, Nazis and Jewish death camp prisoners, all portrayed with great compassion and without judgment, inhabiting their social roles, transcending time and place, reaching the level of human archetypes.
http://www.nationalgalleries.org/whatson/exhibition/5:368/19935/

Saturday 12 Feb 2011 along the River Kelvin

Running along the Kelvin River path on Saturday, thinking about Margaret's Memorial service that would happen in a few hours, I stopped at St. Gregory's Church and spent a few minutes praying at the shrine to the Virgin Mary in the car park at the back of the church: From a niche cut out of the rock face, she looks out toward the River Kelvin. I realized that she has been watching me every time I ran by here for the past 4 years.

A few minutes later, in another of the crazy contrasts that is such a part of our life here in Glasgow, as I ran up the path toward Half-penny Bridge, I came upon a gaggle of fisherman, fishing poles held high…. And a piper arrayed in kilt and all. I stopped to watch, and 30 seconds later, the piper began to play “Scotland the Brave”, the unofficial national anthem of Scotland. He processed over the bridge, followed by about 10 fishermen and various fellow onlookers. On the other side, he stopped, and the fisherman gathered by the rail, while two of them climbed over. A quaich and a bottle of Famous Grouse whiskey appeared. One of the men held the quaich, while the other poured the whiskey into it, then passed the bottle back over the rail where is was used to fill a lot of plastic cups. There was brief ceremony, to mark the opening of fishing season on the River Kelvin, “and may be it be a good a last year’s!”, followed by cheers and toasts and around.

Margaret Linstrom Weitzel, 1950 - 2011

Entry for 6 Feb 2011: (Posted to coincide with Margaret's Memorial Service in Reseda, California)

I first met Margaret in 1964 when she sat next to me in high school Latin 1 class. I was just back from a trip to Europe with my Grandmother, and was just starting to come out of my shell. I don’t remember how she did in the class, but it was a real struggle for me. We were both pretty shy at the time and only developed a friendship over time. I was just starting a spiritual journey that, over the next 8 years, would take me away from the Episcopalianism I’d been raised in, on a long, looping orbit through Quakerism, atheism, Buddhism, Christian Fundamentalism, Roman Catholicism, and eventually back to the Episcopal Church. Margaret was an essential part of the journey for me, drawing me back when I was in danger of flying off into interstellar space, helping me ground myself in the Bible as I accompanied her and her family to the Christian and Missionary Alliance Church in Stockton (and later to one of the Baptist Churches in Lodi), where I was able to experience and to appreciate the importance of a deep grounding in a personal faith and the Bible.

Yesterday, on the 5th of February, 2011, Margaret died of cancer, aged 60. From my point of view, 60 is too young for her to die, but I don’t think it’s how Margaret saw it. Four months ago, as I was recovering from my surgery for prostate cancer, Margaret’s cancer was discovered, already at the metastatic stage. After Gail, her sister-in-law and a long-time friend (whom we’d just seen on her way through Glasgow on a North Atlantic cruise with Margaret's brother Hugh), emailed us in early October about Margaret’s cancer, I was in periodic contact with Margaret by email, as each of us followed our different cancer trajectories. We exchanged stories about our granddaughters and their metaphoric resonance with our situation, and wrote about how our illness was highlighting what was most important to us. I prayed for Margaret; she prayed for me. Through this time, she continued to inspire me, as she always has, with her spiritual, moral and personal witness, even as she grew too weak to respond to me herself and had to have her husband Rich write for her.

This morning, before church, I woke to find Gail’s email saying that Margaret had died. We’d been expecting this, but it was still a shock, as if some part of me had died also. All day I’ve carried this sense of mourning with me.

I heard her voice in today’s lessons: Isaiah 58: 1 -9 and 2 Corinthians 2: 1 - 12. I remembered how she read and quoted the Bible from memory, the excitement and energy and joy in her voice. And I realized that ever since then, whenever I had to get up in church to read a lesson, it was Margaret’s voice speaking through me, echoing the ecstatic cry of the creatures in Revelation, untangling Paul’s sometimes twisted syntax to pull out the meaning.

I remembered also how she “found me” in the Letter to the Hebrews, as, like Jesus, a priest not of the Levites (the Jewish priestly tribe) but “of the order of Melchizedek”, a perfect metaphor that found a place for and validated my restless searching that sometimes seemed to place me outside conventional spirituality.

But most of all, I remembered Margaret’s absolute faith in God, so solid compared to my doubts and waverings. Once, late in high school or more likely early in our university years during a holiday, someone led us through a guided meditation. Margaret visualized herself as a speck of dust, almost insubstantial. “How awful!”, the rest of us said. “No,” Margaret said, “I don’t need to be any more than that, because God is there: He is more real and more solid than I am, and He is all I need. He is the only thing I am sure of, that I know with certainty.” I have never forgotten this vision of hers, and of her ability to be absolutely certain of God. It is this certainty that God was holding her through the cancer that I have carried with me these past months, imagining her surrounded by God’s Light and Love.

After the service I went up to St Anne’s Chapel and put up a prayer request for Margaret; then I went to the back of the Nave and lit a candle for her. It was only then that a huge wave of sadness hit me, and I went and sat down and cried for a few minutes. As I cried, a bit of her certainty suddenly came over me, saying, “Margaret is OK,” and I felt something ease in my body. I said to myself, “It is the rest of us who are hurting. But really, the truth is, she is in all of us still, and she’s not going away.”

I have more to say about Margaret and may do so at another time, but this is enough for now, to mark her passing: For most of my life, even without her knowing it, she has been a personal saint for me, on my sometimes wandering or wavering spiritual journey. I am now experiencing her absence in my outer life, but the deeper truth is that she is still very much part of my inner landscape, and will be for the rest of my life and even, I hope, following her example, in how I approach my own death.


9-12 Feb 2011: Afterword: The Missing Story of the Mother Cat:

Apparently what I wrote above was not enough, because a couple of days later, and after I had sent along the Remembrance piece above to Rich, Hugh and Gail, I had an extremely vivid and complex sequence of dreams. I may share these dreams at a later time, but on reflection it became clear to me that the dreams were telling me that I had left outa very important and timely story of what I wrote above:

When I was about 19, I was home one summer, driving down a country road south of Lodi, when I came around a curve too fast to avoid running over a mother cat leading her kittens across the road. I hesitated, tempted to simply drive on, but then stopped my car and went back to house in front of which I had run over the mother cat. Getting out of my car, I went up to the woman in the front yard and told her I was very sorry but I had just over her mother cat. Now I don’t remember anything else, but later that day or perhaps the next day, I told Margaret about this incident. Pleased with myself for having had the courage to stop, and trying to reassure myself, I said, “But it’s OK because I told the woman who owned the cat.” Margaret paused and said something, calmly and with great conviction, that I have never forgotten: “No, it’s not OK; the mother cat is still dead.” In that moment I felt confronted by my own naïve, moral carelessness. The lesson for me was that although I didn’t intend to harm the mother cat or her owner or her kittens, and although I did take responsibility for my actions, several someones were still damaged by what I had done and it was very important not to lose sight of that.

It’s clear to me now that I previously put off telling this story because it was too emotionally resonant with Margaret’s death. My sense of her deep moral integrity is such that I can only imagine that she would apply the same principle to her own situation even now, in death. But I want to say this to her now: "Although your death causes me pain and leaves me feeling very sad, it is a pain and a sadness that I gladly bear, because it marks how important you have been and will continue to be to me. The sadness I feel at your passing tells me not to pull away but instead to connect with those I love and who love me."

Emotion-Focused Psychotherapy 2011 Level One Training at Strathclyde

Entry for 28 January 2011:

Facilitated by Robert Elliott & Lorna Carrick

Tuesday 30th August – Friday 2nd September 2011, 9.00 – 16.30

University of Strathclyde, Jordanhill Campus, Glasgow

(Sponsored by HASS Research & Knowledge Exchange,

University of Strathclyde)

Emotion-Focused Therapy (EFT) – also known as Process-Experiential Therapy – is a humanistic, evidence-based form of psychotherapy/counselling that integrates person-centred and gestalt therapies, with particular relevance to working with depression, trauma, and anxiety difficulties. It has gained international recognition through the work of Les Greenberg, Robert Elliott, Jeanne Watson, Rhonda Goldman, Sandra Paivio and others. The Counselling Unit at the University of Strathclyde is again pleased to offer Level One professional training in this approach to qualified counsellors and psychotherapists (Diploma level or above).

Now in its sixth year at the University of Strathclyde, this successful, four-day Level One EFT training programme will provide participants with a solid grounding in the theory and skills required to work more directly with emotion in psychotherapy. Participants will receive an in-depth skills training through a combination of brief lectures, video demonstrations, live modelling, case discussions, and extensive supervised role-playing practice. The workshop will begin with an overview of EFT Emotion Theory, including basic principles and the role of emotion and emotional awareness in function and dysfunction; this will be illustrated by Focusing-oriented exercises. Differential intervention based on specific process markers will be demonstrated. Videotaped examples of evidence based methods for evoking and exploring emotion schemes, and for dealing with overwhelming emotions, puzzling emotional reactions, painful self-criticism, and emotional injuries from past relationships will be presented.

Participants will be trained in the skills of moment-by-moment attunement to affect, and the use of methods of dialoguing with parts or configurations of self and imagined significant others in an empty chair. This training will provide therapists from person-centred, psychodynamic, cognitive-behavioural and related backgrounds with an opportunity to develop their therapeutic skills and interests.

Educational Objectives: Participants on the training programme will learn:

1. To implement the basic principles of EFT

2. To identify different types of emotional response;

3. When to help clients contain and when to access emotion;

4. To help clients reprocess difficult emotions;

5. To facilitate emotional processing to resolve self-critical splits and unfinished business.

Programme Outline

Tuesday Morning: Foundations, Emotion, Empathy, & Alliance Formation

• Distinctive features of the EFT: neo-humanism & therapeutic principles

• Process-experiential emotion theory: emotion schemes

• Emotion response types & emotional change principles

Tuesday Afternoon: Therapeutic Tasks, Accessing and Managing Emotion

• Therapeutic tasks and process formulation

• Emotion regulation

• Focusing and Clearing a Space

• Skills practice

Wednesday Morning: Reprocessing Problematic Experiences

• Empathic exploration, evocative empathy, empathic conjecture

• Evocative unfolding, Narrative Retelling, and Meaning Creation

• Skills practice

Wednesday Afternoon: Accessing Primary Adaptive Emotions & Restructuring Emotion Schemes

• Empty chair dialogue and unfinished business

• Supporting the emergence of primary needs

• Helping clients use adaptive emotions to challenge core problematic emotion schemes

• Letting go of unmet needs

• Skills practice

Thursday Morning: Active Expression Processes - I

• Dialectical constructivist models of self

• Two chair dialogue and splits

• Accessing adaptive and problematic emotional responses

• Skills practice

Thursday Afternoon: Active Expression Processes – 2

• Accessing core problematic emotion schemes

• Varieties of splits

• Adapting two-chair work to different kinds of clients

• Skills practice

Friday Morning: Identifying Tasks; Empirical support,

• Review of tasks

• Strategies for identifying and selecting tasks

• Skills practice

Friday Afternoon: Personalized Applications

• Summary of Research evidence

• Practical parameters

• Depression, Post-traumatic stress difficulties

• Social anxiety, Borderline processes

• Question & answer period

About the Facilitators

Robert Elliott, PhD: Robert is professor in the Counselling Unit at the University of Strathclyde, where he teachers on the postgraduate diploma and MSc courses in Person-Centred Counselling. He taught at the University of Toledo 1978-2006, where he was Professor of Psychology, Director of Clinical Training and Director of the Center for the Study of Experiential Psychotherapy. He has also been a guest professor at Katholieke Universiteit Leuven, Belgium, University of Sheffield, UK, and La Trobe University, Australia. He is co-author of Facilitating Emotional Change (1993), Learning Emotion-focused Therapy (2004), and Research Methods for Clinical Psychology (2003), as well as more than 100 published scientific articles or book chapters. In 2008 he received both the Carl Rogers Award, Division of Humanistic Psychology of the American Psychological Association, and the Distinguished Research Career Award, Society for Psychotherapy Research. He is editor emeritus of the journal, Person-Centered Counseling and Psychotherapies and directs the Scottish Consortium for Psychotherapy and Counselling Research and the Strathclyde Centre for Psychotherapy and Counselling Research.

Lorna Carrick, MSc:
Lorna is a lecturer in the Counselling Unit at the University of Strathclyde. She is the course director for the Postgraduate Certificate in Counselling Skills and teaches on the Postgraduate Diploma in Counselling courses. Lorna’s background is in mental health and project development and as a founder member of the first Health Board-funded person-centred counselling service in Scotland, Lorna has over sixteen years experience in counselling, supervision and service development within the field of counselling and psychotherapy. Lorna is currently the director of the Glasgow Counselling in Schools Project and Chair of the Counselling Unit’s management group. Lorna’s research has focused on working with clients in crisis within the Person-Centred-Experiential approach and the use of counselling and Pre-therapy skills in the field of autism services. She has been practicing EFT within a broadly Person-Centred relational approach since 2006, and has also participated as an EFT therapist in the Social Anxiety research protocol of the Counselling Unit’s research clinic. She is committed to helping counsellors/therapists bridge the perceived gap between EFT and nondirective Person-Centred ways of working with clients.

Application Information: If you would like to reserve a place on this training course, please contact me or Jan Bissett for the application form. Places are strictly limited so book early to avoid disappointment.

The fee for this four-day event is has been set at £445. Please note that to keep costs to a minimum, catering is not included in this fee.

We are pleased to offer an Early Bird Discount of £50.00 to those who book before 1st July 2011. To take advantage of this offer, applications must be received by this date with no exceptions.

For further information on this event, please contact Jan Bissett, HASS Research & Knowledge Exchange (jan.bissett@strath.ac.uk, 0141 548 3418).

End of Year Update

Entry for 31 December 2010:

I had been feeling very impatient with the slow pace of my recovery when I saw my surgeon at the beginning of December. Amusingly, when I disclosed my fear that perhaps my progress was being slowed by scar tissue, he said pridefully, “Impossible! The anastomosis was perfect!” Then he told me that my progress was in fact good and was encouraged by my gradual but continuing progress. He told me to give myself at least 6 or 7 months post surgery, and had me schedule a follow-up visit for another 3 months on.

Then they tested my blood for PSA. After a couple of days of anxious waiting, the nurse phoned to say that my 3-month follow-up PSA was undetectable, essentially zero, which was really, really good news, and actually quite a relief for me. This is another sign that the surgery was successful in removing all the cancer, and that it hadn’t spread elsewhere. I now feel like I have my life mostly back.

It is of course still possible that there are undetectable micrometastases floating around my body somewhere, which means that it is now my job to make sure that I live my life to make it less likely that these potential tiny loose cancer cells might take hold somewhere. This means eating healthily, continuing my micronutrient regime, getting plenty of sleep (at least 8 hours a night), keeping the stress down, and restarting my running.

I asked my surgeon if I could start running again and he said yes, so the next day I went out for a run. I am pretty out of shape in terms of strength and aerobic capacity, from the aftereffects of the surgery and the results of the sedentary life I’ve been living for the past 3-plus months. I tried to take it easy the first day, running about half the time on my usual 5k course over Clevedon Hill to the Canal, then down the River Kelvin to the Botanic Garden and home, but it was still a bit too much, so I backed off a bit from that. Since then I’ve been able to work up to running 3 times a week a week, running about half the distance, sometimes under rather appallingly icy conditions in Glasgow. It has felt very good to get out and run again, but I’ve noticed that I’m more tired afterwards than before the surgery. So, I will continue to slowly build my capacity.

The incontinence is another matter: After more than 3 months, I am fine as long as I am laying down or sitting, and am OK if I stand for a few minutes (the latter is a recent development); however, I have problems whenever I have to walk for more than a couple of minutes. This is called stress incontinence, but it certainly doesn’t take much stress for this to happen. This doesn’t sound like much but is in fact progress and makes me hopeful.

So I have settled in for the long haul, the long game. Mostly, I am philosophical about this, put it into perspective: Compared to dealing with metastatic prostate cancer and death, this is a Wonder, a miracle that has given me literally a new lease on life. Living with incontinence is annoying and sometimes pretty frustrating, but it beats dying of cancer by a mile, and I feel very grateful.

Moreover, the lifestyle changes I am now making and continue to forge as I phase back into work are things that I should have done ages ago. My project now is to negotiate with myself and the University a slower, less intense pace of work. A few weeks ago I wrote to my head of school that it was now clear to me that I am going to be able to work 40 hours a week without difficulty, but that the 50- 60 hrs/wk that I’ve been working for the past 30 years is going to be out of the question. She wrote back to remind me that in fact our work week is 35 hrs and that no one is asking me to do more than that. I appreciate this, but it strikes me that the volume of work that we are asked to do exceeds what can be done within 35 hrs/wk, so the real issue is going to be reducing the amount of work in order to fit into the available time. It will be interesting to see how this plays out over the next couple of months.

In the meantime, I've enjoying my time in the US, first touching base in Toledo to finish Christmas shopping before going on to visit my oldest son, Brendan, his partner Mayumi, and our 7-month old granddaughter for Christmas. Mizuki has inspired me these past months with her attempts to crawl, which have recently met with success. We’ve now flown down to Northern California, where we enjoyed a peaceful post-Christmas period with Diane’s family. We then drove up into the Sierra Nevada foothills east of Sacramento to stay at my sister Louisa’s and to celebrate New Year’s Eve with my mom, siblings and their partners. No Murray Creek this year, but still, Happy New Year, everyone!

Empirically Supported Relationships Summaries Published Online

Entry for 13 November 2010:

Last year, Art Bohart, Jeanne Watson, Les Greenberg & I were asked to update our 2002 meta-analysis of research on the relationship between therapist empathy and therapy outcome, published in John Norcross’s Psychotherapy Relationships That Work. The revised version, in book chapter and journal article formats is still in press; however, a sneak preview version has just been published online, along with the rest of the reviews to appear on the second edition of John’s book.

SAMHSA, the Substance Abuse and Mental Health Services Administration, is a branch of the US government responsible for improving treatment of mental health and substance abuse issues by funding research and disseminating information about evidence-based practice. Somehow, the Powers That Be were persuaded to sanction summaries of the current set of meta-analytic reviews being published on their website.

SAMHSA have now published online a set of summaries of evidence supporting the importance of different aspects of the therapeutic relationship for promoting successful psychotherapy or counselling. We updated and replicated our previous analyses with somewhat larger data set and found a moderately strong and highly reliable relationship between therapist empathy and therapy outcome. In addition to empathy, the other Rogerian conditions of therapist warmth and genuineness also fare quite well.

The summary of our review can be found at: http://www.nrepp.samhsa.gov/Norcross.aspx#chapter6

The other reviews can be found in other parts of the same document/webpage.

Reference:

Elliott, R., Bohart, A.C., Watson, J.C., & Greenberg, L.S. (2010). Empathy. In J. C. Norcross (ed.), Evidence-Based Therapy Relationships. National Registry of Evidence-based Programs and Practices (NREPP). Online Resource, available at: http://174.140.153.165/Norcross.aspx#chapter6