'AI-Thou': Can There be Relational Depth with an AI Therapist?

At the recent conference of the UKCP (United Kingdom Council for Psychotherapy), it become increasingly evident that AI-delivered therapy is not a matter of ‘if’ but ‘when’. We will have Chat GPT-like technologies, ‘humanised’, providing therapy to people. But will there always be something missing? Will AI ever be as good as real human therapists? The question is not so much about now—with all the bloopers of Chat GPT, Siri, and other AI platforms; as well as their horrendous environmental impact—but in the near- and further-future, when AI will be refined and developed and able to do even more amazing things than it can do now. Nevertheless, I guess, like a lot of therapists, I am still hoping that there is something unique and special that only human therapists can provide.

And if there is, it is likely to lay in the capacity for providing a deep, interpersonal connection. AI, no doubt, will be able to remember what clients say better than us, to detect patterns and emotions in their language, to provide potential diagnoses or formulations in ways that far exceed our capabilities. In this way, I am sure that AI will become a tool to support our therapeutic work (though issues like confidentiality and data protection will need ironing out first). But, perhaps, the one thing that AI will never be able to do is to relate in the human-to-human way we have defined as relational depth: ‘A state of profound contact and engagement between two people, in which each person is fully real with the Other, and able to understand and value the Other’s experiences at a high level.’

Relational depth can be understood as a state of relating in which each person experiences the other as a ‘Thou’ rather than an ‘It’. This links back to Martin Buber’s concept of the I-Thou attitude. The I-Thou stance has a number of facets to it: (a) We stand alongside the other rather than survey and study them as a thing; (b) We encounter the other as a dynamic stream of being rather than as an object; (c) We relate to the other as a whole rather than as a collection of parts; (d) We recognise the other’s freedom and indeterminism; (e) We encounter the other as a particular, unique being rather than as a representation of particular classes: an ‘Other’; (f) We deeply accept this Other; (g) We relate as a whole, ourselves, rather than from our parts; and (h) We let go of our established ways of doing things and allow ourselves to be transformed in the relationship.

Could a client relate to an AI therapist as a Thou? Perhaps. They could experience them as a unique, accepting, empathic stream of being. The client could relate as a whole, revealing their innermost thoughts and feelings, and in ways that allowed themselves to dive into the ‘relationship’ and be transformed. But the client would also know, at least at some level, that the AI therapist was not free: that it was determined rather than self-directed—programmed to be. There would be a lack of a volitional agency meeting them, such that clients might feel drawn into relating to the AI therapist as a ‘Thou’ (the ELIZA effect), but I think they would also know that, at some level, they were experiencing an It.

And there is also the question of whether the AI therapist could experience the client as a ‘Thou’. I think, here, the answer would definitely be ‘no’. AI, however it was programmed, would always need to break the person down into parts, and to understand them through heuristics and rules. It could never go beyond it’s own knowledge base to comprehend the client in their freedom and indeterminism. By definition, AI would always need principles and procedures by which to make sense of—and respond to—the client. It could only go beyond through new principles and procedures. What’s more, in our research on relational depth, we see that a key feature of it is a genuine care towards the other: that the therapist really, genuinely wants the client to do well. AI, however well programmed, and however caring it acts, can never experience a genuine care. Things, people, cannot matter for AI. So, for the AI therapist, the client would always be an It rather than a Thou.

When people describe the experience of relational depth, they often talk about its interconnected quality: not just ‘I know you’ but ‘I know that you know me’. In those moments of meeting, we feel that the other is meeting us: that we are their Thou just as they are ours. You cannot relate at depth to something or someone who, you know, is not relating at depth to you. Will clients know that, to their AI therapist, they will always be an It? I think, again at some level, that consciousness is always going to be there. We can imagine our AI therapist really recognises us in our uniqueness, that they are able to go beyond their procedures and heuristics to experience us in novel, a-procedural ways; but won’t the client, always, at some level know? And, if so, that knowledge of the ultimate it-ness of themselves in the eyes of their AI therapist will disrupt any true sense of relational depth.

Apologies for the crudeness of this analogy, but the subject of sex toys does come to mind. Sex toys can give stimulation and pleasure, sometimes more so than other humans, but there is also a distinctive human quality missing. It’s not making love: it’s not having that deep physical-psychological-intimacy that, I think, can only be experienced with another human.

Relational depth requires reciprocity. And it requires what has been termed co-intentionality: the sense of another agentic, directional being coming towards us. Daniel Stern describes the way that, in this ‘moments of meeting’, the client and therapist—or, earlier on, the parent/carer and child—come together to share wants, needs, and goals. They align, move towards the same shared possibilities. Could an AI therapist understand and share a client’s goals for therapy? Yes, possibly. And they could certainly align on the tasks of therapy. But would a client ever have a sense of being joined by another agentic being? Like many others, in my book Integrating Counselling and Psychotherapy, I argue that the most distinctive feature of living organism is their directionality: their movement forward to fulfil wants and needs. When I look at my cat Bonnie, I can experience a relational depth because I am sensing that she is wanting something from me, is moving towards me and into me as a means of moving onto somewhere. We can join. But, if passive, dead, responsive-only, then that sense of co-doing-something-together can never quite be there. I’m in the lead—and, fundamentally, alone.

I think this question of whether AI can relate at depth is one that needs asking, and exploring, more and more for the future; because it is essential to the issue of where humans will be—and what humanity will mean—in an AI-infused (or AI-dominated) world. Almost certainly, AI is not going to stop, it’s going to evolve, and probably at a faster and faster rate. So however scary that might be, it’s an issue that we probably need to stare in the face. I’d love to know what people think: do leave comments. Perhaps the issue comes down to the ‘at some level’: to what extent will we—or will we want to and be capable of—denying what we ‘know’ as the truth? People perceived ELIZA, the ‘Rogerian’ chatbot developed in the 1960s, as having empathy and experiences. But did they really? Did they really feel and know this at an existential level? Perhaps, indeed, the non-humanity of AI will become the fifth existential given (alongside death, isolation, meaninglessness, and freedom): something that we all know, unconsciously, is true, but often deceive ourselves into believing does not exist. ‘I will not die… there is a given meaning to my life… and my AI therapist really cares for me as the unique being that I am.’ Perhaps, for the future, retrieving the actuality of human care and connection will be the greatest challenge of them all.

A final thought: If human connection is irreplaceable, it does give me some optimism that, as a humanistic- and relationally-oriented therapist, our approach may have some endurance and importance for the years to come. It’s fairly easy, for the future, to imagine AI delivering sophisticated and personalised CBT techniques, and perhaps also psychodynamic interpretations based on the client’s verbal and nonverbal expressions. And such interventions, I am sure, could be incredibly helpful. But, from a humanistic and relational perspective (including contemporary relational psychodynamics), where the heart of the therapeutic enterprise is in-depth relating, there’s always—at least, as I’ve argued here—going to need to be a human providing it. CBT and classical psychodynamic practices, delivered by AI, may do much to help people pinpoint and address particular problems that people face; but where the deepest client issues are to do with isolation, alienation, and disconnection—with feelings un-accepted by the world and outside of relationships and community—only a human being may be able to provide the ‘deep soul nourishment’ necessary to heal. AI, ultimately, might be able to replace all forms of ‘psycho-technology’ in the counselling and psychotherapy field, but relational depth may always be beyond its grasp.

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Postscript

Interestingly, AI (ChatGPT), itself, agrees with me on this one. This is how it answered the question, ‘Will an AI therapist ever be able to have relational depth?’

Relational depth refers to a profound level of connection between two individuals, where they experience mutual understanding, authenticity, and emotional resonance. This concept is deeply rooted in human qualities like empathy, shared vulnerability, and the ability to adapt to subtle interpersonal dynamics.

While an AI therapist can simulate many aspects of human interaction—such as listening, offering thoughtful responses, and even expressing simulated empathy—it may face challenges achieving true relational depth due to several inherent limitations:

Challenges for AI in Achieving Relational Depth

1. Lack of Subjective Experience:
   Relational depth often arises from shared human experiences, emotions, and the therapist's personal awareness of their own vulnerabilities. AI, being devoid of consciousness or subjective experience, cannot genuinely share in or fully comprehend these dimensions.

2. Authenticity:
   A key aspect of relational depth is the perception of the therapist as a real, authentic person. Knowing that AI responses are algorithmic may create a barrier for some clients in fully trusting or connecting at a deeper level.

3. Subtle Emotional Nuances:
   While AI can analyze verbal and non-verbal cues (e.g., tone, word choice, facial expressions), its interpretations are limited by the quality of its programming and datasets. It may miss or misinterpret the unique subtleties of human emotion, which are crucial in building profound connections.

4. Mutuality:
   Relational depth is often characterized by mutual openness and vulnerability. AI lacks the capacity to share its own vulnerabilities or develop a dynamic, evolving relationship.

Potential Strengths of AI in Therapy

That said, AI does have significant potential to contribute meaningfully to therapeutic processes, particularly for individuals who might feel stigmatized or uncomfortable with human therapists:

1. Non-judgmental Presence:
   Clients might feel less judged or intimidated by an AI, enabling them to open up more freely about certain issues.

2. Accessibility and Consistency:
   AI can provide immediate, around-the-clock support and maintain consistency in its responses, which can be comforting for some individuals.

3. Data-Driven Insights:
   Advanced AI systems can analyze patterns in client speech and behavior to offer tailored interventions, sometimes faster than a human might.

Future Possibilities

AI may approach relational depth if:

• It becomes adept at mimicking emotional resonance.

• Users' perceptions of AI evolve to accept its unique "authenticity."

• Future advancements allow for personalized learning, where AI adapts over time in a way that feels dynamic and deeply attuned.

However, it’s unlikely AI will ever fully replicate the ineffable qualities of a deep human-to-human connection. Instead, AI therapists might excel as complements to human therapists, offering preliminary support, data collection, or ongoing care in between human-led sessions.

Hungry Like the Wolf for Essential Research Findings in Counselling and Psychotherapy: Duran Duran and Me

Back in May 2024, Clare Symons, BACP’s Head of Research, told me that she was giving a talk at the BACP’s Research Conference posters and awards ceremony about how I’d plagiarised my research findings book from Duran Duran song lyrics—brilliant! Unfortunately, I couldn’t make the conference but I heard it had the audience in stitches and, to be honest, I was incredibly touched and honoured that Clare had spent the time on my research book and me. Clare very kindly agreed to let me reprint her talk, and slides, below.

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Birmingham is the home of many rock legends such as Ozzy Osborne, Led Zepellin, Judas Priest, ELO, etc.

This got me thinking, who would we consider to be the rockstars of counselling and psychotherapy research?

John McLeod, certainly. I have seen him in a mosh pit and he’s pretty hard core.

What about Mick Cooper? Maybe. But I’ve always seen him as more New Romantic than rock – which got me wondering so I did a bit of searching and, funnily enough, this is what I turned up:

As you can see, a very fetching photo there on the left of Simon le Bon from Duran Duran – another Birmingham band - and on the right our very own Mick Cooper. I think you’ll agree that the resemblance is uncanny.

But we’re researchers, we don’t draw conclusions based on coincidence, we look at evidence. So I wondered, what evidence there might be for a connection between Mick and Duran Duran. Let me tell you, I was amazed at what I discovered.

A source at Sage very kindly shared this with me:

This is what the cover of Mick’s important book, The Facts are Friendly looked like with its original title which, as you can say, includes a blatant Duran Duran quote.

Unfortunately, the entire print run of the book had to be pulped when royalties costs were found to be too costly to include that in the title. A terrible loss, I am sure you’ll agree.

Let’s revisit where we got to with this Mick Cooper – New romantic – Duran Duran connection. As I said, I wanted to see what evidence there was for this apparent link between Mick le Bon and Simon Cooper. I decided to have a really good look through the Facts are Friendly and… you won’t believe what I found. Let me read you an extract from the book:

This comes from the conclusion where Mick is arguing strongly that students of counselling and psychotherapy should look to the evidence base for inspiration of what to research rather than simply to follow their own idiosyncratic ideas.

Now I don’t know whether any of that sounds in any way familiar to any of you who were around in the 80s but after conducting a systematic and rigorous analysis of the text (using a highlighter), here’s what I found:

These highlighted sections here show something surprising. Mick Cooper, esteemed professor of counselling psychology has been blatantly sneaking Duran Duran lyrics into one of his most widely-read works.

What else might we find if we dig a little deeper?

Here’s something interesting from chapter 2 which is about outcomes research:

Look closely. As you can probably see, there are no Duran Duran lyrics there so perhaps this is a dead end.

However, I don’t know how many of you are familiar with rickrolling – it’s the unexpected appearance of a video of a song by Rick Astley when you click on a link. But it’s actually become so much more than that. There are now very many examples of serious academics finding ways of rickrolling in their research papers. There’s even a published paper looking at how many instances there are in the academic literature.

Now, if we look closely at the section I just read to you…

We can see that we have been well and truly rickolled by Mick Cooper.

Mickrolled, if you will!!

Is Person-Centred Therapy about how we Treat People or How we Conceptualise People?

What really underpins person-centred therapy: ethics or ontology? That is, is it more important how we treat people, or how we understand their fundamental being?

Of course, ethics and ontology are fundamentally intertwined: if we think people are highly malevolent, for instance, we may treat them with extreme caution. But ethics and ontology are not synonymous. You can, for instance, see people as inherently malevolent but still treat them kindly; you can also view people as actualising but treat them very badly. We have all, I am sure, witnessed such contradictions. Believing people are inherently good, prosocial, and actualising is not the same as treating them well. Perception is a predictor of intentions, intentions are a predictor of behaviour, but the relationship is not one-to-one.

Martin Heidegger is a case in point: the greatest of the existential philosophers who fundamentally challenged the mechanisation, de-humanisation, and objectification of human existence. For him, human being was the opening where the Being of the world came to light. Beautiful, deeply humane and humanising. But Heidegger was also a card-carrying Nazi. He betrayed Jewish colleagues; never published anything about the Holocaust; and, perhaps most disturbingly, never apologized for his pro-Nazism.

Heidegger, about 1933, with Nazi insignia

Emmanuel Levinas, the Jewish Lithuanian philosopher whose work critiques and develops Heideggerian philosophy, was a prisoner of war in Nazi Germany, and lost several close family members to the holocaust, including his father and brother who were killed by the SS. You can imagine Levinas, reading the great tomes of Heideggerian literature, thinking: ‘Ontology… what the f….!! You’ve written beautiful ideas, brought Being to light so cleverly and yet, at the end of the day, you’ve colluded with one of the most brutal regimes in history. What good is all that writing, all that pontificating on Being, when your actions defended and legitimised a movement that violently persecuted millions, including those I loved.’ And, to massively over-simplify things, that’s essentially what Levinas wrote—along with Derrida and many of the other postmodernists. That there is something more important that ontology: there’s ethics, how we treat people. And that we can get so rooted and grounded in a particular model of being that, however theoretically humane, we can end up behaving in the most inhumane ways.

When I was a kid, as I’ve written in a previous blog, my favourite film was called The Little Island. In it, three beings, each of whom advocate for one virtue—good, truth, or beauty—end up coming to blow for their beliefs. One doctrine, one truth… how easy it is for those who see their ideology as the correct ideology to derogate and them demonise and then attempt to eradicate others (in acceptance and commitment therapy, the tendency to confuse our perception with the reality is termed cognitive fusion, and considered a major source of psychological difficulties). As social psychological research shows, once we identify with something, bias against the other is not far behind. And as we close into our echo chambers, our frustration and our anger, so that ire can grow. That’s why, for Levinas, care for the other needs to come first. It needs to remain our starting point and our focus. Levinas witnessed, first hand, the violence that ontology can do when held as an ultimate, primordial truth. Yes, of course, we need different models of the person, different philosophies and understandings of being; but, like a horse to a rider, these need to be tamed to a higher purpose: an ethic of care. Bolting, untamed ontology can kill.

I think most people come into person-centred therapy because, fundamentally, they care about people—not concepts. Yes, they may see the actualising tendency as the core of their person-centred beliefs, but they hold this because they have a fundamental desire to extend a deep empowerment to others. When people learn, for instance, that Abraham Maslow, one of the co-founders of humanistic psychology, wrote in his journal, ‘As for unemployed loafers today, in a time of shortages of help, I’d simply be willing to let them starve ultimately’, I think they are pretty horrified. The fact that Maslow was a leading exponent of actualisation theory doesn’t excuse or legitimise his statement. To talk about letting other people starve is horrifying, actualising ontology or not.

Those who criticise a pluralistic approach to person-centred therapy say that it claims to have no foundations: that it is a relativist, nihilist worldview (see, for instance, Ong et al., 2020). But that shows a fundamental misunderstanding of the approach. In our 2011 book, John (McLeod) and I distinguish clearly between a foundational pluralism, that is relativism all the way down, and a normative pluralism, which roots a pluralistic perspective in a particular set of values and beliefs. And we explicitly identify our pluralistic approach with the latter: that is, pluralism is not a foundationless, everything-goes relativism. Rather, we absolutely acknowledge we have certain normative assumptions, but those assumptions are not about how people are, they’re about ethics: how we treat people. Pluralism leaves an ontological conceptualisation open because, like Levinas, we think the question of how we relate to people is more important than how we conceptualise them. More than that, we think that an approach which puts ontology before ethics, like the proverbial Procrustean Bed, can end up cutting off parts of people that do not fit into our a priori schema. So a pluralistic approach does have foundations, but it’s ethical foundations not ontological ones: ‘a prizing of diversity and difference which emerges from a set of fairly specific humanistic values and assumptions which, to a large extent, are not considered negotiable.’

These issues have real, in-the-world consequences. Take a young person who goes to see a school counsellor; and say that school counsellor holds, most fundamentally, that the young person is an actualising organism who has the answers to their problems within themselves. So the counsellor responds to the young person with primarily empathic unfolding responses, reflecting back to the young person what they are saying to help them dig deeper into their experiences. For many young people, as the research shows, that can be extremely helpful, but we also know that there are young people who want something different (see for instance here). For instance, one young person who had person-centred counselling—from an experienced, well-trained, adherence-checked counsellor—said ‘I didn’t receive any techniques or stratigies [sic] to help me. I often came away feeling worse as my problems were out there with nothing to help.’ Now if the counsellor puts their model of the person first—that the young person has the answers within them—there is a real danger that they can miss such actual, expressed wants and needs. Of course, most person-centred therapists wouldn’t do that: they’d be responsive, and I think that evidences that, in reality, relating does tend to be given priority by person-centred therapists over ontology. But the more definitively person-centred therapists hold a particular view of being, the more constrained they may be in their flexibility and openness.

Rogers hypothesises that a set of six conditions were necessary and sufficient for therapeutic personality change in clients. However, his hypotheses were based on the evidence in the 1950s, and the psychotherapy research field has moved on massively since then. The research evidence now tells us a different—though not entirely unrelated—story (see here). Moreover, as Rogers, himself, acknowledged, to make any ‘totalising’ statement about what all clients need doesn’t allow for the highly individual ways in which clients may benefit from therapy. This has taken me a long time to feel brave enough to say: but my view is that it is unethical for therapists to work with clients holding a fixed and definitive belief that, in all cases, Rogers’s conditions are necessary and sufficient for therapeutic personality change. It just isn’t true, and it’s failing to recognise the uniqueness of the individual clients that we work with. That’s not to say that therapists shouldn’t recognise Rogers’s brilliance, or the importance of the core conditions to therapeutic work. But to hold that ontological assumption foremost, that ‘I know who you are irrespective of what you say to me’, is, I think, to put the therapists’ own needs (for instance, for security or self-belief) before the needs of our individual clients.

It also turns therapy into a religion: a set of beliefs which remain consistent irrespective of empirical evidence. And, of course, religions are absolutely legitimate—many of our clients will be religious or spiritual. But the difference is, religions are something that people (or their families and communities) decide on for themselves. By contrast, as therapists, our ‘religion’ exist in relation to the people we work with; and so owning it and bracketing it takes on more importance. If a young person went to see a school pastor, and if that pastor started telling them that they should see the world in a specifically Christian, or Muslim, or Jewish way—without explicit agreement from the young person and/or their parents that that is what was going to happen—there would be uproar. Similarly, if we believe in a particular ontology, that’s great—we’re all, always going to have particular models of how people work. But when we work with clients, we need to recognise that that is our ontology, and it’s a perspective, not a truth.

Sometimes I do feel that such pluralistic principles and thinking lie outside of the person-centred approach: that person-centred therapy is defined by its ontology—a belief in the actualising organism—and that pluralism is of a different type and order. But then, when I talk to students coming into the person-centred field, or reflect back on Rogers’s writings, or read research evidence on clients’ multifacted needs and wants, I really do feel that what Rogers’s person-centredness is about, first and foremost, is a particular mode of relating to others. And I feel that even more when I hear about people being brutalised in the name of ‘person-centredness’: for instance, students being shamed for being ‘too directive’ (as I’ve witnessed or been told about many times), or writings (including my own) being rubbished and demonised by other members of the person-centred. When I experience that, it makes me feel that, yes, what we’ve tried to articulate through pluralism is a really valid, legitimate, and important attempt to articulate what person-centredness is about. And I feel that most of all when I hear about clients—albeit, undoubtedly a minority—coming into person-centred therapy and leaving confused and disappointed, because they felt the therapist was inflexibly un-directive: working from assumptions about who they are, and what they wanted, that just didn’t suit and weren’t transparent.

Ultimately, it may be that someone will show that I’m wrong: that ‘person-centred’ really does refer to a model of the person rather than an ethic and a mode of relating. And, at that point, I’d be happy to walk away from the approach. Because for me, whatever we call it, what matters most is how we treat clients and what we try to do with them, not our particular theoretical model of who they are. But I just can’t quite bring myself to think that, ultimately, the person-centred approach is a cold, impersonal set of theoretical assumptions about the nature of human being. When I think of Rogers, what strikes me most is not the theories, but a felt-sense of a warm and caring man who wanted to bring more compassion, acceptance, and understanding into the world. Naïve, perhaps, but there’s also an astuteness of utmost importance in being able to name what matters most.

Further Reading

Our original paper on the pluralistic approach to person-centred therapy can be found here: Cooper, M., & McLeod, J. (2011). Person-centered therapy: A pluralistic perspective. Person-Centered and Experiential Psychotherapies, 10(3), 210-223, or in blog form here.

Nicola Blunden has written a major new account of the pluralistic approach to person-centred therapy here: Blunden, N. (2024). Pluralistic person-centred therapy. In M. Cooper (Ed.), The tribes of the person-centred nation: An introduction to the schools of therapy related to the person-centred approach (3rd ed., pp. 201-226). PCCS.

Acknowledgements

Artwork by Jules Allan

Kitty Cooper: Celebrating A Life

My mum was born on the 17th December 1932 in east Berlin as ‘Kitty Furstenberg’. She was the first child of poor Jewish parents: their unhappiness compounded by constant quarrelling. Walter, her father, had come out of the French foreign legion, and was struggling as a door-to-door salesman—Jews were barred from most occupations. Her mother, Betty, met her father in a Jewish youth organisation—Betty like all the girls, had been in love with the leader of the youth group: Walter’s handsome older brother, Solly.

Kitty was named after her paternal grandmother, Kreindla (or Katie) Wixon. However, there were so many ‘Katies’ already in the family—including my mother’s favourite cousin ‘Little Katie’, and ‘Big Katie’—that they chose the name ‘Kitty’ instead. Apparently, Kitty’s mother took the name from a Tolstoy novel she had been reading.

Kitty described her childhood in Berlin as a time of terror, abandonment, and isolation. One of her most frightening experiences—that she told me several times as a child and again when Ruby and Maya (my eldest daughters) and I interviewed her in 2010—was of a day when she and her mother had gone to the Gestapo offices. This was something that Jews were forced to do: to show that they were still living in Berlin, and that they were making every attempt—as all my mum’s family were—to leave. One visit, in early 1939, my mother overheard an elderly Jewish woman being told by the Gestapo officer that she had to leave Germany in two or three weeks. The elderly woman said that she had nowhere to go—she couldn’t get out. The officer replied that that wasn’t his problem, and that if she didn’t leave, she would be taken away. I think that was the point that my mother, just a young child, realised that her and her family’s life was in mortal danger.

My mother lived through Kristallnacht, the 9th November 1938, when so many Jewish properties were destroyed and Jews were taken away. She remembered that her father hid in a cousin’s flat: the cousin had already been taken, so my mother’s parents thought that the Nazis would not search there. My mother remembers being told that, if the Nazis did come and asked where her father is, she should say that she didn’t know.

Unlike many of my mother’s extended family who died in the holocaust—including ‘Little Katie’—Kitty and her mother were able to leave Berlin and travel to England to join her father. This was in August 1939, just three weeks before the war broke out. Kitty and her parents were guaranteed to come to England by an uncle, Bernard, who was already living here. There is a haunting photo of my mum’s extended family—all dressed in their finest clothes—saying ‘goodbye’ to Kitty and her mother on the platform in Berlin, my mum sitting on her suitcase. Kitty would never see these family members again. My mum also told the story of how, when she and her mother got to immigration at Dover, it was realised that my mum had not been put on the visa. She should have been refused entry and sent back to Germany. But the immigration officer took pity on her and waived them through. My mum always said that, if it hadn’t been for that kindly English officer, ‘it would have been the end’. She was right.

Kitty and Family at the station platform, Berlin 1939

More abandonment was to come. Three weeks after Kitty arrived in England, she and her classmates were evacuated to Norfolk. Kitty’s mum—who was afraid to tell her that she was going away for some time—had told Kitty that she was just going on a day trip. ‘It was a terrible, terrible shock to me,’ said my mum, ‘I was there for 18 months and cried every day.’ The family she went to were stern, though kindly, and to make matters worse my mother hardly spoke English. In fact, she said, she initially refused to learn English—she told others that they should learn German instead!

Eventually Kitty returned to live with her mother, moving across different rental apartments and primary schools in London. Kitty’s father, who had worked as a welder on the undersea pipeline that supplied the Normandy landings with oil, came home after the war. But that was not easy for Kitty, who was by now 12 years old. She had had relative freedom with her mother, who she described as ‘easy going’, and when her father returned to ‘lay down the law’—bringing home all of his military discipline—Kitty, as well as her mother, were not happy. ‘I was quite a rebellious teenager,’ said my mum, ‘I didn’t want to do anything my parents wanted me to do, I had my own mind of what I wanted to do.’ As a consequence, homelife was often fraught with tension and argument.

Kitty, centre, with friends

Kitty was delighted, however, when her younger sister, Sandra (who Kitty had named ‘Alexsandra’) was born in March 1945. Kitty adored her sister: a close friend, confidant, and companion throughout her life.

The two girls lived with their parents in a prefab on Gayhurst Road, Hackney. Around 1956, they moved to a house in Wood Green. Kitty’s mother worked as a seamstress, and her father set up a small metal welding business.

Kitty went to John Howard Secondary School in Hackney, leaving at the age of 15. She then attended commercial college to learn shorthand typing, which she described as ‘absolutely hating’, and subsequently took up secretarial work. When I was a child, she would tell us about some of the jobs she had, like working for Psychic News. She also worked in the El Al offices, and was there at the time of Eichman’s capture and transportation to Israel.

I didn’t know this, but when we interviewed my mum in 2010 she said that her favourite hobby as a girl had been stamp collecting—like Davina. And she ‘just loved reading books’—as anyone who spent time with her would know. Mum described going to the Hackney Library as a child and finding books that looked interesting: she loved novels, and authors such as Aldous Huxley and John Steinbeck. When my young kids looked at her bewildered, she explained, ‘because there was no television’. Kitty, throughout her life, was a woman of culture: not just literature but also art, photography, and theatre. As a young woman she also loved dancing and would go, either with friends or on her own, to ballroom dancing in Knightsbridge.

When my mum said to Maya and Ruby, in our 2010 interview, ‘What would you like to ask me?’ the first thing my girls said was, ‘Can you tell us about your past boyfriends?’ My mum said that her first great love was an Ethiopian man, then her boyfriend Silvio. Then she met Charles when she was 25 and Charles was 47. ‘Once I met Charles and once I fell in love with him, that was it,’ Kitty said.

Charles and Kitty had met at philosophy evening classes in the late 1950s. After classes, they would go for coffees with friends, and my dad—who was establishing himself as a leading UK film distributor—would tell everyone the latest news from the film industry.

Tragically, as my mum was to find out, Charles’s first wife, Cecilia, had recently died. She was just 44 years old, and together Charles and Cecilia had had two young twins—Adi and Sue—and an elder daughter, Florence.

My mum said that her first date with Charles was at the Curzon Cinema, seeing a Brigitte Bardot film. Kitty was quite shocked that my dad had taken her to something so ‘low brow’, but she discovered later that Charles had had complimentary tickets to the showing.

Kitty and Charles in later life

Kitty and Charles dated for several years. ‘He was very handsome, very presentable, and had all these women who wanted to marry him,’ said my mum. A few times, reported Kitty, she was so upset with Charles for not making things more permanent that she would ‘pack him in’—even moving up to Edinburgh to study at the University—but then they would always get back together because they both loved each other so much.

In 1964, my parents married. Davina was born in January 1965. Sadly, at the same time as Kitty was pregnant, her father Walter had died.

I was born in April 1966. As a young child, I remember my mother as a warm, loving, youthful presence. I always wanted to spend time with her: she was fun. We would play chess together, cards, watch TV. I remember sitting on the top of the bus with my mum as she took me to my speech therapy appointments. My happiest times—my ‘safe space’—was lying between my mum and dad in their bed in the mornings, cuddling them; jumping up and down, then cuddling more. Charles, as well as Kitty, had come from a family background with lots of highly expressed emotions, and so they both wanted to forge a family life that was calm and conflict-free. I never saw them argue. Kitty described her time with Charles as the happiest in her life. The home that they created together in Highgate from 1973—and which my mother stayed in until the end of her life—was a happy and welcoming environment for us and for so many children, grandchildren, family, and friends: a place of stability, vitality, and love.

My mum was a fiercely intelligent woman: she was a demon at Scrabble into her 80s, and she often told us how her name was on a plaque at the University of Edinburgh for getting the highest economics mark for her first year of study. After marrying my father, she went on to work at their company, Contemporary Films, running the International Department. She was a successful businesswoman in her own right, dealing with many of the leading figures in the cinema world, including Agnes Varda, Werner Herzog, Andrei Tarkovsky, and Jean Renoir.

Kitty was deeply political: committed to making the world a fairer and more compassionate place. She joined the Communist Party, alongside Charles, and actively engaged in party meetings and demonstrations.

Friendships, too, were an essential part of her life. She loved, and was loved by, many. Her oldest friend was Ruth Gilbert, who sadly died several years ago; and there was Anita, Pam, Kate, Lilian, Dorothy, Maggie Bowden, Michael Israel, and many, many others. My mum was a wonderful listener and always interested in others—she never put her ego first. She always had time and space for others: a calm, compassionate presence.

Charles died in 2001, after being cared for by Kitty for several years. It was a terrible loss for my mum, and she never really recovered. She missed him enormously and would sometimes see him walking around their Highgate home. Yet, as well as her children and friends, she had a growing brood of grandchildren that she spent time with and loved: Daniel, Jesse, Hannah, Emma, Frania, Rivka, Shane, Maya, Ruby, Shula, and Zac—and then nine great-grandchildren. It was amazing to see, in the hospital before she died, how many people had come to say their goodbyes: from her two-year old great-grandson Ollie to decade-long friends like Lilian.

Shula, Kitty, Zac, and Maya

The last thing my mum said to me, about a week before she died, was that she loved me. And I really felt that from my mum. We had our moments, but I always felt a deep, enduring, and unshakeable love from her. And I know that she felt that towards so many others: her children, grandchildren, and great-grandchildren; her sister and wider family; and all her friends—so many of whom are here today. Trauma, as we know, can do terrible damage to a person’s capacity to attach and relate. Yet my mum, despite all the terror, isolation, and abandonment that she experienced as a child, had a tremendous ability to love and be loved. She connected, cared, drew others in and held them with so much warmth and affection. That capacity to love so deeply and so consistently—despite what she had endured—can only be testament to her remarkable resilience, intelligence, and strength of character. That is truly something, and someone, to celebrate.

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Links

• The Guardian ‘Other Lives’ obituary, Kitty Cooper, written by Davina

• Jewish Chronicle obituary, Kitty Cooper

• Blog post: my reflection and memories of visiting my parents’ in their Soho office

• Correspondence on my grandmother, Betty Wixon, created by my mother, regarding my grandmother’s estate and German pension

Research Interviewing: Some Pointers

Interviewing is one of the most powerful tools we have for answering research questions in the counselling and psychotherapy field—indeed, any field. ‘Interviewing’ is essentially just a technical term for ‘talking to someone’—and it’s a talking that can have a great deal of depth, nuance, and complexity. What better way of finding out the answers to your questions than by going straight to the source: people, real people, and asking them what they experience or what they think. It’s not the only way of answering research questions, and it’s not always the most suitable; but if you’ve got a question about how a particular group of people experience or perceive something, it’s one of the most effective and widely used tools.

Types of interviews

Interviews can be structured, semi-structured, or unstructured. That’s essentially the amount of a priori ordering you give to an interview: how much do you run it along pre-determined lines, with the same questions, asked in the same way, to each participant? Of course, there’s no right or wrong here—it all depends on what kind of questions you are asking. Structured interviews tend to be best for smaller q (i.e., more quantitative-like) research. For instance, if you wanted to compare how much gay and bisexual men found gay-affirmative therapies helpful, you might want to use a structured interview format so that you had clear, comparable answers to analyse. If, on the other hand, you are doing larger Q research (i.e., more in-depth, experiential, explorative) an unstructured format may be better so you can really go ‘with the flow’ in each interview and explore as deeply as possible their responses. In the middle is a semi-structured approach, which is often a good compromise, and means that you are asking every respondent similar questions, but you have flexibility to go into depth and follow up particular areas without worrying too much about ‘sticking to the script’.

Interviews can also be scheduled, unscheduled, or semi-scheduled, which refers to whether questions are asked in the same order or not. Scheduled tends to go with structured, and is more suited to research questions where its important to reduce biases. Unscheduled, by contrast, gives you the flexibility to go into depth in an interview, as and where the respondent seems to be opening areas up. Again, semi-scheduled can be a good compromise, meaning there’s a provisional order to your interview, but scope to go ‘off track’ if it feels like moving the order around will be productive.

As suggested above, a semi-structured, semi-scheduled approach is a good option—and commonly used—alongside a wide variety of qualitative counselling and psychotherapy research methods, including interpretative phenomenological analysis (IPA), grounded theory, and thematic analysis. However, if you are wanting to conduct a very large Q grounded theory or thematic analysis study, a wholly unstructured, unscheduled approach may be best.

Interview Schedule

However you do your interview, even with the most unstructured of approaches, it’s generally good to prepare a schedule or protocol of how the interview is going to go. This is absolutely essential if others are going to be doing the interview as well as you, so that they know what to do and your interview is consistent across participants.

In one of my first research studies, on therapists’ experiences of relational depth, I developed a very basic interview schedule, which consisted just a few questions and prompts:

• Could you tell me about a time when you really felt that you met with a client at a level of relational depth?

  • What was that experience like?

  • What did you take from that experience?

  • What do you think your client took from that experience?

  • How did that experience come about?

• What facilitates your ability to meet clients at a level of relational depth?

• How important do you think that meeting clients at that level of depth is?

An example of a much more extensive interview schedule, for our study of clients’ experiences of working with preferences, can be found here. This was designed for use by myself and another interviewer; and with a team of very experienced international researchers discussing, drafting, and finalising it. As an interview schedule, however, the heart of it was still the questions to be asked. In this case, the main question was:

• What, if any, preferences did you have when you came into therapy?

And then, for each preference, we asked:

• Where do you think this preference might have come from?

• How, if at all, did this preference change over the course of therapy?

• How important was it to you that this preference was (a) elicited/discussed, and (b) accommodated in the therapy?

When writing a schedule, it may be useful to note follow-up prompts for different questions: potential responses you can use after the main question to help the participants go deeper into the exploration. For instance, for the question:

• Where do you think this preference might have come from?

You might then prepare prompts like:

• Was it related at all to your earlier life?

• Have you had therapy before? Was it based on those experiences?

• Are there any other origins you can think of?

On our schedule for the preference study, you’ll see that we also included:

• Notes on the general approach/style to be taken in the interview

• Materials to be taken to the interview and other general instructions

• Approximate wording for the introduction to be given to participants

• Additional questions

In this case, there’s also some guidance on questions that were asked outside of the scope of the main study.

Generally, there’s no harm having as much detail as possible in your schedule, even if it’s about engaging with your participants in an entirely unstructured and unscheduled way. Write it down—it’s a great reminder for you about what to do, something you can draw on when you write up your Methods section and, if you’re writing a thesis, a great resource to put in your Appendices: showing your examiners that you were really clear, consistent, and methodical in what you did.

Piloting

Before finalising your schedule, and definitely before running your interviews, try the interview out on someone—ideally a few people. And who better to start with than yourself. As well as giving you a real sense of what it’s like being interviewed with this schedule (and, perhaps, what’s working and what needs changing), it can help you unpack your biases and expectations with respect to the research question (again, something you may then want to write up and include as an appendix). Even if you aren’t part of the target group for the research study, you can role play it. Then try it out as an interviewer—perhaps with friends, colleagues, or peers—to get a sense of how it feels running the interview (bear in mind you may need ethical approval before doing this). If they are not part of your target group, again, they can always role play, though you will probably want to also pilot the interview with someone who is part of your target group before moving in to the main phase of interviewing. And remember, when you write up, you can describe this piloting process, showing your care and methodicalness in developing and testing out your interview schedule.

In fact, I generally encouraged my research supervisees to transcribe their pilot interviews, and even do some initial coding or analysis on them. That’s not suitable to all methods (particularly if you’re keen to go into each subsequent interview with an entirely open and ‘unbiased’ mindset), but it’s a great way of checking whether you’re data is making sense: that is, whether you’re actually getting meaningful answers to the questions that you’re asking. At the very least, ask yourself: ‘What have I learnt from this/these interviews (including the one with yourself) to the question(s) that I am asking?’ If the answer is ‘nothing’ or ‘I’m really not sure’, you may want to revisit your interview schedule or the focus for your project. Ideally, you’re coming away thinking, ‘Wow, those were some great initial answers to my questions… I’m hungry to learn more.’

Can you include data from your pilot interviews in your main analysis? Ideally, with most methods, not—formally, it’s an activity where you are preparing for the actual method you are going to use. But, as above, it’s great to write up your pilot interviews in your Methods section, and particularly what you have learnt from them. But some approaches, particularly larger Q ones (where there’s less focus on consistency or unbiasedness across interviews), may see less problems folding in your pilot interviews into your main data. If you’ve got really rich and meaningful data from them, why not use it?

Dialogue

Except for very structured, ultra-small q interviews, one of my main pointers for conducting interviews in counselling and psychotherapy research would be to see them as dialogues—with the aim of finding answers to the question(s) you are asking. Too often, particularly with trainees, there is a tendency to conduct interviews a bit like TV’s Question Time: with lots of questions, one after the other—and the interviewer’s nose in their interview schedule—without enough time, space, or attention to really explore the participants’ experiencing or perceptions in depth. I’m sure this often comes out of the interviewer’s anxiety: a worry about what to say next, and a concern to keep things going. But an overly-scheduled interview, with lots of quick fire questions, generally doesn’t allow the richness and depth of a participant’s experiences to emerge. People aren’t always able to answer well the first time around—to say what they really mean—so the interviewer needs empathic reflections, follow-up questions, prompts, paraphrases, summaries (many of the skills you may have learnt as part of a counselling training) to help the participant unpack what has really gone on for them. Below is an example of such dialogue from our study of clients’ experiences of preference work. The participant has already said that they came into therapy with a preference for ‘structure’ but, as an interviewer, I’m using reflections and further questions to try and understand more about what that means.

Interviewer: What would you say your main preferences were when you came into the therapy? You’ve already said about– there was one about structure, there– say a bit more about that.

Participant: ….So like you say, structure was important to me. I didn’t– I’ve never done anything like this before, so it’s completely new to me. I didn’t know what I should be talking about, or how to achieve those goals. So it was more kind of guidance, and what can we do to– that’s going to [pause] […] less anxious, um, I don’t know. I don’t know. I’m completely lost about how to get to those goals. So my structure would be what– what can we do to bring about those changes, how do we work towards that, what– um, so that at the end of the session, you know, I’d think– or I’d come back the next week and say, ‘Have you felt less anxious?’ and my initial reaction was that, ‘Well no, I haven’t felt less anxious, because why would I, nothing’s changed. I’ve done nothing to change it. I don’t know what to do to change it. Um… I’ve had no guidance’, so, yes, my- my answer to the question would be the same, it’s […] unless I’m doing something different.

Interviewer: So you really wanted to be… guided, and have something to do, say in between sessions?

Participant: Yeah, that would have been nice. Yeah. You know, I’ve never done this before, so I didn’t have any expectations. It was just, ‘Let’s see where it goes.’

Interviewer: Yeah, but you wanted– What you’re saying– Did you have that, like when you started therapy, were you thinking, ‘I’d really like some structure,’ or was it something that kind of emerged as the therapy continued?

So we don’t just move on from ‘a preference for structure’ once the participant has said it. Rather, we circle around it, try and go deeper, explore what the participant really means by it and how it links to other responses. It’s a process, all the time, of deepening understanding—again, just as you might do in therapy if you were trying to help a client make sense of particular experiences.

You can see that, in this last question, I’m trying to understand in more depth how this preference emerged. What’s going on in my head is, ‘I really want to understand what the participant wanted in therapy and why?’ That, those core research questions, are my focus, and I’m trying to engage with the participant in a range of different ways so that we can answer those questions. So, at those points, I’m not really thinking about my interview schedule. It’s something I’ll come back to, and I’ll try and make sure I’ve asked all the questions I’ve wanted to; but, at those times, it’s the overall objective that is the orienting point to the interview. I genuinely, deeply, want to discover—with the participant—what the answers are to my research questions. Indeed, I sometimes think that the best interviews are when the interviewer has just one main question, and riffs around it, with the interviewee, in a variety of ways to answer it as best they can.

Interpret along the way

What you can see in the interview above, and my second key pointer for most kinds of medium-to-large Q interviewing, is to try and make sense of what the participant is saying as you go along. Far better than trying to interpret what the participant was saying once you’ve got your transcript, do it as you go along with the participant. Because you’ve got them there to help you, and guide you, and tell you what it is that they actually mean. For instance, in the example above, they’d said that they wanted ‘structure’, but what did this actually mean, and were they saying they wanted guidance or something else? I wasn’t sure, and I asked.

Lots of times in interviews, you’ll be sitting there thinking, ‘I’m not really sure what this person is trying to tell me.’ That’s nothing to be ashamed of—it’s a really valuable indicator to you that you need to be asking more. You can even say to a participant, gently and kindly, something like, ‘Sorry, I didn’t quite get that, can you explain it to me?’ or ‘I think what you’re saying is …, Is that right?’ If you leave an interview really confused by what a participant has told you, chances are you’ll struggle to make much sense of it once it’s transcribed. And, of course, participants won’t always be able to make sense of things or tell you what they really mean. But to the extent that participants can explain and describe their experiences in depth, use the interview—itself—as a way of unpacking all that richness and meaning. In my own experience, I’ve been amazed by how much research participants can actually make sense of their own ‘material’, themselves—given time, space, and a dialogical sounding board to help articulate and explicate on what they are saying. And that way, when you leave the interview, a lot of the hard work of the analysis has already been done.

Just related to this, a point my colleague Gina Di Malta raised, is that it’s important to try and stick to the participant’s own words as much as possible, rather than introducing your own terms and ideas (again, a bit like therapy). You want to interpret, but you want that interpretation to be one of ‘unpacking’ the participant’s meanings, not introducing terms or conceptualisations from outside. So a question like:

• You said you wanted ‘structure’, can you say more about what that means to you?

Is probably better than one like:

• By structure, do you mean having an agenda for the sessions?

Given the power differential in the interviewing situation, a ‘yes’ to the second question really isn’t going to tell you much. Did they really want to have an agenda for the sessions, or were they just ‘deferring’ to you to be polite?

keep to task

Key pointer #3: you’re not the participants’ therapist, and you need to come away from the research interview with answers to the research questions that you’re asking (at least, in the ideal). Something I see a lot in supervisees’ interviewing, particularly when they’re training in a person-centred or relational approach, is that they tend to fall in to a non-directive, therapeutic mode of being: following the participant in whatever the participant wants to talk about. Of course, it’s important to be sensitive, empathic, and non-judgmental when you’re interviewing—and not overly-authoritarian—but participants may well come into the interview with you with things that they want to talk about or tell you about, and what they want to say may not relate in any particular way to what your research questions are asking. A participant, for instance, might want to tell you about difficulties in their marriage when you’re actually focusing on their experiences of a particular service; or they might want to tell you about their experiences of a service when your research project is actually focused on their childhood experiences. Participants have every right to want to tell you what they want to tell you, but it’s both ethically and methodologically important that you help steer the conversation to what you’re research is about. Otherwise, you can end up leaving the interview without any useable material and, more importantly, your participants can go away feeling confused and exposed by a process that was different to what they were invited in to.

So even though participants may take the interview off in all kind of directions (and that’s their right to do so), your role is to gently, sensitively, and compassionately bring them back to the main points of discussion. That doesn’t need to be rude or abrupt: if, for instance, a participant is really going off track, you can gently ask them how it relates to your key research questions, or thank them for their response and go on to the next question. And, in any interview, there’s bound to be material that is less relevant to the researcher’s question(s). In a sense, the issue is less about there being lots of ‘irrelevant’ material, and more about their being insufficient relevant material to be able to answer your research question. Having said that, transcribing and then trying to analyse page after page of material that, actually, isn’t much use to your research can be quite a heart-sink. Again, that’s why it’s really useful to do a few pilot interviews and a bit of an analysis, to make sure that the way your interview is set up is getting you the answers you want.

Keeping an interview on track means that, at times, you may need to be quite directive. For therapists schooled in the idea that directivity is just one step away from satanic worship, adopting a more proactive and leading stance can feel challenging: the natural tendency is just to go with the client/participant and not interrupt, structure, or lead. And, as above, there’s a lot of relational counselling skills that can be really valuable in interviewing work. But interviews do need to be more than just an unstructured, unfocused chat: again, not just for you, but out of an ethical duty to your participants to stick to ‘what you said on the tin’—they didn’t sign up for therapy, so you can start providing it for them.

Below is an excerpt from an interview, from the same study on client preferences, which demonstrates how an interviewer can gently and sensitively focus the interview process. In this case, the participant has been talking about a preference for a therapist who was challenging-but-supportive, but then goes on to talk about a preference for a female therapist. The interviewer positively affirms the expression of the latter preference, but then invites the participant to say more about the original preference so that they can explore it in more detail and systematically:

Interviewer: I guess there are lots of different preferences back on who your therapist is, and what the…

Participant: Oh yes.

Interviewer: …treatment is and…

Participant: Yes, I did prefer women because I just thought I would be more relaxed with that.

Interviewer: That's a good point. That's a really good example of preference, but what you said before, I'll just come back to that because that was really interesting as well. You were saying that you kind of have a preference, so someone who was a bit challenging but also quite supportive. How would you phrase that one?

Fear

Let’s be honest, interviews can be pretty scary to do especially if, like me, you’re natural tendency is towards being quite shy and unconfident. You’re interviewing someone who, pretty much by definition, knows more about something than you, and you may be interviewing people in positions of authority or power. You want to look good: you don’t want to babble away, lose your recording device, or have participants leave the interview thinking, ‘What kind of moron was that!’ Recognising any fears, of course, is the first step in managing them, and talking them through with peers or supervisors can be a really valuable next step. That can help normalise any anxieties, and also help you think about strategies for dealing with them. Ideally, you’re going into the interview feeling pretty calm, so that you can really listen to your participants. You want to have your head in your participants’ worlds—not in your own anxieties. And you also need a degree of confidence to keep your participant to task.

Having said all that, it’s also worth remembering the Yerkes–Dodson law: a bit of arousal isn’t a bad thing, and can help you be focused, attentive, and organised. It also conveys to your participant that you’re taking them and their time seriously: too laid back and your participant might feel a bit taken for granted. And, whatever else, please don’t fall asleep while doing an interview!

Stonewalled

What if you’re interviewing someone who, however, hard you try, doesn’t seem to want to give you much, or just doesn’t seem to be able to give in-depth responses? You’re getting short, one sentence answers; you probe, prompt, try to ‘unpack’ what they’re saying, but it’s just more one sentence responses, ‘I don’t knows’, or even silences. Or perhaps your participant has something that they’re so keen to tell you that you just can’t keep them to task: nothing they are saying—however hard you try—is related to your research questions.

Of course, ethics comes first. To repeat, your participant has the right to come into the interview and do, or not do, what they want (within reason), so if it’s clear that they don’t want to say more or go into more depth, that has to be respected. More than that, it’s important that the participant comes away from the interview feeling that their contribution has been valued, and not that they’ve let you down in some way.

In my own experience and that of my research supervisees, it’s very much the norm that, say out of eight interviews, at least two or three might be more limited in content. So if you’re finding that you’re not getting much from a particular interview—and you’ve tried, as much as would be reasonable and respectful, to invite more, without success—then it’s generally best just to accept that that is how that interview is going to be. In a sense, the quality and depth of a research project is not defined by how many ‘bad’ interviews you have but how many ‘good’ ones there are. And one option, if you are finding that a number of your interviews are quite limited, is simply to do more. Having said that, even where participants give relatively limited responses, the material may still be very helpful: giving an indication of the range of different responses that may be out there. Also, if you’re doing a smaller q study, with some quantification of responses, more limited interviews can still help you develop a sense of how many people experience or see things in a particular way.

Of course, if it’s the case that a large proportion of your respondents can’t give you in-depth responses to your interview questions, then that probably says something important about the way your interview is structured, or what you are trying to do. Again, that’s why it’s so important to pilot your interview schedule and to see whether people—including yourself—can give rich, deep, and interesting answers to the questions you are asking.

Ethics

A few further words on the ethical side of the research interviewing process.

Ethics, as always needs to come first. Interviews can be extremely rewarding for participants, but there are also some risks to be mindful of, particularly if you are exploring highly sensitive topics (for instance, clients’ experiences of childhood difficulties). Some pointers:

• Make explicit in the information sheet what the research will involve, including potential risks, so that prospective participants know what they are signing up for.

• Empathy and a non-judgmental acceptance should be de rigueur throughout the interviewing process: to repeat, you want your participants to leave feeling that their experiences and perceptions have been heard and are of value.

• Pay close attention to maintaining your participants’ confidentiality, particularly if materials are going to be made publicly available (for instance, on a thesis University depository or in a journal). Also, be extremely careful with audio files—it’s a lot easier for participants to be identified if their voices, as well as the content of what they say, is disclosed.

• Hope for the best but plan for the worst. What happens, for instance, if your participant gets extremely distressed during your interview and says that they are going to kill themselves? Make sure you have strategies in place to respond to such emergencies (for instance, making it clear in your information sheet that you would tell their GP if there was serious risk of harm, and providing links to support services like the Samaritans).

• Be careful (as above) not to slip into a therapist role. Some of your interview may be therapeutic for the participant, but the focus should remain on answering your research questions rather than healing for the participant, per se.

Read up on it

Finally, as with any method, it’s important to explore the contemporary literature on interviewing, to get a deeper sense of how it can be done, the issues that can emerge, and different tips and strategies for optimising benefit. My own personal bible on interviewing, for many years, was Steinar Kvale’s (1996) InterViews, now in its third edition as Brinkmann and Kvale’s (2014) InterViews: Learning the craft of qualitative research interviewing. The book gives a brilliantly humanistic, relational guide to the interviewing process. Sage also have a series of videos on in-depth interviewing that you may be able to access.

Acknowledgement

Thanks to Gina di Malta, and trainees on the PsychD Counselling Psychology Programme at the University of Roehampton for suggestions and advice.

Photo by Christina@wocintechchat.com on Unsplash

DISCLAIMER

The information, materials, opinions or other content (collectively Content) contained in this blog have been prepared for general information purposes. Whilst I’ve endeavoured to ensure the Content is current and accurate, the Content in this blog is not intended to constitute professional advice and should not be relied on or treated as a substitute for specific advice relevant to particular circumstances. That means that I am not responsible for, nor will be liable for any losses incurred as a result of anyone relying on the Content contained in this blog, on this website, or any external internet sites referenced in or linked in this blog.

Using Research Evidence to Predict and Optimise Therapeutic Benefit: A Multilayered Approach

How can we use research data to inform and improve therapeutic practice? When I wrote my book Essential research findings in counselling and psychotherapy (Sage, 2008), I did what most writers in the field had done: I tried to organise and make sense the evidence by different ‘factors’. I used the usual suspects: client factors (e.g., the client’s motivation); therapist factors (e.g., the therapist’s gender); relationship factors (e.g., the amount of goal agreement); technique and practice factors (e.g., using two-chair work); and orientation factors (e.g., working in a person-centred way). That gave a fairly simple and clear taxonomy and meant that it was possible to describe the relative contribution of different factors to therapeutic outcomes. For instance, one might estimate, based on the most recent evidence, that approximately 40% of variance in outcomes is due to client factors; 30% due to the relationship; 15% to therapist factors; and 15% due to the particular techniques, practices, or orientation used. This can then be neatly depicted in a pie chart, like Figure 1.

Figure 1. Illustrating the Contribution of Different Factors to Therapeutic Change

Despite its clarity, organising research evidence in this way has its limitations. One very obvious one is that it implies that each of these factors is discrete when, of course, they are likely to inter-relate to others in complex, mutually reinforcing ways. Another problem, more directly related to the framework developed in this article, is that they tend to infer that each client is influenced by each of these factors in the same way and to the same extent: that relationship factors such as empathy, for instance, lead to 30% of outcomes for Client A, and also for Clients B, C, and D. The reality, however, is that Client A may do very well with empathy while Client B may not; and while relationship factors may be essential to Client C’s recovery, Client D may do very well without them. Indeed, much of the cutting edge research in the psychotherapy field—by leading figures such as Zachary Cohen and Jaime Delgadillo—is on the particular factors that lead particular clients to do particularly well in particular therapies; and the algorithms that can then be developed, based on such evidence, to optimise benefit. Organising the evidence by factors may also limit its utility for therapists. As practitioners, we do not tend to think about our work, systematically, in terms of these different factors (e.g., ‘What can I do to improve myself as a therapist?’ ‘What can I do to improve my relationship?’); and it is also important to note that different factors may have very different implications for practice. Knowing, for instance, that clients with secure attachments do better in therapy than those with insecure attachments (a client factor) does not really tell us anything about how to work; while knowing that clients tend do better when their therapists are warm and genuine can have important implications for practice. So although these factors, in Wittgenstein-ian terms, have a ‘family resemblance’, they are actually quite distinctive things.

The aim of this article, then, is to describe a way of organising and conceptualising therapy research evidence that addresses some of these problems: allowing for a more nuanced, comprehensive, and personalised conceptualisation of data; and potentially more useable by therapists. The essence of this framework is a pyramid (or funnel, see Figure 2), with different layers of evidence at increasing degrees of specificity and proximity to the client. Each layer builds on the previous ones: from research evidence that is relevant to all clients to research evidence that is specific to a particular client in a particular session. As this pyramidal form suggests, as we move upwards, evidence may become more sparse. However, because of its greater specificity, and because it is most proximal to clients’ actual experiences—such evidence may be of greatest value. For instance, research suggests that clients generally do better when therapists are empathic (Layer 2), but if evidence exists that the opposite is true for highly paranoid clients (Layer 3), then the latter finding would tend to take precedence to guide practice with a highly paranoid client. However, if it was then established that, for a particular highly paranoid client, they had a strong preference for an empathic therapist (Layer 4), then this higher-layer evidence would take precedence over the group-specific (Layer 3) finding.

Figure 2. A Pyramidal Framework for Organising Therapy Research Evidence

The foundation of the pyramid, Layer 1, is general evidence on client and extra-therapeutic factors that tend to determine good outcomes. For instance, clients who are psychologically-minded tend to do better in therapy, as do clients with more social support. These factors are separated off from other factors (depicted in Figure 2 by a dividing line), because they are less relevant to what therapists do. Rather, they are the grounding—to a great extent outside of the therapist’s control—as to how therapy is likely to proceed. In this respect, these general factors have an important role in predicting outcomes—and, indeed, may explain by far the largest proportion of variance—but do not have much role, per se, in informing or shaping how therapists work.

Note, the term ‘tend to’ indicates that, while these findings are drawn from generally representative samples (or samples assumed to be generally representative), this is not to suggest that these factors will be true for each and every client. Rather, this is evidence, across all clients, of averaged tendencies, around which there will always be considerable group-, individual-, and session-layer variance.

Building on these general client and extra-therapeutic factors are general factors that are related to the therapist and their therapy (Layer 2). This includes therapist factors (for instance, therapist gender), relationship factors (for instance, the alliance), and technique factors (for instance, use of cognitive restructuring). These are findings that reach across all clients and, although still averaged trends, can be very useful for therapists to know. In the absence of any other information, they provide a useful starting point for work: for instance, be empathic, listen, or self-disclose to a moderate extent.

At a greater layer of specificity (Layer 3) is evidence of particular factors that tend to be associated with helpfulness for particular groups of clients. By far the greatest amount of evidence here focuses on clients grouped by particular mental health diagnoses—for instance moderate depression or obsessive-compulsive disorder—as reviewed and operationalised, for instance, in National Institute of Health and Clinical Excellence (NICE) guidelines. Considerable research is also now available on clients with particular cultural identities (e.g., people of colour, lesbian clients), and what tends to be most effective for them. There is also a wide range of research on other ‘aptitude–treatment interactions’ which identifies the factors that tend to be most effective with particular groups of clients. For instance, clients who are more reactive tend to do better in less directive therapies, while the reverse is true for clients who are more compliant. Of course, clients may be members of multiple groups—‘intersectionality’—such that practices indicated may be complex or, potentially, contradictory. Tailoring therapies to particular client characteristics is what Barkham terms ‘precision therapy’, linked to the wider development of ‘precision medicine’: ‘predicting which treatment and prevention strategies will work best for a particular patient’ (NHS England).

Moving up in specificity, to Layers 4 and 5, entails a shift towards individual-level research and data gathering (Figure 3). This is, perhaps, the most important and novel part of the framework being suggested here, because a continuum is being proposed from (a) general- and group-level research to (b) contemporary, individual-level monitoring: one segues into the other. In other words, the framework suggests that what researchers do ‘in the field’ is not so different from what therapists do when they are working with individual clients using routine outcome monitoring (ROM): it is all part of one broad spectrum of using data to help inform practice. This may be helpful for practice because it de-mystifies ‘research’ and puts it on a equal footing with things that a practitioner would typically do. Now, research about populations or groups is not something that researchers do far away on some other planet, but is an extension (broader, but less specific and proximal) of what therapists are, actually, doing all the time. That does not mean it can be waived away, but it does mean that it can be considered a friend rather than enemy (‘the facts are friendly’, as Carl Rogers said).

Describing individual-level data gathering as ‘research’ is a somewhat unusual extension of the term. Almost by definition, ‘research’ is seen as involving generalising from specific individuals to the wider group or population. However, if research is defined as ‘a detailed study of a subject, especially in order to discover (new) information or reach a (new) understanding’ (Cambridge Dictionary), then generalisations can also be at the individual client layer: from, for instance, one session to another, or from assessment to across the course of therapy as a whole. Individual-layer research like this is not something you would see published in a journal, nor could it be summarised in a book like Essential research findings. Even with individual-focused research methods like autoethnography or heuristic research, the aim is to reach new understandings that are of relevance across clients or contexts. But with the individual client-layer research described here, the aim is solely to use data to reach new understandings about this individual client. It is a form of systematic enquiry which the therapist, themselves, does, to help optimise their therapeutic work with the client by drawing on data.  

Figure 3. Individual Level Research

Layer 4, like Layer 3, entails the use of data, prior to the commencement of therapy, to estimate what is most likely to be helpful for a client. While Layer 3, however, makes such assumptions on the basis of group characteristics, Layer 4 focuses exclusively on that client’s individual uniqueness. This is the complex, rich mixture of characteristics and experiences that make the person who they are: irreducible to any particular set, or combination, of group characteristics. In terms of system theory, this is their ‘emergent properties’; in terms of the philosopher Emmanuel Levinas, their ‘otherness’. Understanding how data at this layer may be captured and integrated into therapy is, perhaps, the least well-developed element of this framework. However, one notable and well-researched element here is the client’s preferences: recorded, for instance, on our Cooper–Norcross Inventory of Preferences (C-NIP) at assessment. The focus of such individual layer research, then, is on what this specific client needs and wants from therapy; and the incorporation of such findings into the therapeutic process.

Finally, at the highest layer of specificity (Layer 5), is the use of data to guide the ongoing process of therapy, as in the well-researched and -developed practice of routine outcome monitoring (ROM). In ROM, the therapists uses data from ‘outcome forms’ (like the CORE-10 or PHQ-9), and potentially also ‘process forms’ (like the Session Rating Scale), to track how the client is doing, and to try and adjust the therapy accordingly. For instance, if the client’s layers of symptoms are worsening, the therapist may draw on pre-specified ‘clinical support tools’, such as a protocol for reviewing the therapeutic alliance with the client. In this way, ROM can be considered research at the highest layer of specificity: generalising from data captured at particular points in therapy (for instance, at the start of each session), to the therapeutic work as a whole. Barkham terms this in-therapy, iterative uses of data as ‘personalisation’—distinct from the ‘precision’ tailoring of Layers 3 and 4.

Note, even at these highest layers of specificity, data still only ever gives indications of what might be of benefit to a client at a particular time, not what is. Client preferences, for instance, tell us what a particular client thinks will be helpful, but there are no guarantees that such practices are of benefit; ROM predicts when clients may most be ‘off track’, but there are still numerous sources of ‘error variance’ meaning that, in fact, some of these clients may be doing very well (what has been termed ‘paradoxical outcomes’). As we move up the layers, then, we may move from distal to proximal forms of evidence, less to more trustworthy, but even at the highest layer, we are only ever dealing with approximations. Hence, while higher layer data, where present, may deserve prioritisation, best practice may ultimately come through informing clinical work with data from across multiple layers.

In fact, Layer 5 is probably not the highest and most specific layer of data usage to optimise benefits in therapy. At every moment of the therapeutic work, therapists will be striving to attune therapeutic practices to what they perceive—consciously or unconsciously—as beneficial or hindering to clients. A client seems to become animated, for instance, by being asked about their brother, and the therapist enquires further; a client glances away when the therapist asks about the psychotherapy relationship and the therapist seeks another way of addressing the here-and-now relationship. Stiles refers to this as therapist ‘responsiveness’, and this is represented as a spinning circle right at the top of the pyramid (Figure 4). Bill Stiles, in a personal communication, has written:

Representing responsiveness research as a (spinning?) circle (wheel? ball?) at the top seems to me to convey both the recursive feedback idea (circle, spinning) and the potentially high specificity (possibly millisecond-scale, e.g., responsive adjustments in mid-sentence due to facial expressions).

These five layers of evidence, then, segue into the moment-by-moment, ‘evidence based’ adjustments that therapists are constantly making throughout their work. And, as the highest layer, such responsiveness may be most proximal and attuned to what clients will find most helpful. Nevertheless, in the absence of such proximal information, each of the preceding layers will give valuable information about where best to start with clients. Moreover, as suggested in the previous paragraph, given the vagaries and potential errors inherent in each layer of data (including responsiveness: for instance, the therapist may misread the client’s reaction, or the client may be hiding it through deference), it is probably a combination of evidence from across the layers that is likely to be most beneficial in successfully guiding therapy.

Figure 4. Layers of Evidence Segueing into In-Session Responsiveness

Although each of these layers of evidence have the potential to inform therapeutic practice, different individuals, training programmes, or services may place emphasis on very different layers. For instance, in the IAPT model (Improving Access to Psychological Therapies, now NHS talking therapies), based on NICE guidelines, practice is nearly-exclusively drawn from evidence at Layer 3 (in particular, diagnoses-specific evidence), with little consideration for other layers (see Figure 5). Even responsiveness to the needs and wants to the individual client, during IAPT practice, tends to be subsumed to manualised, ‘evidence-based’ guidance.

NHS/IAPT Emphasis on Diagnosis-Specific Evidence

On the other hand, in approaches like Scott Miller’s feedback-informed therapy, there is a particular reliance on the most proximal evidence: the client’s immediate feedback through ROM (Layer 5), as well as a responsiveness to the particular client in the particular moment (Figure 6).

Figure 6. Feedback-Informed Emphasis on Proximal Data

In contrast to Layer 1, Layers 2 to 5 provide opportunities for therapists to enhance their practice (Figure 7). This is in two respects. First, at a basic level, skills and competences can be developed in practices that have been shown to lead to beneficial outcomes. This is particularly Layer 2 general relationship factors (e.g., enhancing levels of empathy) and technique factors (e.g., developing skills in two-chair work). In addition, at a more meta-level, knowledge and competences can be developed in tailoring practices to group- (Layer 3), individual- (Layer 4), and therapy- (Layer 5) specific evidence. For instance, at Layer 5, trainees can be taught how to use ROM data to monitor and enhance therapeutic outcomes, particularly with ‘not on track’ clients. Such training may be based on informal guidance and feedback (e.g., through supervision) or, itself, may be evidence based: using data to feed back to trainees how they are doing on particular competences. A supervisor, for instance, might rate segments of their supervisee’s audio recordings, across multiple time points, on a practice adherence measure like the Person-Centred and Experiential Psychotherapy Rating Scale (PCEPS). This moves us into the realm of ‘deliberate practice’ and, indeed, a separate pyramid could be developed for the use of research in training: from the most general evidence about factors that improve practice to therapist-specific data on what an individual practitioner might do to improve their outcomes.

Figure 7. Opportunities to Develop Therapist Competences and Meta-Competences

In fact, Layer 1 probably does also offer opportunities for enhancing the beneficial effects of therapeutic work—perhaps to a great extent—though this is rarely the focus of study or training. Here, emphasis is on how clients might be empowered or enabled to develop skills in using therapy most effectively. A good example would be the ‘resource activation’ work of Christoph Flückiger and colleagues, which invites clients to draw on their own strengths and resources to ‘drive’ the therapeutic process. In addition, this is the layer at which therapists might be developing competences in social and political advocacy practices. Developing the ability, for instance, to challenge unjust organisational policies might help to address the psychological distress brought about by racial discrimination.

Of course, research evidence is not the only sources of guidance on how to practice. Therapists may also draw, for instance, from theory, their own experiences, and from their supervision work. These sources are likely to be interlinked in complex ways, but for simplicity sake we can present them as per Figure 8.

Figure 8. Multiple Sources of Guidance on Practice

And, as with the layers of evidence, different individuals, training programmes, or services may place emphasis on very different sources to guide practice. In NHS Talking Therapies, for instance, practice is primarily based on research evidence (Layer 3, diagnosis-specific) (see Figure 9). By contrast, in much of the counselling field, practice is primarily guided by theory, supervision, and the therapist’s own personal experiences—as well as responsiveness in the specific moment—with research evidence playing only a very minor role (Figure 10).

Figure 9. Sources of Practice in NHS Talking Therapies

Figure 10. Typical Sources of Practice in the Counselling Field

Again, one might argue that, in best practice, there is an openness to drawing fully from all potential sources.  

This pyramidal framework for drawing on research evidence is very different from the ‘hierarchy of evidence’ as used, for instance, in NICE clinical guidelines. While the latter ranks research according to its ‘objectivity’—placing randomised clinical trials and their meta-analyses at the top and expert opinion at the bottom—the present framework makes no assumptions about the relative worth of different methodologies. Qualitative research, for instance, may be a very powerful means of understanding what particular methods or practices are particularly helpful for particular groups of clients (Layer 3). Indeed, in this framework, the data that may be of most value to particular episodes of therapy—by being most proximal—is individualised ROM data: very different from the kind of generalised RCT data prioritised in the standard hierarchy of evidence.

Conclusions

When trying to make sense of the vast body of psychotherapy research evidence, there are many different ways of organising the research:

• Different factors (therapist, client, etc)

• Degree of ‘independence’/rigour of the research (the IAPT/NICE approach)

• Effective treatments for different problems (again, the the IAPT/NICE approach)

• Evidence for different therapeutic approaches overall

• The proximity of the research evidence to the actual client and session (what is being proposed here)

Of course, there is no one right way, and these different organising principles can be combined in a wide variety of ways. For instance, the evidence at each layer of the present framework could then be organised by degree of independence of the research, or by different factors. However, each of these frameworks do prioritise and emphasise, even if implicitly, different elements of the research evidence. In the present one, there is as implicit privileging of data that is most proximal to the client—the ‘top’ of the pyramid. This can be seen as emerging from my own humanistic, existential, and phenomenological ‘ontology’ (theory of being) and ethics, which tends to reject the positivist assumption that the universe acts—and can be understood as acting—according to general, underlying mechanisms and laws. Rather, there is an emphasis here on ‘otherness’ and the irreducibility of human being. That is, that human beings’ lived-experiences can be unique, and that focusing on the unique and distinctive aspects of that experiencing is an important element—both ontologically and ethically—of understanding the whole.

Having said that, as Nicola Blunden points out in her comments below, the approach presented here is therapist-centred, in that it is a framework by which therapists can use the evidence. That is consistent with the target audience of my ‘facts are friendly’ book, but it raises the question of what a client-centred, or relationship-centred framework for making sense of the research findings would look like. Perhaps that would start with a greater focus on, and nuancing of, ‘Layer 1’ evidence: What can the client do with this to maximise their therapeutic outcomes? Nicola also raises the interesting point of whether a pyramid is still too hierarchical: would a target or spiral be a better representation of the potential use of data in therapy?

The pyramidal framework presented here is a way of organising research data to inform therapeutic practice. The pyramid builds, in layers, from the most general to the most specific evidence of what works—and is working—for an individual client. This framework does not negate a more factors-based taxonomy—indeed, it can incorporate it—but emphasises, instead, the relative proximity of different data sources to the actuality of each episode of clinical practice. Perhaps what is most useful about this framework is it provides a means of segueing from general and group-level research to individual-level research—and then, even, on to responsivity in moment-by-moment practice. This may allow a greater integration of research data into practice: research, here, is not something separate from what therapists generally do, but something spread on a continuum from the most general to the most specific. This framework is also a means of representing the way different sources of evidence may be weighted in different approaches, as well as the weighting of research evidence against other sources of clinical guidance. And while this framework does not indicate which sources (research or otherwise) should be prioritised, by mapping out possibilities in this way, it hints at the potential value of all. While this framework is a work in progress, it may be a way of organising and making sense of the research evidence that encourage a broader, more encompassing, and more pluralistic conceptualisation of all its uses.

Looking for America: Some Reflections on our Road Trip USA

Let us be lovers, we'll marry our fortunes together.

I’ve got some real estate here in my bag.

I’ve had the words of Simon and Garfunkle’s America in my head since my teens. The glamour and pathos of travelling across the US: sad, soulful, stretching out. Paris, Texas too: Harry Dean Stanton’s endless walking, desert, roads.

My partner Julie and I started with a few days in Chicago, then flew to a conference in Madison, Wisconsin. Hiring a car, we drove west through Minnesota to Badlands in South Dakota and then on to Yellowstone in Wyoming (see map and string, below). After that, we turned south to Salt Lake and Bryce Canyon in Utah. Another turn west to Las Vegas then back east through the Grand Canyon to Santa Fe in New Mexico. Finally, we turned north to Colorado. A semi-spiral of about 4,500 miles driving in total: ten states, eight national parks, three weeks. My dad had lived in the United States in the 1940s and 1950s, and often talked about his trip to Yellowstone (or was it Yosemite), the giant redwoods, and the Grand Canyon. These places had come to have an almost mythical status in my mind.

Nearly all the Americans we met were very friendly and likeable (aside from two scarily right-wing taxi drivers in Las Vegas). And not in a fake, ‘American stereotype’ way, but with genuine warmth and openness. People talked to us: about their lives, their politics, their connections to England and Europe.

‘I love you accent. Where are you from?’

‘Just south of London. Have you been there?’

‘No, I’d love to, I’ve only ever been to Paris in Europe.’

‘It’s beautiful there isn’t it. We love Paris. Did you find it different from here?’

The sheer beauty of the American landscape was, perhaps, the most memorable aspect of the trip. The Grand Canyon, Badlands, Bryce Canyon, Yellowstone, Rockies, Great Sand Dunes… so many places that swallowed you up in their vast otherworldliness (see favourite pictures, below; and full album here). The Grand Canyon was like a cut-away through the Earth; Bryce Canyon had the most weird-and-wonderful red rock sculptures. Breath-taking, and lovingly cultivated through the American national parks system. On the road too, through Wyoming or South Dakota, mile after mile of rolling land beneath the widest of skies. I can see why American colleagues of mine, like Kirk Schneider, write so much about ‘awe’: truly an awe-inspiring region of our planet.

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While American landscapes swallowed us in, urban areas seemed to do the very opposite. Whether in smallish towns like Sioux Falls or large cities like Denver, we felt we just couldn’t find their ‘centre’: the place from which the town or city radiated out? ‘Strip malls’ in the suburb, criss-crossing motorways, empty downtown areas… each time we visited a town or city we tried to start at it beating heart, but it seemed to run through our fingers like sand. Centrifugal rather than centripetal: towns that dispersed, moved away. I realised that the centrelessness I had felt, some years ago, in Los Angeles wasn’t specific to that city, but was more generic to many American conurbations (though not all: New York, for instance, felt much more ‘centred’). It felt so different to our European towns and cities, with high streets and churches at their core. Perhaps, we wondered, it was historical: our towns had evolved when people walked. American conurbations had grown up around the car. But what of community, of people constellated together? For us, as Europeans, we had a powerful sense of disorientation and anomie.

Las Vegas was the worst: we just couldn’t wait to get out of there. Mile after mile of amusement arcades—soulless, empty, barren. The dominance of machines, noise, and flashing lights over any kind of human connection.

I recently read Edmund Burke, the conservative philosopher, for my book on social change. I wanted to look at some counter-arguments to progressive thinking, but haven’t stopped quoting him since. He was writing against the French revolution, and one of his main points was that, by trying to forge something new, we can end up destroying the subtle, nuanced, imperceptible relationships that make things the complex whole that they are. American towns, with their grids of streets and avenues seemed a good example of that. Mathematically perfect and efficient, but something seemed missing: the messiness, complexity, and historicity that gives things their richness, depth, and soul. We wondered if that was why religion was so prevalent in America: because it gave people a community that they did not have otherwise.

As we drove, we listened to several American short stories from The New Yorker. The most memorable was John Cheever’s The Swimmer, written in 1964 (we watched the 1968 movie with Burt Lancaster, also very good, when we got home). It’s the simplest of narratives: a middle-aged confident, handsome man decides that he’s going to swim through the pools of New Hampshire suburbia to get back to his home and his wife and daughters (spoiler alert). In the first few pools, people greet and welcome him, give him cocktails: the local, all-American hero. But as he swims on, it becomes evident that he’s not the success that he seems: neighbours whisper about him behind his back, mock him, tell him to get out of their pool, ask when they’re going to get their money back. Eventually, it becomes evident that even the family and home he thinks he is swimming back to is an illusion: he is ruined, failed, destitute. For us, there was something so poignant about the story, and so reflective of our felt-experiencing of America: beneath the American dream, beneath those straight, clean lines of achievement and success, something much more sad, lonely, and alienated seemed to lie. Edward Hopper’s Nighthawks (1942), which we saw in the Chicago Institute of Art (below), is famous for depicting something very similar about American existence.

We were surprised by how many Americans we talked to were ardent Trump supporters. Thoughtful people, and generally kind and generous, but adamant that Biden was selling America to the Chinese and that Trump was their last hope. Digging deeper into their worldviews, we found a passionate advocacy of ‘negative liberty’: to be free of external restraints and self-determining. ‘No one has the right to tell me what to do’, ‘Why should I support people who don’t work,’ ‘“Global warming” is just the liberal elite trying to control us.’ The pursuant of liberty, but without much sense that that freedom was always within a context and had repercussions for others. Perhaps it’s the space, the vastness that has inculcated a spirit of moving out without a sense of what we might be moving in to.

And, of course, the European settlers were not reaching out over empty, unpopulated lands. As we travelled, we heard story after story of the destruction of native American peoples by the Europeans. Massacres, the abduction of children, killing off the buffalo, forced conversions to Christianity. The complex network of peoples and cultures that had existed for thousands of years was destroyed like a hand through a spider’s web. We saw some acknowledgement of this in museums across the country, but it seemed at a very formative stage compared with, for instance, Aotearoa New Zealand’s acknowledgement of Māori traditions and rights. Racism in America also seemed compounded by the abduction and enslavement of millions of Black Africans, giving it multiple historical and cultural layers.

Julie and I talked about the Europeans who had first come to America and the kind of traces that they might have left: genetically as well as culturally. Not only were these people who wanted to escape religious persecution, but also those willing to brave the journey to a new and uncertain land. Perhaps the most driven of Europeans, or the most courageous, or those who valued independence above all else. A society of strong-willed, determined people: no threads to hold them back.

We also listened to the audiobook of John Steinbeck’s East of Eden during our drive, and managed to get most of the way through its 600 pages. It’s a saga of love and hatred between brothers—inter-generational pushing and pulling, freedom and relationality. America, to me, seemed a land of push, of space, of reaching out to beyond. A wonderful strength of possibilities; but, without the centripetal pull, at risk of dissolution, dispersal, destruction. Reaching out cannot go on forever. Negative liberty pushes, but in that push it can forget that we live, inevitably, within bounds; one person’s push is another person’s subjugation. The American landscape touched that part of me that wanted to reach out infinitely; but, in its social organisation, it reminded me of my desire for relatedness, community, and soul.

The last verse of Simon & Garfunkle’s America:

‘Kathy, I'm lost’, I said, though I knew she was sleeping
I'm empty and aching and I don't know why

Perhaps I felt a little closer to understanding that ache.

Cinema Paradise, Soho: Growing up with Contemporary Films

There was always a whir of excitement, whoever was ringing. First you pulled out the red jack from its socket—its windy, stripy cord attached—and plugged it into the socket for that extension. ‘Hello, Contemporary Films, Can I help you?’ Sometimes it was easy: ‘I’d like to speak to Mr Hedges,’ or, ‘Can I talk to Kitty Cooper in International.’ Then you pulled out the black jack and put it in to that person’s extension. There was a switch that you toggled to call that person—trying, as best you could, to emulate the ‘ring, ring’ of a phone—and then, when the person picked up, you’d let them know who was calling and leave them to it. Sometimes it was trickier: ‘How much is it to rent Battleship Potemkin?’ or, ‘We’re from the Kent University Film Club and we want to know when our films will arrive?’ Then we’d have to get Auntie Rose to rescue us. ‘Um…’ we’d mumble to the caller. ‘We’ll just put you on to someone.’ Then we’d pull the jack out, put them on hold, and sheepishly slide the phone over to Auntie Rose: she always knew what to do. There were small rotating tickers on the switchboard exchange that indicated how much the outgoing calls were costing: the faster they went, the more the units of charge. We used to ask Uncle Harry about the most expensive call ever. Apparently, my dad had once called America… for almost an hour. Uncle Harry told us that the ticker was going round like crazy and he was running up and down the stairs trying to get my dad off the phone.

We started ‘helping out’ on the switchboard of our parent’s film distribution company when I was about five years old and Davina, my older sister, was about six, in the early 1970s. The reception was on the ground floor of a tall, narrow building in Soho. At the back of the reception was Uncle Harry’s shop, with his desk and cash register, and walls covered with film projectors, projector lamps, and film cans. My parents used to say that most of the people who came to buy things were from the local Soho sex shops. Uncle Harry never seemed happier than when he sold a projector. That was rare though. Mostly he sold just a few projector lamps or fuses each day, sitting at the back of the shop and looking out onto Greek Street through a cloud of cigarette smoke.

Me, 1972, about six years old

Auntie Rose was warm, loving, cuddly: some of my happiest memories were sitting on her lap on the switchboard. She would often have the latest copy of The Puzzler in her handbag: a magazine full of crosswords, logic puzzles, and other games. Davina and I would do them with her: I liked the join-the-dots and wordsearches best. When we had finished one magazine she would give us 50 pence to go the local newsagents to buy another, and an ice lolly.

‘Auntie Rose’ and ‘Uncle Harry’ weren’t quite my uncle and aunt. Uncle Harry was the older brother of my dad’s first wife, who had died tragically in her 40s. They had three children together: my oldest sister Flo, and then ‘the twins’, Sue and Adi. A few years after his first wife’s death, my dad got re-married to my mother who was over 20 years his junior. When my dad set up his film distribution company in the 1950s, he had asked Uncle Harry to join him, and Uncle Harry ran the shop while my dad ran the rest of the company.  

I loved Uncle Harry but he could be quite stern. When I was about eight years old, I started going to the Soho amusement arcades, spending one or two pence on the penny falls or the ‘one-armed bandits’. One morning I lost about ten pence. I felt so bad about it, and so determined to win it back, that I did a terrible thing: I went back to the Office and stole a 50 pence piece from Uncle Harry’s cash register. I rushed back to the arcade and, within 20 minutes or so had managed to lose most of that 50 pence as well. Just as I was desperately shoving the last few coins into the penny falls, Uncle Harry appeared in the arcade and took me back to the Office. I guess my parents worked out I must have been there: I never quite knew how. They were particularly worried because, at least according to them, there had been a shooting at the arcade a few weeks before and they were ‘all run by gangsters’. I’m not sure Uncle Harry ever knew I’d stolen his fifty pence and, in fact, he was really kind when he walked me back.

***

My dad’s office was on the second floor. You got to it through his secretary’s office, with Charles Hedges, their publicity person, opposite. My dad had a black leather swivel chair that was brilliant to sit and spin in; a window with iron frames to look down onto bustling Greek Street; and a long black leather sofa—perfect for jumping on or napping. If we went to my dad’s office he’d offer us coffee then ask his secretary to make it. We’d have coffee and biscuits sat facing him in a low leather chair, peering out over his large, laminated desk.

My parents, 1973

Once, in my twenties, I did a psychodrama exercise where we had to imagine our parents as animals. I imagined my dad as a big friendly bear. He was warm, affectionate, social—already in his late 50s by the time I was born (about the age I am as I write this). He was a schmoozer—not much of a listener. He was also, as my girlfriends have endlessly remarked, very handsome: broad-shouldered with a wide, welcoming face and strong jaw. When I went back to Ukraine, where his parents had escaped the pogroms from in the 1890s, I could see where he got his looks: all the men there, I was amazed to see, seemed to have the same square-shaped frame as my dad… and me.

My mum’s office seemed more a place where work actually happened. It was down on the first floor, with most of the other employees. She was in charge of ‘International’. My mum typed at lightning speed and had one of the first Telex machines, which I loved feeding the strips of tape in to. Like my dad, my mum was very intelligent, but less confident. I always assumed she’d been put in charge of International because of her German roots. It was not something that she would easily talk about. She refused to watch films about the holocaust. I always thought it was because of how upset it would make her—she lost several close relatives in the holocaust, including her favourite cousin, ‘Little Katie’. At one film festival, though, she inadvertently saw a film with scenes about the Shoah and, on exiting, starting screaming at two German associates outside the screening room: ‘You see what you lot have done…’. It was rage, not sadness, that she seemed most afraid of unleashing.

***

When Davina and I weren’t on the switchboard we would be in Despatch with ‘the boys’. These were the young men who would receive, check, and send out the film reels to the various cinemas or societies that would rent the company’s films. I loved ‘splicing’: checking over the films that came in to see if there was any damage and, if so, using a splicing machine to put the undamaged ends together again. Sometimes we would watch films on the large, reel-to-reel machines that they had there for checking; or we would watch them in the small preview cinema on the mezzanine between first and second floors, where one of the boys would set up a film for us. I loved that dark, cosy cinema: sinking in to the plush velvety seats. Even better, sometimes I would be allowed to thread the film through the projector and run it. So many cogs, switches, and loops… each had to be exactly right or the film would get twisted and mangled.

The problem, though, was that there was hardly ever any good films to watch. My dad, being a communist since his 20s, had set up a film company that was one of the leading distributors of progressive and foreign language films. Great if you are a member of the Young Communists, but not if you are a five-year-old wanting some entertainment during the school holidays. There were a few Eastern European short films. But, God, they could really be terrifying. One that my parents used to show me at home, where we also kept a projector, was called The naughty little goat: about this cute little baby goat that runs away from its parents’ into the woods… and is eaten by wolves. I would watch it compulsively, glued to the screen and the crescendo of screeching Slavic violin as the goat broke from its farm and rushed headlong into the woods, never to be seen again. I have no idea why my parents showed it to me. Perhaps they knew I was going to be a psychotherapist and were preparing me for dealing with trauma!

When we were really little, the film that Davina and I wanted to watch over and over again was a short about the dangers of cigarette smoking. My dad also had some Marx Brother’s film (unrelated, as I came to learn, to Karl Marx), and we particularly loved Horsefeathers. Another favourite was called The Little Island. This was a 1958 cartoon about three characters who each prize one value (‘good’, ‘truth’, or ‘beauty’) over all others, and eventually come to blows over it (in the form of a terrifying knife fight escalating to nuclear holocaust). Looking back, it’s striking to me that the message of this film—the dangers of privileging one, monolithic set of values—is exactly what we articulated decades later in our ‘pluralistic’ approach to therapy.

Thanks to Uncle Harry, my parents also had the rights to the English Coal Board’s film archives, so that was another option: long infomercials about the British coal industry. When I got into my teens, my best friend James and I would scour through the dusty film canisters that my parents kept in the basement of our house to see if we could find something with some nudity in it. It was an endless, and always disappointing, search. At one point, we were quite excited to find a film called ‘the body’, but when we threaded it onto the projector it turned out to be a medical documentary.

***

Sometimes, Davina and I would go and play in the dilapidated adventure playground off Wardour Street. My parents didn’t like that much more than the arcades because of all the rusting old iron lying about. One time, I got a nail in my foot. Foyles, just around the corner, was a preferred option for whiling away an afternoon. As the biggest bookshop in the world, it seemed an endless maze of dusty book-lined corridors. The system for buying books was particularly archaic. First you had to line up at a counter to get a ticket for the book you wanted to buy. Then you’d walk over to the cashier with the ticket and pay. Then you’d get another ticket to take back to the first counter where they’d finally give you the book in crisp, white paper wrapping. Davina liked novels, like Narnia. I liked Charlie Brown books. Sometimes, at Oma’s house on Sundays, before the lunch of chicken soup with matzo balls and boiled chicken, we’d act out scenes from Charlie Brown. Davina would be Lucy, and I’d be Snoopy, following around after her on all fours.

Oma, my grandmother, 1960s

Oma, as I discovered when I was about eight years old, wasn’t actually called ‘Oma’—she was ‘Betty’—‘Oma’ was German for ‘grandmother’. Oma and my 7-year-old mother had come over to London as Jewish refugees from Berlin in 1939. When I was very young, I sometimes mixed-up Oma with auntie Rose: both warm, loving, caring. Oma spoke with a thick German accent. But she could also be quite pushy: I remember her shoving commuters as we climbed aboard a London bus. Oma would stare intensely into your face when you ate which I always found disconcerting. When I was about 13, my best friend James and I borrowed £5 from her to go to the arcade. We said that we would mow the lawn at her house in Wood Green in return. She reminded me about that week after week but we never did it. I always felt guilty about that: right up until Oma died in the mid-1980s.

Another thing that still makes me shudder with shame. Mick Jagger came to visit the Office. He was considering a part in a film by the German director Werner Herzog and my parents had some of Herzog’s films, so they were going to show it to him at their mezzanine cinema. Davina, about 12-years-old at the time, said that she wanted to be in charge of showing him around. I was a bit nonplussed about it all until the day of the visit, when I decided that, in fact, I did really want to meet him. I rushed back to the cinema from the arcade and, as cool I could, pulled back the velvet curtain, walked into the cinema, and took a seat. I remember Jagger looking up at me as I entered, an expression of vague disinterest. The film was one of those excruciatingly dull foreign language films that my parents distributed. I remember something about a circus and a market. After what seemed an eternity the film ended, and Jagger stood up to go. My dad stood up and shook Jagger’s hand, then Davina did, then others, then I stood up with my hand outstretched. He walked straight past me and out of the cinema. I felt mortified and thought about chasing after him, down the street, so that he would give me a proper handshake. I still feel a pang of embarrassment every time I see pictures of Jagger or hear music from the Rolling Stones.

***

One of the amazing things about growing up in this world was getting to go to the film festivals. Cannes was an annual event in the Spring. For Davina and myself, that meant swimming, playing in the sand, and lounging beneath the umbrellas of the beach clubs: each club with its own adornment of different coloured stripes. We had ham and cheese toasted sandwiches for lunch. Dinner was in small local restaurants. A special treat was steak tartare: raw minced beef forked together with eggs, ketchup, and herbs, my mum looking nervously on. One year, Davina and I were asked to ‘host’ the stall for my parents’ independent film distributors association. We sat proudly behind a desk in the large festival arena, handing out leaflets. Sometimes we also got to go to the films: mostly of the long, boring subtitled types; but children’s films were also sometimes on the programme. One that Davina and I particularly liked was ‘Stubby’, about a young Swedish boy who is so good at football that he ends up playing for the national team. We loved the film so much—Stubby darting through the legs of the grown-up players—that we convinced our parents to buy its UK distribution rights. It bombed: my parents said that no children wanted to watch a film with subtitles.

One night, when Oma came to Cannes with us, my parents stayed out really late. Davina and I were back at the apartment with Oma looking after us, and I remember growing more and more anxious. Where were they? Why weren’t they back yet? I was convinced something awful had happened to them. Panic: a gnawing emptiness in my stomach, something I couldn’t control. I felt like a hole had opened in the earth and I was falling through, nothing to grip on: accelerating, terrified, down and down. Oma seemed scared too. Eventually, maybe 2am or so, my parents returned. No big deal, just a late party. Silence.

And then there was ‘The Machines’ at Venice: the happy place I would go to many years later if asked to visualise a place of safety and joy. We didn’t go to Venice as often as Cannes, but it was the same time of beaches, swimming, and sun lounging for Davina and myself. And just on the main street of the Lido—the sliver of Venice on which the film festival was held—was an arcade that stretches back beyond my earliest memories. Walking past stalls of fresh coconut, their aroma filling the warm night air, was a utopia of mechanical games, lights, and excitement: table football, penny falls, a mini bowling alley.

Some years ago, I began to recognise a lot of parallels between my parents going to film festivals and my own going to academic conferences: the networking, the schmoozing, the being part of a big community. Bumping into old colleagues and talking about the latest research findings or measures—just like my parents talking about the latest films with fellow distributors, directors, and reviewers. It wasn’t a conscious choice for me to enter this world, but perhaps, at some level, it was a way of doing things that felt safe and familiar. Or perhaps I entered into academic life with a confidence borne of seeing my parents immersed and engaged in their own community.

***

One of the best things about a day at the Office was lunch. My parents’ work day seemed to start late, about 10 o’clock, and by noon or so (with a coffee break in between) we’d be talking about where to eat. Italian was the norm, and I’d gobble up my favourite: spaghetti Bolognese. Chinese was also very popular. Oma would take us some times. Davina and I had a reputation for being badly behaved, though I’m not sure we ever were. I do remember once, though, at the Dumpling Inn Chinese restaurant, breaking set after set of chopsticks as we used them for drumming. Oma said, many times after that, that we’d nearly got thrown out of the restaurant.

It wasn’t lost on me: the contradiction between the privilege that we had, and the communism that my parents—and I—espoused. Kids at school would sometimes tease me: if your parents are communists why do you live in a big house in Highgate (a posh London suburb)? One time, there was almost a revolution at my parents’ company. I found out because, driving to work one day, I could hear them talking about an employee—someone close to them—who was stirring up trouble. I was worried it was Auntie Rose and asked. They said ‘No’. It turned out it was the boyfriend of one of my older sisters, who had been working for my parents for about a year or so. He was a bright, ambitious young man, with a pointy beard that made him look like Guy Fawkes. My parents said he was an anarchist. This boyfriend had been steadily promoted, but was now asking that awkward question: if the company was advocating socialism, why was it owned by three bosses (my parents and Uncle Harry) and not a workers’ collective? Worse, he was actually trying to collectivise it. Around half or so of the employees rallied behind him, and for some time my parents were genuinely worried that they might lose control of the company, but eventually the boyfriend left and things returned to normal.

***

By the time I got to my mid-teens, going to the Office meant getting the tube in to Tottenham Court Road with James, badgering my dad for ‘Luncheon Vouchers’, then going off to McDonalds for Big Macs, fries, and milkshakes before spending the afternoon in the arcades. By that time, I was quite seriously addicted to fruit machines—something I only really kicked in my early 20s. Sometimes I took money from my parents. Worse was asking my parents for money to buy clothes, getting the cheapest possible, then spending the rest in the arcades. I think my own kids have been surprised that, when they’ve taken money from me without asking, I’ve never got that angry. But how could I when I did that even worse.

When I was around 18, my parents felt that they couldn’t afford the rents in Soho any more and moved their offices to our house in Highgate. My dad had his own office, my mum shared with a few other staff that moved with them (including, later, Eric Liknaitzky). But my dad was increasingly losing heart, and the realities of the film business at that time meant increasingly big financial risks, which my parents were never really willing to take. The fall of the Soviet empire—and the dissolution of the British Communist Party that followed—also really hit my dad: his life’s meaning had been fundamentally scythed and he never really recovered from that. Nevertheless, my dad continued to work well into his 80s, though by that time it was more sitting in his swivel chair, pushing around a few bits of paper, and speaking into his dictaphone. He talked of making a film about his grandfather Moishe who was kidnapped into the Czar’s army as a young Jewish boy, and actually wrote up a script. Almost 40 years later, my daughter, Maya, would turn that into a short film. 

***

Ironically, the films I adore now are exactly the sort that my parents’ distributed, and which I despised as a kid. Sometimes, I’ll see a really good film and, when I tell my mum about it, she’ll say, ‘Oh, that was one of ours’. I tease my kids—products of a TikTok era where nothing last longer than 10 seconds—that they should join me to watch seven hour epics about communal farms in Slovakia. ‘There’s a scene in it’, I tell them, ‘which goes on for an hour and consists of watching a doctor get drunk in real time.’

‘Daaaad….!’

‘And then there’s an opening shot of 20 minutes of cows walking across a field’. ‘Or we could watch the three hour one about the dad and his daughter in a hut eating potatoes’.

‘Daaad….!’

‘You know what happens?’

‘Whatttt?’

‘Their horse dies.’

***

As therapists, the focus of our work is often on how the past informs the present; and we know how complex this relationship is. Somehow, through these experiences of growing up around cinema—and through thousands of other experiences—I emerged: not created by these experiences; but touched and swayed and nudged. Something complex, rich, ethereal mingled with me, enticed me, helped me develop form. I shaped myself against this world: these people, this community, these machines. When I see myself as a whole, I am also the boy jumping on his dad’s sofa, and getting dragged out of the arcade, and answering the phone on his Auntie Rose’s lap; and all the traces of those experiences as they wove their way through my life. There’s no cause-and-effect here. No simple x made me y. But through that love, that culture, those experiences of joy and shame—through all that multifaceted, intermingled complexity—my own complex and multifaceted way of being and being-in-relation evolved.

---

Further information about my father and Contemporary Films:

• Obituary (Charles Cooper), The Guardian. (4th Dec 2001)

• Dickinson, R. (1999) Rogue reels: Oppositional film in Britain, 1945-1990. BFI.

• Hogenkamp, B. (2000) Film, television and the left, 1950-1970. Lawrence & Wishart. [Including a photo of my dad, looking dapper in a tie, on the cover]

• Contemporary Films website.

The Coronation: Reflections from a Republican Therapist

I don’t bear King Charles or the royal family ill-will. My guess is, like most of us, they’re decent human beings trying to do their best for themselves and the communities around them. William and Kate, I know, have done some valuable work around child mental health. And if people around the world find community, meaning, and pleasure in the royal family and royal celebrations then good for them. I kind of wish I did. There’s enough misery going on in the world that having something to celebrate can’t be bad for people’s psychological health.

But what I worry about is the kind of mind-set that is fostered by the coronation, the royalty, and particularly the recent invitation to ‘swear allegiance’ to the King. We’ve been invited to ‘pay homage, in heart and voice, to our undoubted King, defender of all,’ and swear, ‘true allegiance to Your Majesty, and to your heirs and successors according to law’ (see here). Personally, as a therapist, I just think, ‘What the ****’ Here’s why…

When people come to therapy, it’s rarely to do with insufficient homageness/subservience to authority, or lacking some sense of a sovereign being in their lives. That’s rarely why people suffer.

Rather, in many cases, psychological problems come down to: (1) A lack of self-esteem, and/or (2) Not feeling empowered or being assertive, and/or (3) Deferring choices to others and then not feeling that one’s life is as it should be. People who come to therapy often have a pervasive—albeit implicit—sense of powerlessness: ‘everyone else can do things but me’. So choices don’t get made, others are seen as being more responsible, clients feel that they can’t say or choose towards what they want. And then life becomes unbearably empty and dull: ‘I don’t have what I want because I’ve never felt able to try and get it.’

Here, the role of therapy, so often, is to help clients see that they do have choices. Not all choices—not that they can do whatever they want—but that they have some choices, and that within those limitations they have contingent power, they can move forward. They don’t have to rely on others to lead them and to tell them how to live their lives.

So, to me, pledging homage and subservience to royalty seems the kind of thinking and behaviour that’s associated with poorer mental wellbeing, rather than better. It’s about deferring to authority, seeing someone as better and more important than you and with some god-given right to do something that you can’t do yourself. It’s an ideology that seems to run counter to the the work that therapists do: to help people feel like they’re an equal, that they’re capable and able, that their lives are their own rather than another’s.

Therapeutic wellbeing, so often, is about helping people own and embody their power. It’s about supporting people to recognise that they are ‘adults’, that they’re responsible human beings who can (and need) to take part in the development of their communities: not expect others to do it for them: they’re ‘citizens’ rather than ‘subjects’ (as Deborah Flynn-Harland wrote in response to an earlier draft of this blog). These are people that have the capacity to take leadership: who recognise that we can all lead, and develop, and be brilliant—not just a chosen few.

As a society, we worship all kinds of celebrities. Football players, musicians, artists, business moguls. That’s probably not ideal too. But the difference is that these people, in most cases, have at least done something—we look up to them because of what they achieved and what we might not be able to do ourselves. But with the royals—or with nobility and other inherited privileges—they haven’t actually done anything special or different to earn their status. They just got born into a particular class. So when we pay homage to them, when we look up to them, we’re essentially regurgitating an ideology that says, ‘You are not as good as others just because of who they—and who you—are. You’re not as worthy because you are you.’ And what does that do to people’s psyches?

I’ve been reading Jonathan Haidt’s The righteous mind (Penguin, 2012), and it’s a brilliant book about how we develop and maintain particular moral positions. Haidt argues that a morality based around the principle of obedience to authority is just as valid as one based around principles of care or fairness. It’s an interesting and challenging argument, but I think Haidt is wrong. Care and fairness advantage multiple people, it helps to create a world in which more people can benefit more of the time (as I’ve argued in my recent book, Psychology at the heart of social change , Policy, 2023). But what does obedience to authority benefit? Perhaps it gives people a sense of security, perhaps it gives society some stability. But it has so many downsides too: inequalities, marginalisation, oppression, a lack of freedom or creativity. If obedience to authority was core to wellbeing, then why isn’t it at the heart of practices like therapy, or other wellbeing-oriented practices like social and emotional learning in schools. I can’t think of one therapeutic practices that tries to help clients be more obedient to authority as a means of fostering psychological health. I can think of hundreds that try to improve self-esteem, assertiveness, and a willingness to be ‘adult’.

Actually, having said that, there is one approach to mental wellbeing that does advocate a more hierarchical approach: positive parenting. Here, in this well-evidenced practice, you do try and encourage your children to listen to you and follow you, even if, at times, you can’t fully explain why (screams: ‘Don’t cross the road, a car is coming’). But positive parenting is what adults do with children, so it begs the question, are we children to the royals? Are we their infants and they our parents? Perhaps, psychologically, we can become so; but in a world facing climate catastrophe, war, genocide, do we need more infantalised adults? Rather, I think we need more adultified adults: who can take on responsibility, and feel that they are—and can be—the backbone for a future.

When I was a teen, I was of the ‘hang the monarchy’ persuasion. Now, I think that kind of ideology is as inhumane, destructive, and unhelpful as a pro-Royalist one. And I’m going to be having fun on Saturday: albeit at our ‘Definitely Not Celebrating the Coronation’ house party. But for all the pomp, pageantry, and ‘glamour’ of the coronation (and expense!), I really can’t see how reinforcing subservience and homaging is going to help us move in the direction of personal, social, and/or environmental wellbeing—directions we so desperately need to move in right now.

Acknowledgement

Photo by Jared Subia on Unsplash

Measure Development and Testing Research: Some Pointers

Have you ever had one of those dreams where you’re running towards something, and the faster you go the further away it seems to get? That, to me, is what doing research in the measure development field seems like. Every time I think I have mastered the key methods some bright spark seems to have come up with a new procedure or analysis that is de rigueur for publishing in the field. No mind, I have to say that developing measures has been one of the most satisfying and even exhilarating elements of my research career, however humbling it might be at times. And, indeed, having gone from knowing next to nothing about measure development to creating, or helping to test, some fairly well-used measures (including one with my name on it, the Cooper-Norcross Inventory of Preferences!), I’m pretty confident that it’s a research process that anyone—who’s willing to devote the time—can get involved in.

And, of course, the point of developing and validating measures is not just for the narcissistic glory. It’s research that can help to define phenomena and explore their relationship to other factors and processes. Take racial microaggressions in therapy, for instance. Measures can help us see where these are taking place, what’s leading to them, and help us assess methods for reducing their prevalence. Of course, the downside of measures is that they take complex phenomena and reduce them down to de-contextualised, linear variables. But, in doing so, we can examine—over large, representative samples—how these variables relate to others. Do different ethnic groups, for instance, experience different levels of racial microaggressions in therapy? We could use qualitative methods to interview clients of different ethnicities, but comparing their responses and making conclusions is tricky. Suppose, for instance, of the Afro-Caribbean clients, we had four identifying ‘some’ microaggressions, two ‘none’, and three ‘it depended on the therapist’. Then, for the Asian clients, we had two saying, ‘I wasn’t sure’, three saying ‘no’, and two saying, ‘it was worse in the earlier sessions’. And one Jewish client felt that their therapist made an anti-Semitic comment while one didn’t. So who had more or less? By contrast, if Afro-Caribbean clients have an average rating of 3.2 on our 1 to 5 scale of in-therapy racial microaggressions, and Asian clients have an average rating of 4.2, and our statistical analysis show that the likelihood of this difference being due to chance is less than 1 in a 1,000 (see blog on quantitative analysis), then we can say something much more definitive.

From a pluralistic standpoint, then, measure development research—like all research methods—has a particular value at particular points in time: it all depends on the question(s) that we are asking. And while, as we will see, it tends to be based on positivistic assumptions (that there is a real, underlying reality—which we can get closer to knowing through scientific research), it can also be conducted from a more relativist, social constructionist perspective (that no objective ‘reality’ exists, just our constructions of it).

What is Measure Development and testing Research?

Measure development research, as the name suggests, is the development of ‘measures’, ‘scales’, or ‘instruments’ (also known as the field of psychometrics); and measure testing research is assessing those measures quality. Measure development studies will always involve some degree of measuring testing, but you can have measure testing studies that do not develop or alter the original measure.

A measure can be defined as a means of trying to assess ‘the size, capacity, or quantity of something’: for instance, the extent to which clients experience their therapist as empathic, or therapists’ commitment to a spiritual faith. In this sense (and particularly from a positivist standpoint), we can think of psychological measures as a bit like physical measures, for instance rulers or thermometers: tools for determining what’s out there (like the length of things, or their temperature).

Well known examples of measures in the counselling and psychotherapy field are the CORE-OM (Clinical Outcomes in Routine Evaluation – Outcome Measure), which measures clients’ levels of psychological distress; and the Working Alliance Inventory, which measures the strength of therapist-client collaboration and bond. There’s more information on a range of widely used ‘process’ and ‘outcome’ measures for counselling and psychotherapy here.

Measures generally consist of several ‘items’ combined into a composite score. For instance, on the CORE-OM, two of the 34 items are ‘I have felt terribly alone and isolated’ and ‘I have felt like crying’. Respondents are then asked to score such items on a wide range of different scales—for instance, on the CORE-OM, clients are asked to rate the items from 0 (not at all) to 4 (Most or all of the time)—such that a total score can be calculated. Note, in this way, measures are different from ‘questionnaires’, ‘surveys’, or ‘checklists’ that have lots of different items asking about lots of different things. Indeed, as we will see, the ‘combinability’ of items into one, or a few, scales tends to be a defining feature of measures.

A measure can consist of:

• One scale. An example is the Relational Depth Frequency Scale, which measures the frequency of experiencing relational depth in therapy.

• Two or more scales. An example is the Cooper-Norcross Inventory of Preferences, which has scales for ‘client preference for warm support vs focused challenge’, and ‘client preference for past focus vs present focus’.

• Two or more subscales: meaningful in their own rights, but also summable to make a main scale score. An example is the Strengths and Difficulties Questionnaire for children, which has such subscales as ‘peer problems’ and ‘emotional symptoms’, combining together to make a ‘total difficulties’ score.

Generally, A single scale measure or a subscale will have between about four and 10 items. Less than that and the internal consistency starts to become problematic (see below); more than that and the measure may too long to complete, with items that are redundant.

Measures can be designed for completion by therapists, by clients, or by observers. They can also be nomothetic (where everyone completes the same, standardised items), or idiographic (where people develop their own items, for instance on a Goals Form).

Underlying Principles

Most measure development and testing research is underpinned by a set of principles known as classical test theory. These are fairly positivistic, in that they assume that there are certain dimensions out there in the world (known as latent variables) that exist across all members of the population, and are there independent of our constructions of them. So people’s ‘experiencing of racial microaggressions’ is a real thing, just like people’s temperature or the length of their big toe: it’s an actual, existent thing, and the point of our measure is to try and get as close as possible to accurately assessing it.

You might think, ‘If we want to know about clients’ experiences of racial microaggressions in therapy, why don’t we just ask them the question, “To what extent do you experience racial microaggressions in your therapy?”’ The problem is, from a classical test theory perspective, a respondent’s answer (the ‘observed score’) is going to consist of two components. The first component is going to be the part that genuinely reflects their experiencing of microaggressions (the ‘true score’ on the latent variable). But, then, a second part is going to be determined by various random factors that influence how they answer that specific question (the ‘error’). For instance, perhaps the client doesn’t understand the word ‘microaggressions’, or misunderstands it, so that their responses to this particular item don’t wholly reflect the microaggressions that they have experienced. Here, what we might do is to try and minimise that error by asking the question in a range of different ways—for instance, ‘Did your therapist make you feel bad about your race?’ ‘Did your therapist deny your experiences of racism?’—so that the errors start to even out. And that’s essentially what measure development based on classical test theory is all about: developing measures that have as little error as possible, so that they’re evaluating, as accurately as they can, respondents’ true positioning on the latent variable. No one wants a broken thermometer or a wonky ruler and, likewise, a measure of the experiencing of racial microaggressions in therapy that only reflects error variance isn’t much good.

As you can see, all this is based on very positivist assumptions: a ‘true’, underlying (i.e., latent) reality out there in the world; acting according to laws that are true for us all; and with ‘error’ like an uninvited guest that we’re trying to escort out of the party. Not much room for the existence of unpredictability, chaos, or individual uniqueness; or the idea that ‘reality’ is something we construct according to social mores and traditions. Having said that, adopting classical test theory assumptions, for the purposes of measure development, doesn’t mean you have to be a fully-fledged positivist. From a pragmatic standpoint, for instance, you can see measure development as a means of identifying and assessing something of meaning and importance—but whether or not it is something ‘real’ can be considered a mute point. We know, for instance, that there is something like racial microaggressions that can hurt clients and damage the therapeutic relationship, so we can do our best to find ways of assessing it, while also acknowledging the inherent vagaries of whatever we do. And, perhaps, what we call ‘racial microaggressions’ will change over time and vary across cultures and individuals, but that shouldn’t stop us from trying to get some sort of handle on it, so that we can do our best to find out more and intervene.

Developing a measure

So how do you actually go about developing a measure? It might seem like most measures are developed on the back of the proverbial ‘fag packet’ but, OMG, it is vastly more complicated and time-consuming than that. I worked out that, when Gina di Malta (with myself and Chris Evans) developed the 6-item Relational Depth Frequency Scale, it took something like six years! That’s one year per item.

That’s why, for most of us who have developed measures, the first thing we say to people who want to develop their own measures is to first see if they can use measures that are already out there. That’s unless you really have the time and resources to do the work that’s needed to develop and validate your own measure. Bear in mind, a half-validated measure isn’t much valid at all.

So why does it take so long? To a great extent, it’s because there’s a series of stages that you need to go through, detailed below. These aren’t exact, and every measure development study will do them slightly differently, but the sections below should give you a rough idea of what steps a measure development study will take.

Defining the Latent Variable

Before you develop a measure, you have to know what it is that you are trying to measure. To some extent, this may emerge and evolve through your analysis, but the clearer you are about what you’re looking for, the more likely your measure will be fit for finding it.

‘I’d like to know whether clients feel that they’ve got something out of a session.’ OK, great, but what do we mean by ‘got something out of’? Is this feeling that they’ve learnt something, or finding the session worthwhile, or experiencing some kind of progress in their therapy? ‘Maybe all of those things.’ OK, but feeling like you’ve learnt something from a session may not necessarily correlate with feeling like you’ve made progress. They may seem similar, but perhaps some clients feel there’s a lot they’ve learnt while still coming out of a session feeling stuck and hopeless.

Things that just naturally seem to go together in your mind, then, may not do so in the wider world, and disentangling out what you want to focus on is an important starting point for the measure development work. How do you do that? Read the literature in the area, talk to colleagues, journal, look at dictionaries and encyclopaedias: think around the phenomenon—critically—as much as you can. What you want to identify is one discrete variable, or field, that you can really, clearly define. It could be broader (like ‘the extent to which clients value their sessions’) or narrower (like ‘the extent to which clients feel they have developed insight in their sessions’), but be clear about what it is.

item generation

Once you know what latent variable you want to measure, the next step is to generate items that might be suitable for its assessment. At this stage, don’t worry too much if the items are right or not: brainstorm—generate as many items as you can. In fact, one thing I’ve learnt over the years is that you can never have too many items at this stage, and often you can have too few. Probably around 80% or so of items end up getting discarded through the measure development process, so if you want to end up with a scale of around 5-10 items, you probably want to start with around 25-50 potential ones. Bear in mind that you can always drop items if you get to the end of the measure development process and have too many, but it’s much more difficult to generate new items if you get to the end and find you have too few.

Ideally, you want to do this item generation process in one or more systematic ways, so it is not just the first, ad hoc, items that come into your head. Some strategies for generating items are:

• Search the literature on the topic. Say we wanted to develop a measure to assess the extent to which adolescent clients feel awkward in therapy (we’re interested in differences in awkwardness across types of therapies, and types of clients). So let’s go to Google Scholar to see what papers there are on young people’s awkwardness in therapy, and also we should check the more established psychological search engines like PsychInfo and Web of Science (if we have access, generally through a university). Supposing, there, we find research where young people say things like, ‘I felt really uncomfortable talking to the counsellor’ or ‘The therapist really weirded me out’. So we can use these statements like that (or in modified form) as items for our measure, and it might also trigger some ideas about further items, like ‘I felt really comfortable talking to the counsellor’ (a reverse of the first statement here), or ‘The therapist seemed really weird’ (a modification of the second statement).

• Interviews and focus groups. Talk to people in the target population to see what terms they use to talk about the phenomena. For instance, an interview with young clients about their experiences of counselling (approved, of course, through the appropriate ethical procedures) might be an ideal way of finding out how they experience ‘awkwardness’ in therapy. What sort of words do they use to talk about it? How does it feel to them?

• Dictionaries and thesauruses. Always a valuable means of finding different synonyms and antonyms for a phenomena.

Remember, what you are trying to do is to generate a range of items which are, potentially, a means of ‘tapping into’ your latent variable. Have a mixture of phrasings, with some items that are as closely worded to your latent variable as possible (for instance, ‘I felt awkward in therapy’), but other that might come at it from a different angle, providing ‘triangulation’ (for instance, ‘The interaction with my therapist seemed unusual’). It’s also good to try reversing some items (so, for instance, having items that are about not feeling awkward, as well as feeling awkward)—though having such items in a final scale is no longer considered essential.

At this point, you’ll also need to start thinking about your response categories: the ways that people score your items. For instance, do people rate the items on a 3- or 5-point scale, and what labels might you use to describe these different points? This is an enormous field of science in itself, and usually it’s best to keep it simple and use something that’s already out there so that it’s been tried and testing. For instance, if you decide to develop your own four point scale with labels like 1 = Not at all, 2 = A really small amount, 3 = Quite a bit, 4 = Moderately, 5 = Mostly, How do you know that Quite a bit means less to people than Moderately; and couldn’t the difference between 2 and 3 (A really small amount and Quite a bit) be a lot more than the difference between 4 and 5 (Moderately and Mostly)? So have a look at what other validated and well-used measures use as response categories and see if anything there suits. Two common ones are:

1. = Strongly disagree

2. = Moderately disagree

3. = Mildly disagree

4. = Mildly agree

5. = Moderately agree

6. = Strongly agree

   Or

1. = Not at all

2. = Only occasionally

3. = Sometimes

4. = Often

5. = Most or all of the time

At this point, you’ll also need some idea of how you phrase the introduction to your measure. Generally, you’ll want to keep it as short as possible, but there may be some essential instructions to give, such as who or what to rate. For instance, for our racial microaggressions measures, we might want to say something like:

Please think of your relationship with your current therapist. To what extent did you experience each of the following?

In this instance, we might also consider it essential to say whether or not the clients’ therapists will see their scores, as this may make a big difference to their responses.

Testing items

Expert Review

The next stage of the measure development process is to pilot test our items. What we would do is to show each of our items to experts in the field (ideally experts by experience, as well as mental health professionals)—say between about 3 and 10 of them—and ask them to rate each of our potential items for how ‘good’ they are. We could do this as a survey questionnaire, on hard copy, or through questionnaire software such as Qualtrics. An example of a standardised set of questions for asking this comes from DeVellis’s brilliant book on scale development. Here, experts can be asked to rate each item on a four-point scale (1 = not at all, 2 = a little, 3 = moderately, and 4 = very well) with respect to three criteria:

1. How well the item matches the definition of our latent variable (which the experts are provided with)

2. How well formulated the item is for participants to fill in

3. How well, overall, the item is suited to the measure

Once the responses are in, those items with the lowest ratings (for instance, with an average < 3) can be discarded, leaving only the most well formulated and suitable items to go forward for further testing and analysis.

Three Step Interviewing Technique

Something else that I’ve learnt, from Joel Vos, that can be really useful for selecting items in these early stages is called The Three-Step Test Interview. This essentially involves asking a few respondents (ideally the kind of people the measure is for) to ‘think aloud’ while completing the measure, and then to answer some interview questions about their experiences and perceptions of completing the measure. This, then, gives us a vivid sense of what the experience of completing the measure is like, and what’s working and what’s not. Through this process, for instance, it might become evident that certain items—even if the experts thought they were OK—don’t make much sense to participants, or are experienced as boring or repetitive. And respondents might also have ideas for how items can be better worded. Again, questions that don’t work well can be removed at this stage and, potentially, new or modified items could be added (though bear in mind they haven’t been through the expert review process).

Exploratory psychometrics

You’re now at the stage of sending your measure out to survey. The number of respondents you need at this stage is another field that is a science in itself. However, standard guidance is a minimum of 10 respondents per item, with other guidance suggesting at least 50 respondents overall if the aim is detect one dimension/scale, and 100 for two (see, for instance, here).

At this point, you almost certainly want to be inviting respondents to complete the measure online: for instance, through Qualtrics or Survey Monkey. Hard copies are an option, but add considerably to the processing burden and, these days, may make prospective participants less likely to respond.

Ideally, you want respondents to be reflective of the people who are actually going to use the measure. For instance, if it’s a measure intended for use with a clinical population, it’s not great if it’s been developed only with undergraduate students or with just your social media contacts. Obviously, too,it’s also important to aim for representativeness across ethnicity/race, gender, age, and other characteristics.

If you’ve got funding, one very good option here can be to use a Mechanical Turk service, such as Prolific. This is, essentially, a site where people get paid to complete questionnaires; and because it’s such a large pool of people, from all over the world, it means you’ve got more chance of recruiting the participants you need. We used this, for instance, to gather data on the reliability and validity of the Cooper-Norcross Inventory of Preferences (see write-up here), and it allowed us to get US and UK samples that were relatively representative in terms of ethnicity, gender, and age—not something we could have easily achieved just by reaching out to our contacts.

Once you’ve got your responses back, you’re on to the statistical analysis. The aim, at this point, is to get to a series of items that can reliably assess one or more latent dimensions, in a way that is as parsimonious as possible (i.e., with the fewest items necessary). This scale shortening process can be done in numerous ways, but one of the most common starting points is to use exploratory factor analysis (EFA).

EFA is a system for identifying the dimension(s) that underlie scores from a series of items. It’s a bit like putting an unknown liquid on a dish and then boiling it off to see what’s left: perhaps there’s crystals of salt, or maybe residues of copper or gold. EFA has to be done using statistical software, like SPSS or R (not Excel), and you need to know what you’re doing and looking for. On a 1-10 scale of difficult stats, it’s probably about a 5: not impossible to pick up but also does require some fair degree of training, particularly if you don’t have a psychology degree. What follows (as with all the stats below) is just a basic overview to give you an idea of the steps that are needed.

The first thing you do in EFA is to see how many dimensions actually underlie your data. For instance, the data from our ‘experiences of racial microaggression’ items may suggest that they are all underpinned by just one dimension: How much or how little people have experienced microaggressions from their therapists. But, alternatively, we may find that there were more latent dimensions underlying our data: for instance, perhaps people varied in how much they experienced microaggressions, but also the degree to which they felt hurt by the microaggressions they experienced. So while some people could have experienced a lot of microaggressions and a lot of hurt, others might have experienced a lot of microaggressions but not much hurt; and any combination across these two variables might be possible.

What EFA also does is to help you see how well different items ‘load’ onto the different dimensions: that is, whether scores on the items correlate well with the latent dimension(s) identified, or whether they are actually independent of all the underpinning dimensions on the measure. That way, it becomes possible to select just those items that reflect the latent dimension well, discarding those that are uncorrelated with what you have actually identified as a latent scale. At this point, it’s also common to discard those items that load onto multiple scales: what you’re wanting is items that are specifically and uniquely tied to particular latent variables. At this point, there’s many other decision rules that can also get used for selecting items. For instance, you might want items that have a good range (i.e., going the full length of the scale), rather than all scores clustering in the higher or lower regions; and the items also need to be meaningful when grouped together. So this process of scale shortening is not just a manualised one, following clearly-defined rules, but a complex, nuanced, and selective art: as much alchemy as it is science.

By the end of this exploratory process, you should have a preliminary set of items for each scale or subscale. And what you’ll then need to do is to look at the items for each scale or subscale and think about what they’re assessing: how will you label this dimension? It may be that the alchemical process leads you back to what you set out to find: a ‘prevalence of racial microaggressions’ dimension, for instance. But perhaps what crystallised out was a range of factors that you hadn’t anticipated. When we conducted our first Cooper-Norcross Inventory of Preferences study, for instance (see here), we didn’t really know what preference dimensions would emerge from it. I thought, for instance, that we might find a ‘therapist directed vs client directed’ dimension, as we did, but I was surprised to see that there was also a ‘focused challenge vs warm support’ dimension emerging as well—I had just assumed that therapist directiveness and challenge were the same thing.

Testing the Measure

As with exploratory measure development, there are numerous methods for testing the psychometric properties of a measure, and procedures for developing and testing measures are often iterative and overlap. For instance, as part of finalising items for a subscale, a researcher may assess the subscale’s internal reliability (see below) and, if problematic, adjust its items. These tests may also be conducted on the same sample that was used for the EFA, or else a new sample of data may be collected with which to assess the measure’s psychometric properties.

Two basic sets of tests exist that most researchers will use at some point in measure development research: the first concerned with the reliability of the measure and the second concerned with its validity.

Basic Reliability Tests

The reliability of a measure is the extent to which it produces consistent, reproducible estimates of an underlying variable. A thermometer, for instance, that gave varied readings from one moment to the next wouldn’t be much use.

• Internal consistency is probably the most important, and frequently reported, indicator of a scale’s ‘goodness’ (aside from when the measure is idiographic). It refers to the extent that the different items in the scale are all correlating together to measure the same thing. If the internal reliability is low, it means that the items, in fact, are not particularly well associated; if high, it means that they are all aligned. Traditionally, internal consistency was assessed with a statistic called ‘Cronbach’s alpha (α)’, with a score of .7 or higher generally considered adequate. Today, there is increasing use of a statistic called ‘McDonald’s omega (ω)’, which is seen as giving a less biased assessment.

• Test-retest reliability is very commonly used in field of psychology, but is, perhaps, a little less prevalent in the field of counselling and psychotherapy research, where stability over time is not necessarily assumed or desired. Test-retest reliability refers to the stability of scores over a period of time, where you would expect people to score roughly the same on a measure (particularly if it is a relatively stable trait). If respondents, for instance, had wildly fluctuating scores on a measure of self-esteem from one week to the next, it would suggest that the measure may not be tapping into this underlying characteristic. Test-retest stability is often calculated by simply looking at the correlation of scores from Time 1 to Time 2 (an interval of about two weeks is typically used), though there are more sophisticated statistics for this calculation. Assessing test-retest reliability requires additional data to be collected after the original survey—often with a subset of the original respondents.

• Inter-rater reliability is used where you have an observer-completed measure. Essentially, if the measure is reliable, then different raters should be giving approximately the same ratings on the scales. In our assessment of an auditing measure for person-centred practice in young people, for instance (see here), we found quite low correlations between how the raters were assessing segments of person-centred practice. That was a problem, because if one rater, on the measure, is saying that the practice is adherent to person-centred competencies, and another is saying it isn’t, then it suggests that the measure isn’t a reliable means of assessing what is and is not a person-centred way of working.

Basic Validity Tests

The validity of a measure is the extent to which it measures the actual thing that it is intended to. Validity can be seen as the ‘outward-facing’ element of a measure (how it relates to what is really going on in the world), whereas reliability can be seen as the ‘inward-facing’ element (how the different parts within it relate together).

• Convergent validity tends to be the most widely emphasised, and reported, test of validity in the counselling and psychotherapy research field. It refers to the extent that scores on the measure correlate with scores on a well-established measure of a similar construct. Suppose we were developing a measure to assess how prized clients feel by their therapists. No measures of this exact construct exist out there in the field (indeed, if it did, we wouldn’t be doing this work), but there’s almost certainly other scales, subscales, or even individual items out there that we’d expect our measure to correlate with: for instance, the Barrett-Lennard Relationship Inventory’s ‘Level of Regard’ subscale. So we would expect to find relatively high correlations between scores on our new prizing measure and those on the Level of Regard subscale, say around .50 or so. If the correlations were zero, it might suggest that we weren’t really measuring what we thought we were. But bear in mind that correlations can also be too high. For instance, if we found that scores on our prizing measure correlated extremely closely with scores on Level of Regard (> .80 or so), it would suggest that our new measure is pretty redundant: the latent variable we were hoping to tap has already been identified as Level of Regard. Assessing convergent validity means that, in our original survey, we might also want to ask respondents to complete some related measures. That way, we don’t have to do a further round of surveying to be able to assess this psychometric property.

• Divergent validity is the opposite of convergent validity, and is essentially the degree to which our scale or subscale doesn’t correlate with a dimension that should be unrelated. For instance, our measure of how prized clients feel wouldn’t be expected to correlate against a measure of their degrees of extraversion, or levels of mental wellbeing. If they did, it would suggest that our measure is measuring something other than we think it is. Measures of ‘social desirability’ are good tools to assess divergent validity against because we really don’t want our measure to be associated with how positively people try to present themselves. As with assessing convergent validity, assessing divergent validity means that we may need to add a few more measures to our original survey, if we don’t want to go through a subsequent stage of additional data collection.

• Structural validity is the degree to which the scores on the measure are an adequate reflection of the dimensions being assessed. EFA, as discussed above, can be used to identify one or more underlying dimensions, but this structure needs validating in further samples. So this means collecting more data (or splitting the original data into ‘exploratory’ and ‘confirmatory’ subsamples), and then the new data can be analysed using a procedure called confirmatory factor analysis (CFA). CFA is a complex statistical process (about a 9 on the 1-10 scale), but it essentially involves testing whether the new data fits to our ‘model’ of the measure (i.e., its hypothesised latent dimension(s) and associated items). CFA is a highly rigorous check of a measure, and it’s a procedure that’s pretty much essential now if you want to publish a measure development study in one of the higher impact journals.

• Sensitivity to intervention effects is specific to outcome measures, and refers to the question of whether or not the measure picks up on changes brought about by therapy. We know that therapy, overall, has positive benefits, so if scores on a measure do not show any change from beginning to end of intervention, it suggests that the measure is not a particularly valid indicator of mental wellbeing or distress. To assess this sensitivity, we need to use the measure at two time points with clients in therapy: ideally at the start (baseline) and at the end (endpoint). Measures that show more change may be particularly useful for assessing therapeutic effects. For instance, in our psychometric analysis of a goal-setting measure for young people (the Goal Based Outcome Tool), we found that this measure indicated around 80% of the young people had improved in therapy, as compared with 30% for the YP-CORE measure of psychological distress.

Advanced Testing

…And there’s more. That’s just some of the basic psychometric tests and, like I said earlier, there seems to be new ones to catch up with everyday, with numerous journals and books on the topic. For instance, testing for ‘measurement invariance’ seems to becoming increasingly dominant in the field, which uses complex statistical processes to look at whether the psychometrics of the measures are consistent across different groups, times, and contexts (this is about a 15 out of 10 for me!). And then there’s ‘Rasch analysis’ (see here), which uses another set of complex statistical procedures to explore the ways that respondents are scoring items (for instance, is the gap between a score of ‘1’ and ‘2’ on a 1-5 scale the same as the gap between ‘3’ and ‘4’?). So if you’re wanting to publish a measure development study in the highest impact journals, you’ll almost certainly need to have a statistician—if not a psychometrician—on board with you, if you’re not one already.

Developing benchmarks

Once you’ve got a reliable and valid measure, you may want to think about developing ‘benchmarks’ or ‘cutpoints’, so that people know how to interpret the scores from it. This can be particularly important when you’re developing a clinical outcome measure. Letting a client know, for instance, that they’ve got a score of ‘16’ on the PHQ-9 measure of depression, in itself, doesn’t tell them too much; letting them know that this is in the range of ‘moderately severe depression’ means a lot more.

There’s no one way of defining or making benchmarks. For mental health outcome measures, however, what’s often established is a clinical cut-off point (which distinguishes between those who can be defined as being in a ‘clinical range’ and those in a ‘non-clinical range’); and a measure of reliable change, which indicates how much someone has to change on a measure for it to be unlikely that this is just due to chance variations. For instance, on the Young Person’s CORE measure of psychological distress, where scores can vary from 0 to 40, we established a clinical cut-off point of 10.3 for males in the 11-13 age range, and a reliable change index of 8.3 points (see here). The calculations for these benchmark statistics are relatively complex, but there are some online sites which can help, such as here. You can also set benchmarks very simply: for instance, for our Cooper-Norcross Inventory of Preferences, we used scores for the top 25% and bottom 25% on each dimension as the basis for establishing cut-off points for ‘strong preferences’ in both ways.

the Public domain

Once it’s all finalised and you’re happy with your measure, you still need to think about how you’re going to let others know about it. There’s some journals that specifically focus on the development of measures, like Assessment, though they’re by no means easy to get published in. Most counselling and psychotherapy journals, though, will publish measure development studies in the therapy field, and that puts your measure out into the wider public domain.

At this stage you’ll also need to finalise a name for your measure—and also an acronym. In my experience, the latter often ends up being the toughest part of the measure development process, though sites like Acronymify can help you work out what the options might be. Generally, you want a title that is clear and specific to what your measure is trying to do; and a catchy, easy-to-pronounce acronym. If the acronym actually means or sounds something like what the measure is about—like ‘CORE’—that’s even better.

If there’s any complexities or caveats to the measure at all in terms of its use in research or clinical practice, it’s good to produce really clear guidelines for those who want to use it. Even a page or so can be helpful and minimise any ambiguities or potential problems with its application. Here is an an example of the instructions we produced for our Goals Form.

It can also be great to develop a website where people can access the measure, its instructions, and any translations. You can see an example of this for our C-NIP website here.

Regarding translations, its important that people who may want to translate your measure follow a standardised procedure, so that it stays as consistent as possible with the original measure. For instance, a standard process is to ‘back translate’ an initial draft translation of the measure to check that the items are still meaning the same thing.

In terms of copyright, you can look at charging for use of the measure, but personally I think it’s great if people can make these freely available for non-commercial use. But to protect the measure from people amending it (and you really don’t want people doing their own modifications of your measure) you can use one of the Creative Commons licenses. With the measures I’ve been involved with, we’ve used ‘© licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0)’ so that others can use it freely, but can’t change it or make money from its use (for instance, by putting it on their own website and then charging people to use it).

Conclusion

At the most advanced levels, measure development and testing studies can be bewildering. Indeed, even at the most basic level they can be bewildering—particularly for those who are unfamiliar with statistics. But don’t let that put you off. There’s a lot of the basic item generation and testing that you can do without knowing complex stats, and if you’re based at an institution there’s generally someone you can ask to help you with the harder stuff. There’s also loads of information that you can google. And what you get at the end of it is a way of operationalising something that may be of real importance to you: creating a tool which others can use to develop knowledge in this field. So although measure development research can feel hard, and like a glacially slow process at times, you’re creating something that can really help build up understandings in a particular area—and with that the potential to develop methods and interventions that can make a real difference to people’s lives.

Acknowledgements

Photo by Tran Mau Tri Tam ✪ on UnsplashDisclaimer

 The information, materials, opinions or other content (collectively Content) contained in this blog have been prepared for general information purposes. Whilst I’ve endeavoured to ensure the Content is current and accurate, the Content in this blog is not intended to constitute professional advice and should not be relied on or treated as a substitute for specific advice relevant to particular circumstances. That means that I am not responsible for, nor will be liable for any losses incurred as a result of anyone relying on the Content contained in this blog, on this website, or any external internet sites referenced in or linked in this blog.

Person-Centred Therapy: Four Currents

It’s generally accepted now that the person-centred approach isn’t just one ‘thing’: it’s made up of lots of different ‘tribes’ or ‘branches’, like the ‘classical approach’ and ‘emotion-focused therapy’ (see blog here).

But how do all these different strands come together? It seems to me that we can think about the person-centred approach—from where it started to where it is now—in terms of four ‘currents’. Like the different movements of water running through an ocean, these current flows into each other and intermingle; but at the same time they have some distinctive elements and can, at times, pull in different directions.

1. The Client-as-Expert

This is pretty much where Rogers started from, and is still seen by many—particularly of a ‘classical’ persuasion—as the defining (or even sole) stream of person-centred theory and practice. It’s the belief, as Carl Rogers puts it in 1961, that:

‘It is the client who knows what hurts, what directions to go, what problems are crucial, what experiences have been deeply buried…

Rogers work was a reaction to the more didactic, expert-led styles of counselling that were prevalent in his early years. He wanted to develop a ‘new’ form of psychotherapy and counselling that, instead of being directive, was non-directive: that trusted the client to be able to take the lead and find the answers that were right for them.

Central to this current, as it developed, was the concept of the actualising tendency. This is the idea that all of us have an inherent tendency—and ability—to maintain and enhance ourselves, and can do so given the right conditions (of empathy, acceptance, and congruence).

In recent years, however, there’s been some challenges to the concept of the client-as-expert. It is based, for instance, on an assumption that all wisdom and knowledge is ‘within’ the client, but contemporary philosophy and psychology have questioned the idea that the client—like any of us—is a self-enclosed, separate and distinct entity. Aren’t we all fundamentally relational beings (see Current #2, below)? Also, most developmental theorists and researchers, like the infamous Swiss psychologists Jean Piaget, would say that learning can happen from the ‘outside-in’ as well as the ‘inside-out’. If you go to a CPD workshop, for instance, it’s great to have space to brainstorm, discuss, and develop your own ideas; but isn’t there also a place for being directly taught things through, for instance, Powerpoint. We don’t want death-by-Powerpoint, but at the same time some degree of it can be really useful; so does learning—therapeutic or otherwise—always need to be just self-generated? Isn’t that a bit black-and-white?

2. Relational

So another current running through the person-centred approach is an emphasis on the importance of relationship. This is evident in Rogers’ ‘necessary and sufficient’ conditions which include empathy, unconditional acceptance, congruence, and contact—and it’s very clear in much of his later work, when he focuses on the healing power of relationships and of encounter in groups. For Rogers, and for most practitioners across the person-centred approach, it is not techniques or ‘interventions’ that really help someone, but the cultivation of an in-depth personal relationship. That’s been central to the work that Dave Mearns and I have done on relational depth: where the relational encounter is really brought to the fore.

From this relational perspective, the client—like all human beings—is seen, not so much a separate and distinct individual, but as part of a relational and communal network: we’re all in it together. And it’s when we find our togetherness with others that we thrive most fully. This links person-centred therapy to other approaches like interpersonal therapy and Bowlby’s attachment theory, that also put relating at the heart of healthy development.

Rogers’ focus on the client-as-expert draws from humanistic philosophy (for instance, the French eighteenth century thinker Jean-Jacques Rousseau), whereas the relational elements are more associated with contemporary dialogical and ‘intersubjective’ philosophy—as, for instance, in the work of the twentieth century Austrian-Jewish philosopher Martin Buber. Are we separate or are we inter-related? Peter Schmid, the late great person-centred writer, brought these two currents together brilliantly by showing how we could be both.

3. Experiential/Emotion-Focused

Rogers, as we’ve seen with Current #1, starts with the client, and from here he goes on to adopt a phenomenological perspective on both the person and on therapeutic work. Phenomenology, which Rogers takes in the 1940s from two psychologists, Snyggs and Combs, is a philosophical and psychological approach which emphasises experiencing as the starting point for understanding human beings and their psychological processes. Experiencing is our subjective, ever-changing, moment-by-moment ‘all that is going on’ that is potentially available to awareness. It’s our perceptions and our senses, our desires and meanings. Experiencing is my sense, right now, of a slight chill on my shoulders as winter creeps in, the darkening light in the room, and my feeling of excitement and engagement as I write this.

Rogers model of psychological distress is all about how we get estranged from our experiencing. We come to see ourselves as fixed ‘selves’, with particular qualities and characteristics (based on what we have been told are ‘good’ characteristics) and so we get alienated from that natural flow. That’s a problem, because that flow of experiencing has, as we saw in Current #1, an actualising direction: it is towards maintaining and enhancing ourselves. So, for instance, if we deny the feelings of vulnerability or hurt that are part of that organismic experiencing, we don’t allow ourselves to strive for what we need: which, for instance, might be care or protection from others.

Eugene Gendlin, who was probably the most important of Rogers’ progeny, was particularly central to this experiential current. For Gendlin, it was this process of connecting with our bodily-felt experiencing, and allowing it to ‘carry forward’ (and carry us forward with it), that was the healing process. But, critically, Gendlin did not believe that clients would always know how to connect with, and unfurl, that experiencing in the most helpful way possible. So, in the development of ‘focusing’, Gendlin proposed methods that could help clients—or people more generally—create the environment in which their bodily felt senses, their embodied wisdom, could be carried forward.

Along with felt-senses, a core part of our experiencing is our emotions: our hurt, our fears… and also an enormous spectrum of affects like anger, shame, and joy. These emotions are often a particularly hidden part of our experiencing, because we have been taught that showing emotions is not ‘good’: to be people who others like (and to like ourselves), we shouldn’t have many of the feelings we have. But the problem is, we do have them, and they’re an important part of us; and the more we suppress them the more they can tend to resurface—and often in less controlled and more destructive ways. This emphasis on emotions have been particularly developed by the ‘emotion-focused therapy’ (EFT) branch of the person-centred approach.

We can see here that a focusing on experiencing and emotions (Current #3) emerges from a belief in clients’ (Current #1) self-righting and self-healing capacities: if we help clients to connect with their true, primary emotions, then they can find ways of sorting out their own problems. But here’s the question: how able are clients, actually, to connect with their own experiences and emotions and draw on them to improve things in their lives? This is where these current can start to part ways. From a Client-as-Expert position, clients know best: we don’t need to do anything to help them connect with their experiences and emotions other than what we always do, which is to empathise, accept, and be real. But those from an experiential and emotion-focused approach tend to believe that, actually, clients can sometimes do with a bit of help in getting in touch with their underlying emotions and that therefore there can be a place for therapists’ techniques and expertise. This isn’t about directing the content of what client’s say; but it is about adopting a more ‘process-directive’ stance: helping clients develop skills and techniques that can support them to connect with their deeper felt-senses and emotions.

4. Ethical/Political

Finally, there’s a way of ‘reading’ the person-centred approach which really brings to the fore it’s commitment to social justice, equality, and engaging with others in caring and community-spirited ways. This egalitarian spirit was, perhaps, what drove Rogers in the first place—he wanted clients to be treated as equals to their counsellors, rather than as lesser beings—and it is certainly there in his later work with groups and communities. Rogers, in this later life, was amazing in travelling to places like Northern Ireland and South Africa to try and help overcome political conflict (see, for instance, The Steel Shutter, which documents his work in Northern Ireland). It is clear here that Rogers saw the person-centred approach in much broader terms than just as a clinical practice: for him it was about transformation at a social and global level to a better, fairer world.

Our own pluralistic approach to person-centred therapy is one attempt to really follow through on this current in the person-centred approach (see blog here). For instance, in terms of therapeutic practice, we really prioritise engaging with clients in caring and respectful ways. This is likely to mean seeing the client as an expert in their own life (Current #1), and also focusing on relationships (Current #2) and experiences and emotions (Current #3); but these are all in service of a respectful, caring relationship—not ends in themselves. So, for instance, if a client really feels that they would benefit from therapist expertise, and we have expertise that might help, why not? Who are we to decide for the client what it is that they really need or want in therapy.

But the pluralistic approach also goes broader than that, and understands the therapeutic process as just one forum within which positive change can happen. There’s also change, for instance, at the social and economic level; and pluralism argues that tackling issues like racism, economic inequalities, and looming climate catastrophe can all be really important ways of helping clients. Here, there’s a focus on prizing of difference and diversity—within the client, across people, across communities and nations—which is much broader than therapeutic work alone. It is about creating a better world for us all.

Conclusion

From the dawning of Rogers’ work to the person-centred field today, we can watch these four currents mingling, merging, separating, pulling apart, and mingling again. No doubt, there are other currents that flow through the person-centred approach: for example, an existential current; or a current of creativity—as articulated, for instance, in the work of Natalie Rogers and the person-centred creative arts field today. None of these currents are the one, ‘true’ Rogerian perspective: Rogers, like all of us, said different things at different times and in subtly different ways. And, even if he did not, there’s new perspectives and directions coming into—and out of—the person-centred field all the time, that can only add to our richness, complexity, and depth.

***

A Chinese translation of this blog is available here.

Skills Practice: Some Pointers

If you’re a trainee on a counselling, psychotherapy, or counselling psychology programme, skills practice is likely to be a central part of your training. This practice is invaluable in helping you develop your competences as a therapist, so it’s essential to know how to make the best use of it.

Skills practice is often in pairs or ‘triads’ (with the three roles of speaker/client, listener/therapist, and observer).

Some pointers to help you make the best use of your time:

Listener/Therapist

• Be natural: Don’t ‘play-act’ at being a Therapist or pretend that you’re in a situation other than the one you’re in. You’re probably in a classroom, listening to a peer, with someone watching you—that’s fine. So no need, for instance, to pretend you don’t know your ‘client’, or for elaborate introductions to the therapy—unless that’s a specific skills that you’re practising. Just focus on doing your best to listen and respond therapeutically, to the real person that is there in the room with you.

• If there’s a specific area of skills that you want to work on, and get feedback on, it may be helpful to let the Observer know before you start, so that they can focus on that.

• Remember that when you are practising a particular skill (such as active listening) this is not necessarily how you should always do counselling practice. Later on, for instance, you may also develop skills in empathic reflections, self-disclosures, or even advice-giving. But it’s good to be able to develop specific skills to a point where you feel confident and capable in them—then you can do more.

• Don’t rush things, or feel that you have to demonstrate everything in the practice time you have. If your client has a lot to talk about you may ‘just’ be listening. So if, for instance, you’ve got 15 minutes for practice, think of doing the first 15 minutes of a session, rather than trying to do the whole session in 15 minutes.

Speaker/Client

• Given the context and time available, it’s important you only talk about something you are comfortable sharing. At the same time…

• …It’s helpful to the Therapist if you can talk about something with some emotional resonances for you: for instance, a current worry and concern. If it’s a purely intellectual issue (like what you are going to cook for dinner) it can be hard for the therapist to engage and practice real skills.

• Use the time usefully. That’s most helpful for the Therapist (if it’s something that you’re wanting to talk about) and also most useful for you. If you’re not sure what to talk about, take a few minutes at the beginning of the time to think about what would be helpful to talk about, or just about how you’re feeling at that point in time.

• Don’t feel responsible for the Therapist, or that you have to make things ‘easy’ for them. It’s your time, and the Therapist needs to learn to deal with more difficult/complex situations, as well as with someone who can easily talk. So, for instance, if you’re feeling stuck as you talk, no need to apologise to the Therapist—give them the opportunity to practice learning how to deal with such situations.

• A Tutor may come, at times, to listen in to how your Therapist is doing, so that they can offer feedback. If you’re talking about something that you don’t want them to hear, it’s normally fine to ask them to leave.

• If you run out of things to say, try to stay in roles for the allocated time, rather than ‘switching over’ and giving someone else a go. It can be uncomfortable if things dry up but, as above, it can be important for the Counsellor to learn how to deal with such situations, and it means you can relax more into the allocated time. As the Client, you don’t have to talk if you don’t want to.

Observer/Feedback Process

•  Your feedback should be to the Therapist, not the Client. You really don’t want to get into commenting on the Client’s material, or asking them more questions about what is going on. The whole point of this exercise is to help the Therapist develop their skills, not ‘sort the Client out’ (however much you might feel you know what they should do).

• Try to give specific feedback on specific Therapist activities rather than general, vague comments.

• Keep in mind what the purpose/focus of the exercise was—for instance, to develop skills in empathy or practice minimal encouragers—and keep your comments oriented to that. If you’re not clear what the exercise/practice is for, it’s worth clarifying that before you start.

• Positive feedback is as important as more challenging feedback, so make sure you include positives and encouragements as well as possible areas for development.

• …And challenging feedback is as important as positive feedback. That can sometimes feel really tough to give, you don’t want to upset your peer (or prime them to challenge you when it’s your turn) but it’s also what can really help them learn. Some things that can help to make challenge more productive:

  • Be descriptive rather than evaluative: what you observed, saw, and felt; rather than what is ‘right’ and ‘wrong’.

  • Unconditional positive regard is, of course, essential: focus on the behaviours and activities rather than the person: ‘challenge’ rather than ‘criticism’.

  • Remember that your view is your view: just one perspective on what went on. As legitimate as everyone else’s, but not more so.

• As Observer, you might find it useful to take notes, but make sure these are confidentially destroyed at the end of it.

• Recording the session (audio or even video) and then playing it back may be useful in terms of giving concrete feedback. Again, however, it’s essential that any recordings are destroyed (or stored securely, as per ethics and relevant regulations e.g., GDPR]) to maintain Client confidentiality.

• It’s often useful to start the feedback process with the Client, as they are the one who experienced the session and have the best sense of how it went.

• In the observation and feedback process, there are some really helpful scales that you might want to use to support and structure the feedback process.

  • Person-Centred and Experiential Psychotherapy Scale-10 (PCEPS). This is a recently developed measure to assess an essential range of person-centred competences, such as ‘emotion focus’ and ‘accepting presence’. You can download the form here, and a paper describing its development and testing is here.

  • For counselling practice for work with young people, there is a PCEPS-YP that you can download from here, and a shortened version of it here. A paper describing the development and testing of the PCEPS-YP is available here.

  • To assess the depth of experiencing that counsellor and client are working at, you can consider using the Experiencing Scale. This has seven levels: from the most ‘disowned’ description of events to a deeply-felt ‘unfolding’ of experiencing. Excerpts and further information are available here.

Afterwards

• Of course, everything that the Client shared is strictly confidential, and it’s essential that none of the content is disclosed outside of that context. That includes, for instance, talking to the Client later about an issue that they shared, unless they specifically indicate to you that they would like to discuss it further.

• As the Therapist, think about what specifically you can take away from this session into your practice. Perhaps make some notes about your learning, some action points, or incorporate it into your journaling.

Skills practices

Here are some basic exercises that you might want to use, in triads, to develop core counselling skills.

Active Listening

• Choose who will be Counsellor, Client, and Observer. Each person should get a turn in each role.

• Client: Talk about an issue or concern that has some emotional resonance for you (see guidance above), for 10 minutes.

• Counsellor: Focus on just listening to the Client. Try to put to one side (‘bracket’) any need to:

  • Advise

  • Reassure

  • Guide

  • Inform

  • Solve the problem, etc.

  Just listen—take in what the Client is saying. If you want to prompt or ask questions to help the Client unpack their experiences, that’s fine (you don’t need to leave awkward silences), but try to keep it minimal. Don’t take over!

• After 10 minutes, feed back with the Observer on how that was. How easy did the Counsellor find it just to listen? What kind of things were they having to ‘bracket’? What was the need behind wanting to say those things, and would they have actually have been helpful to the Client? (perhaps ‘yes’, perhaps ‘no’).

Empathic reflections

• Choose who will be Counsellor, Client, and Observer. Each person should get a turn in each role.

• Client: Talk about an issue or concern that has some emotional resonance for you (see guidance above), for 5 minutes. No interjections from the Counsellor, except for minimal encouragers (‘mm hm’, ‘yes’, etc).

• Counsellor (5 mins): Your task now is to summarise, in your own words, what the Client said that they are (or did) experience: What are they (or were they) feeling, thinking, imagining, wanting? Try to describe their subjective, felt-experience of particular events (how it was for them), rather than the events or behaviours themselves. For instance:

  • ‘You felt upset when your brother was cold to you. You wanted to talk to his boyfriend. You imagined how it would be to have a brother who would really look after you…’

• The Client and Observer should now feed back on how well the Counsellor summarised the Client’s felt-experiences (5 mins). The question here is not so much whether they remembered everything, but whether they fed back at the level of subjective experiences (feelings, emotions, thoughts, perceptions, fantasies, desires, etc) or whether they focused more on objective, external ‘facts’.

• Once everyone has had a chance to do this exercise, you can move on to practising empathic reflections in a more interactive way.

  • Counsellor counsels the Client (10 mins), offering the Client summaries and reflections of the Client’s experiences as the session progresses (and not just at the end).

  • Feedback with the Observer on how much the Counsellor reflected back the Client’s subjective felt-experiences (5 mins).

ACKNOWLEDGEMENTS

Photo by Handy Wicaksono on Unsplash

DISCLAIMER

The information, materials, opinions or other content (collectively Content) contained in this blog have been prepared for general information purposes. Whilst I’ve endeavoured to ensure the Content is current and accurate, the Content in this blog is not intended to constitute professional advice and should not be relied on or treated as a substitute for specific advice relevant to particular circumstances. That means that I am not responsible for, nor will be liable for any losses incurred as a result of anyone relying on the Content contained in this blog, on this website, or any external internet sites referenced in or linked in this blog.

Getting Published in Higher Impact Journals: Some Pointers

Let me start with some caveats. First, I couldn’t claim to be an expert in getting published in high impact journal. I’ve had some successes—with articles, for instance, in journals like Lancet Child & Adolescent Health, Journal of Consulting and Clinical Psychology, and Clinical Psychology: Science & Practice—but also numerous failures, including a really disappointing rejection just a few nights ago. Compared to the Michael Barkhams or Clara Hills of this world, I’m a mere novice.

Second, not everyone should, or does, want to get published in higher impact journals. Indeed, for many people, it’s an elitist, Global North-centred system that excludes non-academics and those who aren’t willing to comply with a positivist, scientistic mindset. So this blog is not suggesting that higher impact journals are good to get published in, or better than other journals, or something that all academics (and non-academics) should be aspiring to. But it is written on the basis that, for some academics, getting published in higher impact journals is important: for their careers and, perhaps, more importantly, for the maintenance and development of counselling and psychotherapy programmes in higher education (HE). In the 2000s we witnessed many counselling courses at HE institutes get closed down and, in some cases, this was because the teams were seen as not producing enough research output at a sufficiently high level. So for the maintenance and enhancement of counselling in the UK and globally, it may be really important for academics to be publishing at the highest possible level: not just for them but for the counselling community as a whole.

What is an ‘impact factor’?

So what do I mean by higher impact journals? Well, for those who don’t know, impact is essentially an indicator of the status of a journal, and it’s operationalised in terms of the amount of citations that the average article will have over the two year period from publication (for a more general guide to publishing in therapy journals, see here). You can go to any journal home page and if you look under tabs like ‘Journal Metrics’ you’ll find the impact factor (sometimes specifically called the ‘2-year impact factor’): for instance, for Psychotherapy Research it’s 3.768. This means that, on average, an article in Psychotherapy Research has been cited 3.768 times by other articles, in any other academic journal, over that two year period. Higher is, of course, ‘better’, meaning that articles in that journal are being more widely drawn on by other members of the academic community.

Impact factors for journals vary a lot by particular disciplines. For instance, in the medical and scientific fields, there’s quite a quick turn-over of articles: they come out quickly and then are rapidly drawn on by other members of those disciplinary communities. That means that journals like Science Robotics or Cancer Research can easily have impact factors of 10 or more. In the counselling and psychotherapy research field, impact factors tend to be a bit more modest, though they have increased in recent years. They range from about 1 (e.g., British Journal of Guidance and Counselling) to 5 or more (e.g., Journal of Consulting and Clinical Psychology), with some of the more psychiatric journals even higher (e.g., Lancet Psychiatry with an impact factor of 27.083).

So by ‘higher impact journals’, I mean counselling and psychotherapy journals with an impact factor of, say, about 2.5 or more. In many instances, these are US-based journals; and, as above, in most cases they are of a relatively positivist, scientistic mindset. There are journals that are more experientially- or constructionistically-focused (like the European Journal of Psychotherapy & Counselling and BACP’s Counselling & Psychotherapy Research), but mostly they either have a low impact factor or none at all.

Just to note, not having a formal impact factor doesn’t mean that there are no citations to papers in that journal. To have a formal impact factor, a journal needs to be recognised by an organisation called Clarivate (formerly Thomson-Reuters), and they are very selective about the journals that are recognised. Applying for recognition can also be a very slow process. So there are some very good journals, like the Journal of Psychotherapy Integration and Counselling Psychology Quarterly, that don’t have a formal impact factor. However, these days, such journal may calculate their own 2-year impact factor and present it on their site; so a single organisation’s monopoly over impact factors seems, thankfully, to be waning.

‘Playing the game’

As indicated above, nearly all the higher impact journals in counselling and psychotherapy can be quite positivist, scientistic, and realist in their mindset. And the reality is, that’s not likely to change (at least, not in the short term). They’re bombarded with articles and can pick and choose what they want to publish, often with rejection rates of 70% or more. So if you approach them, say, with an autoethnographic study of authenticity in therapy, you can argue with them until you are blue in the face about the importance of reflexivity and the social construction of reality, but they are unlikely to budge. They’re generally quite conservative: they have their ways of doing things, and they simply don’t need to change—whether or not they should. So, as a first and overarching pointer, if you want to publish in these journals, you generally need to ‘play by their rules’. It’s an uncomfortable reality for many of us, but it’s the way things are.

Learn Stats, or Find a Statistician

And this is a first implication of playing by their rules: if you want to stand a good chance of getting published, having a high quality statistical analysis is often a good way in. Most of the higher impact journals prefer quantitative articles to qualitative; indeed, some have explicitly said that they’re not interested in publishing qualitative articles (primarily because they’re seen as lacking generalisability because of low sample sizes). And the stats we’re talking about here is more than just some means and standard deviations (see blog on quantitative analysis, here). We’re talking structural equation modelling, multilevel analysis, cross lag panel designs… the kind of stats that, I know for myself, I can only just about understand—let alone do.

So options are to learn, in depth and detail, one particular statistical method (or a few) and then apply that. Or, and this is what most of us do, bring on board a statistician who is able to do analyses at the requisite level. That latter strategy is fairly pervasive across the research field: you collaborate with someone who specialises in statistics, and pass on the data to them for an in-depth analysis. If you’re at a university, there may well be someone in your department or faculty that has that role—or you can try linking with stats experts at other universities. Generally, someone with an in-depth understanding and specialism in stats is always going to do better than a non-stats person trying to learn a new, specialised method—unless that person really love maths and stats, and has the time and inclination to learn complex methodologies.

Control, Control, Control

Controlled experimental studies (where, for instance, some participants are allocated to an intervention and some are not) are the lifeblood of the psychological field, and they’re very popular amongst the higher impact therapy journals too. Why? Because they are seen as the ‘gold standard’ means of demonstrating causal effects. Everything else—pre-post studies, qualitative research, observational studies, etc.—tend to be seen as correlational only. So if there’s a way of conducting a controlled study in your area of interest (and doing it in a highly rigorous way using, for instance, CONSORT [Consolidated Standards of Reporting Trials] guidelines), there’s a good chance of getting it published. Ideally, you’ve also got the numbers of participants to make the trial ‘powered’ at an adequate level (see more about statistical ‘power’, here). That could be 100 or so participants per condition; but even if you cannot achieve that, a ‘pilot’ or ‘feasibility’ study should be possible and publishable (albeit in lower impact journals). Also, a controlled study doesn’t have to be a trial of a full intervention. For instance, you might test the use of a particular homework exercise, or of using visualisations as part of the therapeutic work. Or perhaps you’d give some clients full information about the therapy, and others only basic information, to see if that makes a difference. Whatever you’re line of research interest, controlled trials are nearly always possible; and you can normally also conduct qualitative research alongside them to get a more experiential, in-depth understanding of the intervention effects.

If you’re doing qual, do it systematically

Having said all that, there are higher impact journals who will consider—and do publish—qualitative research, so it’s by no means impossible to get qualitative research published. But, even so, some journals can tend to assess it with a fairly ‘quantitative’, positivistic mindset (what’s been called ‘small q research’). That means that studies with larger samples, and some quantification of themes, may be preferred (for instance, ‘framework analysis’). Also, very importantly, evidence of inter-coder reliability—or some triangulation of coding—may be expected. That means having some means of demonstrating that the coding process wasn’t dependent on just the ratings of one person, but has some ‘objective’ reality. That could be done, for instance, by having two or more analysts working independently on a set of transcripts, and then agreeing together the coding. Or having a group conduct the analysis, as in consensual qualitative research. Another way of doing this would be to have a second coder do some coding and then compare this with the main coder, producing some statistic for inter-rater reliability (such as Cohen’s kappa).

There are exceptions to this. For instance, some higher impact psychotherapy research journals have published interpretative phenomenological analysis studies where there is limited or no evidence of inter-coder reliability (see an excellent example here; an IPA study on the therapeutic relationship in CBT for adolescents). And, hopefully, such kinds of studies are becoming more common in the higher impact journals. However you do it though, what’s essential is that the qualitative research is conducted systematically. That can mean sticking closely to an established, defined methodology (such as reflexive thematic analysis); or, if you are using a mixed or new method, explaining the rationale and the procedures in that very clear. It’s also essential that the methodology is in line with the aims of your research: Why use this method to be trying to answer these research questions? And finally, do make sure you really process the data: spend time with it, examine it in depth, work out what it is really telling you. There really is no easy way to sophisticated knowledge.

Systematic Reviews

If you’re not keen on stats, another option that the higher impact journals are often open to is systematic reviews. These tend to be popular because they are generally well-cited, boosting the impact factor of the journal itself (remember, journal editors will be thinking about how often your article is likely to be cited—they want to keep their impact factors up!). Again, journals often prefer statistically-based reviews of the literature (i.e., meta-analyses), but they can also be open to narrative and other types of in-depth review. If you want to increase your chances of being accepted, though, again it needs to rigorously follow well-established methods for conducting such research. So, for instance, base the review around the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines: with, for instance, multiple coders during the study selection process, flow charts, and formal assessment of bias procedures.

Plan from the Start

One of the biggest mistakes I’ve made in my academic career is starting research projects thinking, ‘Oh, I’m sure this will generate some interesting data,’ and then getting to the end of the data collection process and realising that, actually, it is not quite the right data for a high quality publication. So I’ve learnt that it is really important, if you want to publish in a higher impact journal, to plan right from the start: What the specific aims of the study are, What you want to contribute to the literature, and Where you want to publish it. Different journals have different interests, so having a specific journal in mind for publication (and knowing the kinds of articles that journal publishes) helps to ensure that you are progressing along the required tracks. Michael Barkham, Professor of Clinical Psychology at the University of Sheffield and a world-leading psychotherapy researcher, says:

I always tell folk when working out plans and methods to imagine how they are going to write this up for a high-quality journal—so your ‘headset’ is the final product that then helps to shape the process. The point here is that having a ‘headset’ of a high-quality journal output from the start becomes the guiding process for delivering better quality research (although it doesn't guarantee publication success).

If you can set your plans out in a study protocol or study analysis plan and then ‘pre-register’ it on a site like the Centre for Open Science, it can then also really help to convey to journal reviewers the rigour with which your study has been conducted. And consult: send your protocol to people who have published in those journals and see what they think. Better to make tweaks at this earlier stage then get all the way to the end of data collection before you realise your method has some severe limitations.

It Takes time

My highest impact journal publication (that I’ve led on) took about six years from conception to publication (the ETHOS study: an RCT on the effectiveness of school counselling), and there was about a decade before that of previous work in the school counselling field. To get published in these journals, you really need to be at the absolute forefront of a field—to know everything there is to know about it—and then to conduct research that is going to significantly take that field forward. So it’s not something you can do overnight, it takes times: to build up expertise, to set out a research study, to gather the requisite amount of data, to write and to finesse a paper with multiple drafts and re-drafts. Generally, developing expertise in a specialist field—and then publishing and publishing on that—is a better strategy that trying to be a generalist (and I say that from my own experience of trying to cover too much). If you get spread too thin, there’s no way that you can be at the forefront of every field. Rather, choose a field—like counselling for people with autism, or empathy in the therapeutic relationship, or moments of deep connection in therapy—and work at it and work at it and keep researching, reading, and linking up with other leading people in that field.

Work in a Team

And that links to team work. It’s very rare these days that people publish papers in leading journals that they’ve written alone. Rather, there’s often a list of three or more—and, in some of the scientific papers, hundreds—of co-authors. That’s because people have developed the research as a team, and having multiple people working with you—within the same institution, or across institutions—is often essential in bringing together the expertise needed to publish research at the highest level. If you’ve got a team, for instance, you can have world-leading expertise in research design, and in statistics (as above), and then in a particular intervention—how many people have all that in themselves? In a team, everyone can help you, as a whole, to ensure you’re at the forefront of that field. And the great thing is, for academic auditing systems like the Research Excellence Framework (REF), it doesn’t matter whether you are the first author or just one of the co-authors, it all counts towards your published ‘outputs’.

If you’re yet to publish in higher impact journals, joining up with (and contributing to) a team of more experienced researchers can give you a crucial toe-hold in this world, says Michael Barkham. ‘It gives you a connection from which you can learn how this work can be done—start as a small cog and progress from there.’ So this is about being a junior partner with more senior colleagues: for instance, conducting the qualitative analysis in a primarily quantitative trial, or being part of a coding team. That way, you can learn the craft of higher impact journal publication, and take things forward from there.

Mentoring

Allowing oneself to be mentored by a well-published researcher, suggests Michael Barkham, can be an essential part of this process. This might be an informal arrangement between colleagues (within or across universities); or a more formal arrangement, such as a PhD programme. In the US and in much of Europe, this is exactly the system that produces so many well-published young researchers. Senior academics take on a small handful of PhD students, and work closely with them—over several years—to produce high impact research. By the time the students have left the PhD programme, they have learnt the skills and requirements of higher impact journal production, and are ready to ‘fly the nest’ and lead research on their own.

Funding

Finding the time to develop that expertise isn’t always easy: not for you, and often not for your potential colleagues. So if you can get funding to pay for your time, and to bring in additional researchers (for instance, through grants from the Economic and Social Research Council), that’s nearly always a great basis for developing high quality research programmes. Getting that funding is tough, no doubt, but there’s numerous potential sources (see, for instance, Research Professional); and the more you can develop expertise in a particular area, the more successful you’re likely to be. Again, it’s about ‘playing the long game’: not one-off attempts at high impact publication, but a long and sustained development of expertise in a particular area, that will eventually bear high quality fruits.

Show Added Value

For the higher impact journals, doing a well-conducted study is not enough. Great, so you did an IPA study the right way, or conducted some high quality statistical analysis, but what does it all mean? Journals are looking for papers that really take the field forward, so you have to make it explicit in your paper what it is that you’re adding to what was already known. Maybe you’ve discovered that clients really value a particular form of therapist self-disclosure, or that relational depth is a key predictor of therapeutic outcomes. Of course, you need to be honest about the limitations of your research; but if it’s all limitations, and null results, and ambiguities, higher impact journals may be more likely to send it back. Why publish something that, at the end of the day, doesn’t tell us too much when they can publish papers that will have clear and robust implications for practice, training, or research?

Don’t Give Up

Maybe this is all a bit bleak, but it’s written from (bitter) experience. And, having said all that, it is really possible to get published in some of the best journals in the world—you just need to be smart and strategic about it. And, perhaps more than anything, you need to be resilient and keep going in the face of rejection (…after rejection, after rejection, after rejection—says a man who is still smarting after his rejection email a few days ago). These higher impact journals can be brutal in assessing work. And they can be infuriating in imposing standards that you may think are totally wrong. But if you keep at it, and learn from the feedback you’re receiving, there’s a good chance that sooner or later you’ll succeed.

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Publishing in higher impact journals is hard, it’s really hard. So it can’t be an afterthought or something you think you’ll have a go at as a corollary to something else. For instance, if you’re doing some research primarily as ‘personal development’, but then think, ‘Well, let’s see if the top journals are interested in what I’ve produced,’ the chances are, they won’t be. Rather, as above, if you want to publish in these higher impact journals, this has to be your focus and your goal, your ‘headset’, from the start. And there is a point here, perhaps, for the wider UK counselling and psychotherapy community. If we want to be part of this higher impact publishing world, then organisations (like BACP and UKCP), and counselling academics, need to be oriented this way from the off. We need, for instance, BACP to work with counselling academic groups—as I know they are trying to do—to set up specialised research programmes, with mentoring and PhDs so that there is a sustainable programme of research at the highest possible level.

Should we be compromising to get published in these higher impact journals? I read a brilliant paper by Virginia Braun and Victoria Clarke, developers of thematic analysis, on the London Underground into work this morning, and it made me feel like, ‘No, what the hell, we should be developing qualitative and phenomenological and reflexive inquiry in a way that we believe in, and we can and should be getting that work published—at the highest possible level.’ Perhaps so. I honestly don’t know. Maybe the mountain will come to us. I guess, in my own career and in the career of those in the UK counselling field, I just haven’t seen that happen too much. I was a radical in my youth. Now, as I get older and older, I see more and more the virtues of compromise. Or, perhaps more positively, compromise as a means of achieving, ultimately, more radical results. And also, compromise as a respect to those who have different views and takes on the world. There can be an arrogance in radicalism—there was in my own radicalism—which contradicts its very essence.

Finally: writing this blog makes me realise that, ultimately, getting published in higher impact journals is a process, not an outcome: publishing in these top journals needs to be embedded in a wider programme of research, development, and impact. You can’t just go off, on your own, and write a high quality paper (or, at least, I can’t). Rather, it’s about specialising, focusing, developing expertise in a particular field—and being an integral part of a community that is doing the same thing. Then, it’s not that you want to publish in the higher impact journals, it’s that they want to publish you.

Acknowledgements

Thanks to Michael Barkham for input and guidance. Photo by alex starnes on Unsplash

Disclaimer

 The information, materials, opinions or other content (collectively Content) contained in this blog have been prepared for general information purposes. Whilst I’ve endeavoured to ensure the Content is current and accurate, the Content in this blog is not intended to constitute professional advice and should not be relied on or treated as a substitute for specific advice relevant to particular circumstances. That means that I am not responsible for, nor will be liable for any losses incurred as a result of anyone relying on the Content contained in this blog, on this website, or any external internet sites referenced in or linked in this blog.

Pete Sanders (1951-2022): Memories and Reflections

One of the strongest memory I have of Pete is a bit of a strange one. It’s of him playing table tennis with my (ex)wife and kids in the hall in our house in Glasgow. He was, to my surprise, actually pretty good. And I remember him laughing, smiling, chatting, having fun. It was great to see him happy and I have lots of memories of Pete happy – staying with him and Maggie at their house and helping Pete cook (he loved cooking). I remember visiting one time and going to the local pub with him and Tony Merry. They were laughing and joking all evening long. They were great mates and I know that Pete missed Tony so badly when he died – also really suddenly.  

I also have memories of Pete being great with our kids: really kind and caring. He took us all to a stone forest near where he and Maggie used to live. We went down the river in a boat. We talked about person-centred therapy, and life, and how things were going but mostly I just remember Pete having fun and laughing. He really laughed a lot.

One time I went through a really bad episode of anxiety. Pete was amazing. He’d ring me up every day or two, check on how I was doing… for months I remember Pete being there. Nothing too intrusive: just a warm, gentle, caring presence; someone I knew that I could turn to.

PCCS book, which Pete set up, was also a bit like that. What an amazing thing to do: to set up a whole publishing company that could publish books for the person-centred field. And also for other areas that Pete cared deeply about, like the abuses of psychiatry and ways of empowering service users. Pete set up PCCS books because he wanted there to be a way of communicating ideas and practices that wasn’t determined by financial drivers – as the big publishing houses tend to be. And he and Maggie were brave and courageous and took real risks – real risks – in setting up PCCS as a service that was there for us all. Just as one example, Pete took on the publishing of our person-centred journal, Person-Centered and Experiential Psychotherapy and Counselling, without any strong guarantees that it would be financially viable. And, perhaps more to the point, he was happy for the journal to move on to a larger publisher when he knew that that was best for the journal. Pete was such a generous man and really led by principles: it was about doing the right thing rather than the thing that was going to suit his finances or his ego.

I always looked forward to seeing Pete and the PCCS team at conferences. He’d be there at the PCCS stand, at lunch, or when the talks got a little wordy, or during the encounter groups (Pete always seemed to opt out of those!), and you could nip off and have a chat with Pete. He’d always be up for a discussion, and it could be personal or professional or just joking around. Pete was like a great anchor in our counselling and person-centred world, or perhaps like a harbour. It was always somewhere safe you could go back to and feel like you could reconnect to someone and to yourself.

When I passed on news of Pete’s death on social media, one of the things that people most reflected on was his First steps in counselling book, and how that had, indeed, been their first steps into the counselling and person-centred worlds. Pete had an incredible ability to write clearly and simply: to convey complex and difficult ideas in ways that people could really understand. It was clear to me that so many people really loved that book: but, more than that, they loved a man who had taken the time to really present counselling ideas in a way that was accessible and meaningful to them.

But that was Pete. Someone deeply, deeply committed to social justice and to creating a world in which everyone has access to all the best things that life can offer. Everything, in all his activities, pointed to that end: he lived a person-centred ethos as much as he wrote about it and promoted it through PCCS.

I find it impossible to imagine that Pete is gone. It’s a massive Pete-shaped hole in our person-centred and counselling community. It’s an anchor that has been raised, a harbour that’s been destroyed: it’s an existential shock, and I imagine we’re all going to need a bit of time to re-orientate ourselves.

Pete was a loving man, and a fighter, and someone you could really rely on and who held so much together. He was so sharp, smart – but also compassionate and warm. Our world will be a really different one for his loss. But in all the sadness, I can still see Pete running around that table tennis table, and laughing and smiling. For all his depth, profundity, and commitment to social justice, he also brought an amazing joy to my life and the lives of so many others, all over the world.

Quantitative Analysis: Some Pointers

When it comes to counsellors and psychotherapists, everyone hates stats. Well, almost everyone. Aside from a few geeks like myself who would prefer nothing better than sitting in front of an Excel spreadsheet for days.

…Oh yes: and, then, there’s also the funders, commissioners, and policy-makers who all rely almost exclusively on the statistical analysis of data. And that creates a real tension. Most of us don’t come into therapy to do statistical analysis. We want to engage with people—real people—and studying people and processes by numbers can feel like the most de-humanising, over-generalising kind of reductionism. But, on the other hand, if we want to have an impact on the field and influence policy and practice, then we do need to engage with quantitative, statistical analysis. Or, at least, understand what it is saying and showing. If not, there’s a danger that those therapies that are most humanistic and anti-reductionistic are also those that are most likely to get side-lined in the world of psychological therapy delivery.

And there is also another, less polarised, way of looking at this. From a pluralistic standpoint, no research method—like no approach to therapy—is either wholly ‘right’ or ‘wrong’ (see our recent publication on pluralistic research here). Rather, different methods of research and analysis are helping in asking different questions at different points in time. So if you are asking, for instance, about the average cost of a therapeutic intervention; or whether, on average, a client is more likely to find Therapy A or Therapy B more helpful; then it does make sense to use statistics. (But if you wanted to know, for instance, how different clients experienced Therapy A, then you’d be much better off using qualitative methods).

This blog presents a very basic introduction to terms and concepts in quantitative analysis. This may be helpful if you are wanting to present some basic statistical analyses in a research paper, or if you are reading quantitative research papers and want to get more of a grasp on what they are meaning and doing. You can find many books and guides on the internet that give more in-depth introductions to quantitative analysis, one of the most popular being Andy Field’s Discovering Statistics Using IBM SPSS Statistics.

Quantitative analysis and statistical analysis are essentially the same thing (and will be used synonymously in this blog): the analysis of number-based data. The principle alternative to quantitative analysis is qualitative analysis, which refers to the analysis of language-based data.

Descriptive Statistics

There are two main sorts of quantitative analysis. The first is descriptive statistics. This is where numbers are used to show what a set of data looks like (as opposed to testing particular hypotheses, which we’ll come on to). Descriptive statistics may be used in a Results section to present the findings of a study but, even if you are doing a qualitative study, you may use some descriptive statistics to present some data about your participants. So always worth knowing.

Frequencies

Probably the most basic statistic is just saying how many of something there are: for instance, how many participants you had in a study, or how many of them were BAME/White/etc. There are two basic ways to do this:

• Count. ‘There were nine participants in the study; three of them were of a black or minority ethnicity and six were white.’ Count is just the number of something, and about as simple as statistics gets.

• Percentage. Percentage is the amount of something you would have if there was 100 in total. It’s a way of standardising counts so that we can compare them. For instance, if we had three BAME participants out of nine total participants in one study; and ten BAME participants out of 1000 total participants in a second study; the count of BAME participants in the second study is higher, but actually they were more representative in the former. We work out percentages by dividing the count we’re interested by the total count, then multiplying by 100. So our percentage in the first study is 3/9 * 100 (‘/’ means ‘divide by’, ‘*’ means ‘multiply by’), which is 33.3%; and in our second study is 10/1000 * 100, which is 1%. 33.3% vs. 1%: that really shows us a meaningful difference in representation across the two studies. Percentages are easy to work out by Excel: just do a formula where you divide the number in the group of interest by the total number, and multiple by 100. Only do percentages when it’s needed though: that is, when it would be hard for the reader to work out the proportion otherwise. With small samples (less than ten or so) you probably don’t need it. If we had, for instance, one White and one BAME participant, it’s a bit patronising to be told that there’s 50% of each!

Averages

One way of pulling together a large set of numerical data is through averages. This is a way of combining lots of bits of data to give some indication of what the data, overall, looks like. There are three main types of averages:

• Mean. This is the one that you come across most frequently, and is generally the most accurate representation of the middle point in a set of data. The mean is the mathematical average, and is worked out by adding up all the scores in a set of data and then dividing by the number of data points. For instance, if you had three young people who scores on the YP-CORE measure of psychological distress (which ranges from 0 to 40, with higher scores meaning more distress) were 10, 15, and 18, then we could work out the mean by adding the scores together (which gives us 43) and then dividing by the number of scores (which is 3). So the mean is 43/3 = 14.3. Whenever we have several bits of data along the same scale—for instance ages of participants in a study, or scores of participants on a measure of the alliance—it can be useful to combine it together using the mean. Means are easy to do on Excel using the function AVERAGE. Note, don’t worry about lots and lots of decimal points. Really, for instance, that the mean above is 14.3333333333333333333333333 etc but no-one needs to know that level of detail. It just looks like we are trying to be clever and actually makes it harder for the reader to know what is going on! So normally one decimal point is enough (unless the number is typically less than 1.0, in which case you could give a couple of decimal points).

• Median. Sometimes our data might have an usual distribution. Supposing, for instance, that we did a study and our participants ages were 20, 22, 23, 24, and 95. Well, the mean here would be 36.8 years old, but it doesn’t seem to describe our data very well because we have one ‘outlier’ (the 95 year old) who is very different from the other participants. So an alternative kind of average is the median, which is where we line up our values in a consecutive sequence, and then identify the middle. In this instance, we have five values and the middle one is 23 years old. The MEDIAN function on Excel is also very easy to use, and is a useful way of describing our data when there isn’t too much of it or it’s not smoothly spread out. If the mean and median of a set of values are very different, it’s normally helpful to give both—less important if they are virtually the same.

• Mode. Let’s be frank, the mode is like the useless youngest sibling of the central tendency family: it doesn’t really tell you much and doesn’t get used very often. The mode is just the most common response. So, for instance, if we had YP-CORE scores of 20, 20, 23, 25, and 40 the mode would be 20 because there are two of those scores and one of every other one. Not much use, huh! But some times it can be quite informative. For instance, it’s an interesting fact that the modal number of sessions attended at many therapy services is 1. So even though the mode and median may be closer to 6 or so sessions, it’s interesting to note that the most common number of sessions attended is much less. MODE can be shown in Excel, but only report it if it adds something meaningful to what you are presenting.

Spread

Say you had a group of people who were aged 20, 30, and 40 years old. Then you had a second group that were aged 29, 30, and 31 years old. If we just gave the mean or the median of the groups, they’d actually be the same: 30 years old. But, clearly, the two sets of data are a bit different, because the first one is more spread out than the second one. So, if we want to understand a dataset as comprehensively as possible, with as few as possible figures, then we also need some indication of spread.

• Range. The range is the simplest way of giving an indication of the spread of a dataset, and just means giving the highest and lowest values. So, for instance, with the first dataset above you might say: ‘Mean = 30 years old, range = 20-40 years old’. That can be pretty informative, though for larger datasets the highest and lowest numbers don’t tell us much about what is in the middle.

• Standard deviation. The standard deviation, or SD, is an indication of the spread of a dataset. In contrast to the frequencies or central tendencies, it’s not a number that intuitively means much, but it’s essentially the average amount that the values in a dataset vary from the mean. So in the first group above, the standard deviation is 10 years and in the second group it’s 1 year. Essentially, a higher standard deviation means more spread. Pretty much always, if you’re giving a mean you’ll also want to give the standard deviation; so, in a paper, you’ll see something like: ‘Mean = 30 years old (SD = 10)’. Means look pretty naked without an SD. But it’s not easy to work out yourself, and you’ll need to use something like Excel that can calculate it using the function STDEV.

• Standard error. This is getting a bit more complicated, and you’re unlikely to need standard error (SE) if you’re just presenting some simple descriptive statistics, but it is worth knowing about because it’s the basis for a lot of subsequent analyses. Let’s say we’re interested in the levels of psychological distress of young people coming in to school counselling, and we use the YP-CORE to measure it. We get an average level of 20.8 and a standard deviation of 6.4 (this is what we actually got in our ETHOS study of school-based counselling). So far so good. But, of course, this is just one sample of young people in counselling, and what we really want to know is what the average levels of distress of all young people coming into counselling is: the population mean (so sample is the group we are studying, and population is everyone as a whole). So how good is our mean of 20.8 at predicting what the population mean might actually be? OK, so here’s a question: if that mean came from a sample of 10,000 young people, or if it came from a sample of five young people, which would give the most accurate indicator of the population mean (all other things being equal)? Answer (I hope you got this), from the sample of 10,000 people. Why? Because in the sample of five young people, any individual idiosyncrasies could really influence the mean; whereas in a much larger sample these are likely to get ironed out. So the standard error is an indication of how much the sample mean is likely to vary from the true population mean, and it’s worked out by dividing the standard deviation by the sample size (square-rooted). Don’t worry about why it’s the square root (the number that, when multiplied by itself, gives that value—for instance the square root of nine is three). But it just means that the larger a sample, the smaller the standard error gets: indicating that it varies around the true population mean by a smaller amount. Phew!

• Confidence intervals. Again, the standard error, as a statistic, isn’t a number that intuitively means much. One thing that is often done with it, however, is to work out the confidence intervals around a particular mean. The confidence interval is our guestimate of where the true population mean is likely to lie, given our sample mean. And it’s always at a particular level of confidence, normally 95% (or sometimes 99%). So if you see something like ‘Mean YP-CORE score = 20.8, 95%CI = 19.5 - 22.1)’ it’s telling us that we can be 95% certain that the true population mean for YP-CORE scores of young people coming into counselling is between 19.5 and 22.1. Pretty cool, and confidence intervals are used more and more these days, because there’s a move from pretending we know precisely what a population mean is to being more cautious in suggesting whereabouts it might lie. Confidence intervals aren’t too difficult to calculate—for 95% CIs, you add, and take away, 1.96 * the standard error—but, like standard errors, there’s no automatic way of doing it on Excel: you need to set up the formula yourself. Or use more sophisticated statistical analysis software like IBM SPSS. Why 1.96? There’s a very good reason, but for that you need to look at one of the more in-depth introductions to stats. 

effect sizes

Effect sizes are a really good statistic to know about when you are reading research papers, because they are one of the most commonly reported statistics these days. Also, if you are wanting to compare anything statistically—for instance, whether boys or girls have higher levels of distress when they come into counselling—you’ll want to be giving an effect size.

In fact, there are hundreds and hundreds of different effect size statistics. An effect size is just an indicator of the magnitude of a relationship between two variables. So that might be gender and levels of psychological distress, or it might be the relationship between the number of sessions of art therapy and subsequent ratings of satisfaction. Whatever effect size statistics is used, though, the higher it is the stronger the relationship between two variables.

• Cohen’s d. The most common form of effect size that you see in the therapy research literature is Cohen’s d, or some variant of it (for instance, ‘Hedges’s g’ or the ‘standardised mean difference’). This is used to indicate the difference between two groups on some variable. For instance, we could use it to indicate the amount of difference in levels of psychological distress for boys and girls coming into counselling, or to indicate how much difference counselling made to young people’s levels of psychological distress as compared with care as usual (which is what we did in our ETHOS study). Cohen’s d is basically the amount of difference between two scores divided by their standard deviations. So, for instance, if boys had a mean level of distress on the YP-CORE of 20, and girls had a mean of 22, and the standard deviation across the two groups was 4.0, then we would have an effect size of 0.5. (This is the difference between 22 and 20 (i.e., 2 points) divided by 4.0). Dividing the raw difference in scores by the standard deviation is important because if, for instance, boys’ and girls’ scores varied very markedly already (i.e., a larger standard deviation), then a difference of 2 points between the two groups would be less meaningful than if the differences in scores were otherwise very small. Typically, when we interpret effect sizes like Cohen’s d:

  • 0.2 = a small effect

  • 0.5 = a medium effect

  • 0.8 = a large effect

  So we could say that there is a medium difference between girls and boys when coming into counselling. In our study of humanistic counselling schools, we found an effect size of 0.25 on YP-CORE scores after 12-weeks between the young people who had counselling and those who didn’t, suggesting that the counselling had a small effect. We can also put a confidence interval around that effect size, for instance ours was 0.03 to 0.47, indicating that we were 95% confident that the true effect of our intervention on young people would lie somewhere between those two figures.

correlational analyses

Correlations are, actually, another form of effect size. But they specifically tell us about the size of relationship between linear variables (i.e., where the scores vary along a numerical scale, like age or YP-CORE scores) rather than between a linear variable and categorical variable (i.e., where there are different types of things, like White vs. BAME, or counselling vs. no counselling).

• Correlations. These are used to indicate the magnitude of relationship between just two linear variables. It’s a number that ranges from -1 to 0 to +1. A negative correlation indicates that, as one number goes up the other goes down. So, for instance, a correlation of -.8 between age and levels of psychological distress would indicate that, as children get older, their levels of distress go down. A correlation of 0 would indicate that these two variables weren’t related in any way. A positive number would indicate that, as children get older, so they are more distressed. Correlations can be easily calculated on Excel using the function CORREL. Typically, in interpreting correlations

  • 0.1 = a small association

  • 0.3 = a medium association

  • 0.5 = a large association

Tables

If you’ve got lots of different bits of quantitative data (say six or more means/SDs), it’s generally good to present it in a table. Below, for instance, is a table that we used to present data from our ETHOS study about young people who had school-based humanistic counselling plus pastoral care as usual (SBHC plus PCAU group) and those who had pastoral care as usual alone (PCAU group).

In our text, we also gave a narrative account of the main details here (for instance, how many females and males) but the table allowed us to present a lot of detail that we didn’t need to talk the reader through. Generally, tables are a better way of presenting the data than figures, such as graphs, because they can more precisely convey the information to a reader (for instance, a reader won’t know the decimal points from a graph). Just to add, if you are doing a table of participant demographics, the format above is a pretty good way to do it, with different characteristics listed in the left hand column, grouped under subheadings (like ‘Disability’). That works even when there’s just one group, and is generally better than trying to do different characteristics across the top.

Graphs

…But graphs do look prettier, and sometimes they can communicate key relationships between variables that a table or narrative might not. For instance, below is a graph showing our ETHOS results that gives a pretty clear picture of how our two groups changed on our key outcome measure of psychological distress over time. This gives a very immediate representation of what our findings were, and can be particularly useful when conveying results to a lay audience. However, for an academic audience, graphs can be relatively imprecise: if you wanted to know the exact scores, you’d need to get a ruler out! So use graphs sparingly in your own reports and only when they really convey something that can’t be said in a table. And I’d generally say NAAPC (nearly always avoid pie charts): you can get some lovely colours in them, but they take up lots of space and don’t tend to communicate that much information.

Main outcomes from the ETHOS study

Inferential Statistics

Basic principles

So now we come on to the second main type of quantitative analysis: inferential statistics. This is where we use numbers to test hypotheses: that is, we’re not just describing the data here but trying to test particular beliefs and assumptions. Inferential statistics are notoriously difficult to get your head around, so let’s start by taking a step back and thinking about the problem that they’re trying to solve.

Let’s say we find that, after 10 weeks of dramatherapy, older adults have a mean score of 15 on the PHQ-9 measure of depression, while those who didn’t participate in dramatherapy have a mean score of 16. Higher scores on the PHQ-9 mean more depression, but is this difference really meaningful? What, for instance, if those who had dramatherapy had mean scores of 15.9, as opposed to 16.0 for those without—what would we make of that? The problem is, there’s always going to be some random variations between groups—for instance, one might start off with more depressed people—so any small differences between outcomes might be due to that. So how can we say, for instance, whether a difference of 0.1 points between groups is meaningful, or a difference of 1 point, or a difference of 10 points? What we’re asking here, essentially, is whether the differences we have found between our samples are just a result of random variations, or whether they reflect real differences in the population means. That is, in the real world, overall, does dramatherapy actually bring about more reductions in depression for older adults?

So here’s what we can do, and it’s a pretty brilliant—albeit somewhat quirky, on first hearing—solution to this problem. Let’s take our difference of 1 point on the PHQ-9 between our dramatherapy and our no dramatherapy groups. Now, we can never say, for sure, whether this 1 point difference does reflect a real population difference/effect, because there’s always the possibility that our results are due to random variations in sampling. But what we can do is to work out the probability that the difference we have found is simply due to random variations in sampling. The way we do this is by saying, ‘If there were no real differences between the two groups (the null hypothesis), how likely is it that we would have got this result?’ For instance, ‘If dramatherapy was not effective at all, how likely is it that we would have got a 1 point difference between the two groups?’ We can work that out basically by looking at the ratio between how much scores tend to vary anyway across people (i.e., the standard deviation), and then how much they vary between the two specific groups. For instance, if we find lots of differences in how older adults score on the PHQ-9 after therapy, and only very small differences between those who had, and did not have, dramatherapy, the likelihood that the mean differences between the two groups would be due to just random variations would be fairly high. The exact method to calculate this ratio is beyond this blog (and Excel too—you generally need proper statistical software), but the key figure that comes out of it all is a probability value, or p-value. So this is a number, from 1.0 downwards, which tells you how likely it is that your results are just due to chance. So you might get a p-value of .27 (which means that there is a 27% likelihood that your results were due to chance) or .001 (which means that there is a 0.1%, one-in-a-thousand, likelihood that it was due to chance).

So what do you do with that? Well, the standard procedure is to set a cut off point and to say that, if our probability-value is less than that, we’ll say that our difference is significant. That cut-off point is typically .05 (i.e., 1-in-20), and sometimes .01 (i.e., 1-in-100). So, essentially, what we do is to see whether the probability of our results coming about by random is 1-in-20 or less and, if it is, we say that we have a significant result. Why 1-in-20? Well, that’s a bit random in itself, but it’s an established norm, and pretty much any paper you see will use that cut off point to assess whether the likelihood is so low that we’re going to say we’ve found a meaningful difference. Note, if we don’t find a p-value of less than 1-in-20 we can’t say that we’ve shown two things are the same. For instance, if our p-value for dramatherapy against no dramatherapy was 0.27, it doesn’t prove that dramatherapy is no more effective than no dramatherapy. It just means that, at this point, we can’t claim that we have found a significant difference.

Statistical tests

There are a large number of statistical tests that you’ll see in the literature, all based on the principles outlined above. That is, they all ways of looking at different sets of data and asking the question, ‘How likely is it that these results came about by chance?’ If it’s less than 1-in-20, then the null hypothesis that the results are just due to random variations is rejected, and a significant finding is claimed. That’s what researchers are looking for; and it’s a bit weird because, as you can see, what we’re trying to do is to disprove something we never really believed in in the first place! It’s all based, though, around the principle that you can only ever disprove things, not prove things—see Karl Popper’s work on falsifiability here.

Some of the most common families of statistical tests you will come across are:

• T-tests. These are the most simple tests, and compare the means of two groups. This may be ‘between-participants’ (for instance, PHQ-9 scores for people who have dramatherapy, and those who do not have therapy) or ‘within-participants’ (for instance, PHQ-9 scores for people at the start of dramatherapy, and then at the end).

• Analysis of variance (ANOVAs). These are a family of tests that compare scores across two or more different groups. For instance, the PHQ-9 scores of participants in dramatherapy, counselling, and acupuncture could be compared against each other. Multiple analyses of variance allows you to compare scores on different dimensions, and then also the interactions between the different dimensions. For instance, an experimental study might look at the outcomes of these three different interventions, and then also compare short term and long term formats. Repeated measures analyses of variance combine within- and between-participant analyses: comparing, for instance, changes on the PHQ-9 from start of therapy to end of therapy for clients in dramatherapy, as compared with one or more other interventions.

• Correlational tests. Correlations (see above), like differences in means, are very rarely exactly 0, so how do we know if they are meaningful or not? Again, we can use statistical testing to generate a p-value, indicating how likely the association we find is due to random chance.

• Regression analysis. Regression analysis is an extension of correlational testing. It is a way of looking at the relationship between one linear variable (for instance, psychological distress) and a whole host of other linear variables at the same time (for instance, age, income level, psychological mindedness). Categorical variables, like gender or ethnicity, can also be entered into regression analyses by converting them into linear variables (for instance, White becomes a 1 for ‘yes’, and a 0 for ‘no’). So regression analyses allow you to look at the effects of lots of different factors all at once, and to work out which ones are actually predictive of the outcome and which are not. For instance, correlational tests may show that both age and ethnicity are associated with higher levels of distress, but a regression analysis might indicate that, in fact, age effects are cancelled out once ethnicity is accounted for.

• Chi-squared tests. As we’ve seen, some data, like gender or diagnoses, is primarily categorical: meaning that it exists in different types/clumps, rather than along continua. So if we’re asking a question like, ‘Are there differences in the extent to which boys and girls are diagnosed with ADHD vs depression?’, we can’t use standard linear-based tests, because there’s no outcome variable. Instead, we use something called a chi-squared test, which is specifically aimed at looking at differences across frequency counts.

… And that’s just the beginning. There’s a mind-boggling number of further tests, like structural equation modelling, cross-panel lag analysis, multilevel modelling, and a whole family of non-parametric tests, but hopefully that gives you a rough idea. There all different procedures, but they’re all based around the same principle: How likely is it, given the results that you got, that there is no difference between the groups? If that likelihood is less than 1-in-20, we’re going to say that something ‘significant’ is going on.

Final thoughts

Whether you like stats or not, they’re there in the research, so if you want to know something of what the research says, you do need to have a basic understanding of them. But we don’t need to get into either/or about it. Stats have their strengths and they have their limitations: from a pluralistic standpoint, they tell one (very helpful at times) story, but it’s not the only story that tells us what’s going on.

Stats, to some extent at least, is also changing. When I trained as a psychology undergraduate in the 1980s, for instance, it was all about significant testing. Today, particularly in psychotherapy research, there’s more emphasis on using stats descriptively, in particular effect sizes and confidence intervals. That’s through a recognition that the kind of yes/no answers you get from inferential tests are too binary and too unrepresentative of the real world.

If you’re staring blankly at this blog and thinking, ‘What the hell was that about?’ do let me know in the comments what wasn’t clear and I’ll try and explain it better. I do, I guess, wish the therapy world would love stats a bit more. I guess that’s partly because it’s so important for understanding what’s getting commissioned and funded and making a difference there; but maybe more because I can see, for myself, so much beauty in it. And that doesn’t in any way take away from the beauty of words or language or art or the many, many other ways of knowing. But numbers can also have a very special place there in helping us to understand people and therapy more; and once you’ve got a basic grasp of what they are trying to do, hopefully they’ll feel more like friend than foe.

Acknowledgements

Photo by Mick Haupt on Unsplash

Disclaimer

 The information, materials, opinions or other content (collectively Content) contained in this blog have been prepared for general information purposes. Whilst I’ve endeavoured to ensure the Content is current and accurate, the Content in this blog is not intended to constitute professional advice and should not be relied on or treated as a substitute for specific advice relevant to particular circumstances. That means that I am not responsible for, nor will be liable for any losses incurred as a result of anyone relying on the Content contained in this blog, on this website, or any external internet sites referenced in or linked in this blog.

The ‘Research Mindset’: Some Pointers

After years of supervising—and teaching—Master’s and doctoral research students in counselling, psychotherapy, and counselling psychology, there’s one thing that, I’ve come to believe, is the key to success. It’s hard to describe, but goes something like this….

When you study or research at undergraduate level, it’s all about showing how much you know. You have to convince your assessors that you are ‘up to it’: that you know enough to meet the learning outcomes for that award.

Students often approach Master’s or doctoral research with the same mindset: they want to show how much they know, that they’re doing it the right way, that they understand the process and the content of the research that they are conducting.

For Master’s and doctoral research that is, indeed, still important; but there is also something much more. When you do research at this level, you are moving from being a student to being a teacher. You, now, are the one who knows. And what the academic community, including your examiners, want from you is not so much to test you or to check your knowledge in a particular field, but to learn from you. We’re looking to you to tell us about what you’re discovering because you know more than us. Yes, that’s right. You do (or, at least, will do); and you need to be able to own that authority.

This can be a hard one: ‘Who am I, I’m just a student, how am I supposed to know anything special?’ But, at doctoral (and to some extent Master’s) level, you are, by definition, being asked to make an original and significant contribution at the leading edge of your field. So, to some extent, this shift needs to happen whether you like it or not. You need to be the big person in the room.

Is this about being arrogant? No, of course not. Is it about pretending you know everything? No, not that either. Is it about patronising your supervisors or your examiners? Definitely not, no. What it is about is being confident and secure in your knowledge and feeling that you have something to educate others about—something to even the most senior figures in the field.

Because the reality is, you do. If you’re researching at Master’s or doctoral level, you should be focusing on a question that no-one else, or very few other people, have ever asked. And that does make you the expert. You know more than us. You know more than your supervisors, you know more than your examiners. You know more than other people in the academic field. And what’s really important to recognise is that we want to learn from you. When someone agrees to examine you for your viva, for instance, or when they come to see you present your research at a conference, they’re not thinking, ‘Mm, I’ve always wondered whether [insert your name here] is good enough for a Master’s/doctoral degree’, or, ‘I’ve always thought [insert your name here] is really just pretending to know things, and I’m now going to find out for sure.’ Nope, that’s probably the last things on their minds. Rather, a large part of the reason they’ve agreed to spend two days reading your thesis and then travelling to your university to examine you, etcetera, is because they’re interested in what you’ve discovered and want to find out more. After all (and apologies to the narcissists here) would anyone really want to spend two or more days of their life just checking up on you? In a world where everyone is so furiously busy what people mostly want is to learn, as effectively and efficiently, what you know so that they can inform and develop their own work and ideas. We want to learn from you.

Doing it despite

Of course that can be scary. When we start off learning in any field, we are inevitably novices; and some of us have ‘imposter syndrome’ throughout our careers. That’s totally understandable. But researching at doctoral and Master’s level means being and doing something despite these fears. It means holding, and owning, our knowledge, skills, and expertise. So if you find it difficult to own that teacher role, this might be something useful to take to therapy: ‘Why is it so difficult for me to see myself as an authority here?’ It gets to the very heart of who we are and how we feel about ourselves.

A key to researching and writing

Although this ‘teacher mindset’ is relatively hard to describe; once you can get into it, it can really unlock the research and writing up process. It means you can write with confidence; and with balance, because you know that what you are saying is important, and that people are wanting a serious, reflective, critical commentary from you. And it means that you are likely to avoid some of the pitfalls stemming from a wholly ‘student mindset’. One problem you sometimes see in students’ theses, for instance, is that their Discussion says next to nothing about their own findings—it focuses solely on the research and theory introduced in their Literature Review. Why does that happen? Probably because, to some extent, the student doesn’t really believe that their own findings have much to say: so they just skip over it and back to the ‘important stuff’. Get into that teacher mindset, however, and you’ll find that you naturally take your own findings much more seriously: they’re not just some throw-away bits of data, they’re carefully curated evidence that have a meaning and significance to the wider field of knowledge.

Narrowing down your focus

One key thing in getting to be—and feeling like—the expert is ensuring that the scope of your research is sufficiently narrow. If you take on a massive area, like ‘the effectiveness of therapy’, you’re never going to feel like (or, indeed, be) the leading authority in that area. There’s people who have spent their lifetimes researching this, carried out hundreds of studies, so, of course, you are going to feel less knowledgeable than them. But if you narrow down your focus—for instance, ‘the effectiveness of compassion-focused therapy (CFT) for health anxiety’—then, immediately, the number of leading authorities in the field dramatically reduces. Sure, people might know about the overall effectiveness of CFT more than you, or the processes by which it supports change; but when it comes to CFT for health anxiety, you’re likely to be in a field of one. And that’s when everyone starts to turn to you to discover what you’ve found, because you’re then genuinely contributing to the knowledge-base. So if you’re feeling like you could never ‘hold’ that expert position in your field, it may be worth looking at how broad your field is. You can, I promise, get to that expertise level, but it is very dependent on the breadth of the question you are asking.

Against authority

But is it OK to be an ‘authority’? Perhaps another block to that teacher mindset, for those of us from more humanistic and person-centred orientations, is that we’re wary of taking on too dominant a role: we don’t like to position ourselves as ‘better’ than others. Here, equality, respect, treating the other as like ourselves are all the principal values. Yes, absolutely; but recognising that we know more than others in one particular field isn’t saying we’re better or smarter than others. We can know lots and others can know lots as well; and if we all share our specialist knowledges—and dialogue between them—then we can all make contributions to a better world for all. Equality doesn’t have to mean sameness. Indeed, recognising our own special knowledges—and giving that away to others—can be part of a world that celebrates difference, diversity, and uniqueness for all.

facing the unknowable

To adopt that teacher mindset, you also have to be willing to face the unknowability of a lot of the questions you are asking. At school and at undergraduate level, the questions you were asked had ‘right’ answers—or, at least, your teachers and lecturers told you they did. Multiple choice questions make it clear that there are ‘rights’ and ‘wrongs’. But when you’re leading the field, when you’re at the cutting edge of developments, there’s often not one right way of going forward. You’re ahead now, and you have to decide which path to cut. Should you use IPA or grounded theory? Two or three levels in your multilevel analysis? Well, sorry, but as your supervisors, examiners, and readers it’s very likely that we don’t actually know. We’ve got our own ideas, but what we’re hoping for is that you’ll be able to face those really difficult questions and, in the absent of any certainties, work if out for yourself (in a sensible, informed, and transparent way). And that’s not because we want to provide a non-directive environment to teach you to work these things out for yourself: it’s because we genuinely, really, don’t know.

That’s what doctoral level competences are about: being able to move forward in the face of incomplete knowledge. If you don’t know, it’s almost certainly not because you are incapable or dumb, but because the reality is that no one else knows either: no one has managed to work it out yet. And what we’re hoping for is that you’ll do the work of working it out. There’s so many questions, uncertainties, and unknowns out there; and if you can take one small chunk of this and do some thinking that can contribute to the wider field, you’ll be doing a massive benefit to all of us.

Conclusion

Be serious, then, about your research. You do nothing for yourself, or for the field, if you treat your research as simply an academic exercise that you have to get through—that isn’t ever going to teach anyone about anything. Sorry if that sounds harsh; but be serious about your research in the same way that you would be serious about your work as a therapist. That doesn’t mean not being able to laugh, or joke, or enjoy it along the way; but it does mean having the confidence to believe that you can give something meaningful to the wider world. And if you don’t feel that, take some time to work on it, in the same way that you would work on your insecurities as a therapist (in research supervisor, for instance, or in therapy, or on your course). Get to a position where, in transactional analysis terms, you’re an adult: where you’re able to own your strengths and your abilities to contribute, as well as your limitations. You have so much to offer.

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Acknowledgements

Photo by Ben White on Unsplash

Disclaimer

 The information, materials, opinions or other content (collectively Content) contained in this blog have been prepared for general information purposes. Whilst I’ve endeavoured to ensure the Content is current and accurate, the Content in this blog is not intended to constitute professional advice and should not be relied on or treated as a substitute for specific advice relevant to particular circumstances. That means that I am not responsible for, nor will be liable for any losses incurred as a result of anyone relying on the Content contained in this blog, on this website, or any external internet sites referenced in or linked in this blog.

Overview of the Thesis: Some Pointers

OVERVIEW OF THE THESIS: SOME POINTERS

A good thesis is like a journey of discovery: think Odyssey, Lancelot, Charlie and the Chocolate Factory. You’ve set out to find an answer to a question (or some answers to some questions), and each section of your thesis is a stage on that journey:

• Introduction: why this question is of value

• Literature Review: how other people have answered it

• Method: how you will try and answer it

• Results: what you have found out

• Discussion: what your findings mean (particularly in relation to previous findings).

To that you can add:

• Title: Concise statement of your research question/enquiry

• Abstract: Summary of all the sections in your thesis

• Conclusion (after Discussion): A summary of what you have found and any outstanding issues.

Each of these sections should be logically linked, so that, if all is as it should be, you should be able to reduce your dissertation down to a single, coherent narrative of not more than a paragraph or so (your abstract, effectively). Below is an example:

The Benefits and Limitations of Using the Two-Chair Technique in Person-Centred Therapy: An Interpretative Phenomenological Analysis

Understanding the benefits and limitations of the two-chair technique in person-centred therapy is important because a number of person-centred approaches, such as person-centred experiential therapy for depression, are moving towards their use [Introduction]. Greenberg has shown that clients can experience the two-chair technique as beneficial, but these findings are primarily quantitative and there is little data on why clients might experience this technique as helpful—or unhelpful—per se [Literature Review]. For this reason, I carried out a series of semi-structured interviews with ten clients in person-centred therapy who engaged with the two-chair technique to find out their views on it. I recruited these clients through social media. Their interview data was analysed through interpretative phenomenological analysis [Method]. In terms of benefits, clients said that the two-chair technique had helped them express feelings that they found difficult to express otherwise. It also helped them identify different aspects of themselves, and helped them feel closer to their therapist. On the other hand, for some clients the two-chair technique had interfered with the therapeutic alliance. The main reason for this was that it made them feel embarrassed, and in one case the client actually left counselling as a result [Results]. It would seem, then, that Greenberg and others are right that the two-chair technique can be very useful as an adjunct to person-centred therapy, however there may be some contraindications of this technique [Discussion].

Have a go at summarising your research in this way, whatever stage you are up to in your write-up (even if you haven’t started). And if you don’t have results yet, have a go at just imagining what results to your question might be: this isn’t about prefiguring your Results, but about getting some sense of what might be meaningful answers to your questions.

A key issue to focus on here is whether all the different sections of your thesis are aligned. That is, are they all oriented around the same question(s) or, rather, are they actually asking and answering different questions? You may find, for instance, that the Literature Review you’re planning doesn’t really answer the questions you’re posing in your title; or that your Results are answering a different set of questions to the ones you reviewed the literature on. These differences may be subtle (for instance, your Literature Review might focus on what clients find helpful in therapy whereas your Results reveal what they experience in therapy), but any minor differences can become magnified as your research and write-up progresses. And such differences can really ‘do your head in’, because you can then get into a terrible muddle about what it is you are asking and answering. So make sure you have a set of really clearly defined questions (see blog here), and then ensure all the sections of your thesis revolve around that.

One way of developing that alignment is by taking your Title or Literature Review and asking yourself, ‘What might be meaningful answers to the questions that I am posing and addressing here?’ Then you can look at your Results and see if they do, indeed, match the questions being asked. Or you can do the same process backwards: Take your Results and ask yourself, ‘What kind of questions are these answering?’ If your Results are providing answers to questions that, in fact, you never asked in the first place, you know you need to do some work on re-aligning your thesis.

The ‘Cafe Test’

Here’s another way of checking the coherence of your research study. Imagine that you are sitting in a cafe chatting to a friend. They are really interested in your work, and they ask you what you have discovered in relation to your research question. What would you say to them? How would you answer that question in a simple, non-jargon way—that gave them a genuine, meaningful, interesting answers to their question. You might want to actually try that with a friend and record your answer – because often that is the most succinct summary of your research and your findings that you’ll give. And if you don’t have results yet, again, try it anyway, and just imagine what kind of results you might have. Note if you are finding it difficult to respond; and also note if the response you are giving in the Café Test is very different from what you have written—or are planning to write—in your thesis itself. Is it, for instance, that you have written a lot in your thesis that isn’t actually that related to your research question? Or perhaps emphasised answers that, in more everyday conversation, aren’t actually that interesting. Try, wherever possible, to align your Results and Discussions to what you would, genuinely, describe as meaningful in an everyday conversation—although, of course, the language and structure needs to be more formal in your write-up. That’s the most exciting bit of what you’ve found, so ‘big it up’: make sure it’s at the heart of what you are communicating to your academic audience.

Acknowledgements

Photo by Handy Wicaksono on Unsplash

Disclaimer

 The information, materials, opinions or other content (collectively Content) contained in this blog have been prepared for general information purposes. Whilst I’ve endeavoured to ensure the Content is current and accurate, the Content in this blog is not intended to constitute professional advice and should not be relied on or treated as a substitute for specific advice relevant to particular circumstances. That means that I am not responsible for, nor will be liable for any losses incurred as a result of anyone relying on the Content contained in this blog, on this website, or any external internet sites referenced in or linked in this blog.

Research Aims and Questions: Some Pointers

Your aims are the beating heart of your research project, and your write-up. Whether you are conducting an exploratory study or a hypothesis testing one, whether qualitative of quantitative, you are trying to do something in your research, and specifying what that doing is is the key that holds your project together.

Wherever you are in a research project, try specifying exactly what your aims for it are, for instance:

In this project… I am trying to discover how clients’ experience preference work

In this project… I am trying to find out if school counselling is effective

In this project… I am trying to assess the psychometric properties of the Goals Form

In research, the aim is to always find something out, so it’s always possible to also reframe your aims as a question:

How do clients’ experience preference work?

Is school counselling is effective?

What are the psychometric properties of the Goals Form?

Framing it either way is fine. But it’s essential that your aims and your questions match, and it’s generally helpful to be aware of both forms as you progress through your research.

If you’re struggling to articulate the aims of your research, ask a friend or peer to ‘interview’ you about it. They can ask you questions like:

• ‘What are you trying to find out?’

• ‘What’s the question that you are asking?’

• ‘What do you want to know that isn’t known up to this point?’

• ‘What kind of outcome to this project would tell you it’s been a successful one?’

Trying to articulate your research aims/questions isn’t always easy, and it’s generally an iterative process: one that develops as your research progresses. Sometimes, it’s a bit like an ‘unclear felt sense’ (from the world of focusing): you kind of ‘know’ what the aim is, but can’t quite put it into words. It’s on the tip of your tongue. That’s why it can be helpful to have a colleague interview you about it so you can try and get it more clearly stated.

Another way into this would be to ask yourself (or discuss with peers):

• ‘What might be meaningful findings from my project?’

For instance, with the research questions above, meaningful findings might be that ‘clients find it irritating to be asked about their preferences’, or that ‘the Goals Form has good reliability but poor validity?’ Of course, you don’t want to pre-empt your answers, but just seeing if there are potential meaningful answers is a good way of checking whether your question makes sense and is worth asking. If you find, for instance, that you just can’t envisage a meaningful answer, or that the only meaningful answers are ones that you already know about, it may mean that you need to rethink your research question(s). There needs to be, at least potentially, the possibility of something interesting coming out of your study.

You may have just one aim, you may have more than one aims. A few aims is fine, but make sure there aren’t too many, and make sure you’re clear about what they are and how they differ. Disentangling your aims/research questions can be complex, but it’s essential in a research project to be able to do that: so that you and whoever reads your research knows what it’s all about, and what your contribution to knowledge might be.

If you find it difficult to articulate your aim(s), it may be that, at the end of the day, you’re not really sure what your research is about. That’s fine: it’s a place that many of us get to, particularly if our research has gone through various twists and turns. So it’s not something to beat yourself up about, but it is something to reflect on and see if you can re-specify what it is, now, that you’re trying to do and ask, so that you can be clear. This may mean turning away from some of the things you’ve been interested in, or some of the questions that you were originally asking. It can be sad to let go of aims and questions; but it’s generally essential in ensuring you’ve got a nice, clear, focused project—not one where you’re going to be lost in a forest of questions and confusion.

If you specify your aims but can’t rephrase them as questions that’s also worth noting. That may be an indicator that really what you are trying to do is to prove something, rather than conducting a genuine inquiry. For instance, you may find that your aim is, ‘to show that people living in poverty cannot access counselling?’ or ‘to establish that female clients prefer self-disclosure to male clients’. If that’s the case, try and find a way of re-framing your research in terms of an open question(s): one(s) that you genuinely don’t know the answer to. It’s so much more powerful, interesting, and meaningful to conduct research that way. Indeed, if you’re struggling to articulate your research question, one really valuable question to ask yourself is:

• ‘What is the question that I genuinely don’t know the answer to?’

And ‘genuinely’ here does mean genuinely. If you’re pretending to yourself that you don’t know something so that you can show it anyway, then that’s likely to become evident when you write up your research. So really see if you can find a question that you genuinely, really genuinely, can’t answer at this point—but one that you would really love to be able to. That’s a fantastic place to start research from.

Once you’ve got your beating heart, write it up on a stick it note and put it on your wall somewhere or put it on your screensaver. Keep it in mind all the time: the aims of your research and the questions you’re asking. When you’re interviewing your participants, when you’re doing your analysis… keep coming back to it again and again. It’ll keep you focused, it’ll mean that you keep on track, and it’ll keep you with a clear sense of where it is you want to go and what you are trying to do.

If you deviate, that’s fine, we all do that. Just like in meditation, notice you’re moving on, then try and bring yourself back. Or, if you really can’t bring yourself back to your aims/questions, then it may be that they need to change. That’s fine in a research project and it does happen but, again, be clear and specific about what the aims and questions are changing to, and make sure that the rest of your project is then aligned with those new directions. What you don’t want, for instance, is a Literature Review asking one set of questions, and then a Results section that answers an entirely (or even slightly) different set of aims.

And when you write up your thesis or research paper, start with your aim(s)/question(s). Often people put them towards the end of the Literature Review (i.e., just before the Methods section), but you can also put them earlier on in your Introduction. Write them down just as they have been formulated as you’ve progressed: clear, succinct, a line or two for each. If there’s more than one, write them down clearly as separate aims/questions. You probably don’t need to give them in both formats and you could use different formats in different places: for instance, they could be stated as aims in your Abstract and Introduction, then as questions just before your Methods section.

Once you’ve got those aims/questions stated, you can build all the other parts of the research and write-up around it. For instance:

• Literature Review section: You can structure this by the questions you’re asking, with different sections looking at what we know, so far, in relation to each question.

• Interview questions: In most instances, the questions you ask your participants should match, pretty much exactly, your overarching research questions. So if you are interested in how clients experience preference work… ask them. No need to faff about with indirect or tangential interview questions: just go into the heart of what you really want to know, and have a rich, complex, multifaceted dialogue about it.

• Results section: Whether qualitative or quantitative, you can present your findings by research question: So what did you find in relation to question a, then in relation to question b, etc.

• Discussion section: This, too, can be structured by research question—though I would tend to do this in the Discussion or in the Results (not both), so that the sections don’t overlap too much with each other.

• Limitations: Don’t just say what’s good or bad about your research: say how the answer you got to your questions might have been biased by particular factors, and what that might mean.

• Abstract: When you come on to write this, make sure your aims/questions are clearly stated, and then clear answers to each question are given.

Being clear about your research aims and questions, and focusing your research around them, may seem obvious. It may also seem pedantic or overly-explicit. But it’s key to creating a coherent, focused research project that—as required at master’s or doctoral level—makes a contribution to knowledge. It can be hard to do; but working out, for yourself, what you are trying to do and ask is a key element of the research process. Research isn’t just a question of mucking in, generating data, and leaving it to your reader (or your assessor) to work out what it all means. You need to do that: to guide the reader from question(s) to answer(s), and to help them see how the world is a better-understood place (even if it’s just a little better understood) for what you have done.

Acknowledgements

Photo by Bart LaRue on Unsplash

DISCLAIMER

The information, materials, opinions or other content (collectively Content) contained in this blog have been prepared for general information purposes. Whilst I’ve endeavoured to ensure the Content is current and accurate, the Content in this blog is not intended to constitute professional advice and should not be relied on or treated as a substitute for specific advice relevant to particular circumstances. That means that I am not responsible for, nor will be liable for any losses incurred as a result of anyone relying on the Content contained in this blog, on this website, or any external internet sites referenced in or linked in this blog.

The Branches of the Person-Centred Tree: Some Pointers

Person-centred therapy is a wonderfully rich set of therapeutic approaches, based on the work of the US psychologist Carl Rogers. The aim of these pointers is to give a brief and systematic description of each of the principle ‘branches’, or ‘tribes’, of the person-centred approach.

The selection, and description of, these approaches is inevitably subjective, and other authors have articulated the principal branches in somewhat different ways (e.g., Sanders, 2012). Of course, there are no ‘right’ answers and the field of person-centred counselling and psychotherapy—as a complex, multifaceted entity—could be ‘organised’ in a multiplicity of ways. Indeed, one could say that there are as many different person-centred therapies as there are person-centred therapists.

This means, too, that the branches are not clearly separable entities, but overlapping sets of concepts and practices with numerous commonalities between them. The following pointers tend to emphasise the differences, to try and highlight the distinctive contributions of each branch; but please bear in mind these are, in the main, tendencies and emphases rather than ‘hard-and-fast’ polarities.

Note, also, that due to my language (in)abilities the selection of branches, and literature, here is relatively Anglo-centric. There may be many very exciting developments across Europe, South America, Africa, and Asia in non-English languages that have not been captured in this taxonomy. If colleagues are aware of these or, indeed, any other major branches, please do add some information in the comments below.

As with Sanders (2012), I have described these branches as members of the ‘person-centred’ nation, but it may be more accurate to describe the field, as a whole, as ‘person-centred and experiential’ (as, for instance, the journal Person-Centered & Experiential Psychotherapies). Again, there are no right answers: it depends how the term ‘person-centred’ is defined.  

An earlier version of this blog is available as a pdf post that can be downloaded from here.

What is a ‘branch’?

I have defined a person-centred ‘branch’ as a form of therapeutic practice, that:

• Has evolved, wholly or primarily, from Rogers’s work.

• Is a comprehensive form of therapy in itself, rather than solely a ‘bolt-on’ to another practice.

• Has a ‘community’ of currently active practitioners (> 100 or so practitioners).

• Has key texts, trainings, and websites currently available.

General Resources

• Core text: Sanders, P. (Ed.). (2012). The Tribes of the Person-Centred Nation: An Introduction to the Schools of Therapy Related to the Person-Centred Approach (2nd ed.). Ross-on-Wye: PCCS Books.

• Core journal: Person-Centered & Experiential Psychotherapies

• Core website: World Association for Person Centered & Experiential Psychotherapy & Counselling
  

Classical Client-Centred Therapy

Non-directive practice, as originally developed by Rogers, in which the therapist provides the client with an empathic, accepting, and genuine therapeutic relationship, thereby supporting the client’s own actualising process.

Founding Figure(s)

• Carl Rogers (1902–1987, US). Other figures associated with classical CCT include Barbara Brodley, John Shlein, Jerold Bozarth, Tony Merry, Pete Sanders, Elizabeth Freire.

Timeline

• 1928: Rogers begins career as psychologist, working with children and families.

• 1942: Publication of Counselling and Psychotherapy: Newer Concepts in Practice, where Rogers introduces principles of non-directive practice.

• 1951: Publication of Client-Centred Therapy, detailing theory of development and behaviour.

• 1957: Classic paper on ‘necessary and sufficient conditions’ (Rogers, 1957).

Develops Rogerian Principles of…

• Non-directivity.

• ‘Core conditions’: empathy, acceptance, congruence.

Other Influences

• Philosophical humanism (e.g., Rousseau).

Key Concepts

• Actualising tendency is core motivating drive: towards maintaining and enhancing organism. ∴ Clients can find own answers to problems, if allowed to re-connect with inner experiencing and not swayed by externally-imposed conditions of worth.

Key Practice(s)

• ‘Empathic understanding response process’ (Brodley): tentative following of client and reflecting back/summarising meanings and understandings, in non-judgmental and genuine way.

• Principled (rather than instrumental) non-directivity: attitude of recognising client’s autonomy and following their lead—not technique or mechanistic practice.

Client Populations

• Diverse.

Evidence base

• Large number of controlled studies, for diverse populations, showing relatively good effects, though possibly marginally less than for more directive approaches (Elliott et al., 2013).

• Core conditions (as rated by clients) associated with positive outcomes (Norcross & Lambert, 2019), though not evidenced as necessary or sufficient.

Current Dissemination

• Large, classical-ish PCT practitioner communities in UK and several other countries (e.g., Germany, Austria, Argentina). Only small community remaining in US.

Examples of Practice

• Numerous Rogers videos available online, most famously Gloria (09:27–40:38). Brief: Richie.

• For contemporary CCT work with young people (including outcome tools), see here.

Further Resources

• Introductory chapter: Merry, T. (2012). Classical client-centred therapy. In P. Sanders (Ed.), The Tribes of the Person-Centred Nation (2nd ed., pp. 21-46). Ross-on-Wye: PCCS.

• Core text: Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21(2), 95-103.

• Website/Training: www.the-pca.org.uk/ (UK), www.adpca.org (US)
  

Child-Centred Play Therapy

Application of non-directive principle to therapy with children, based around play, as children’s natural mode of expression.

AKA

• Non-Directive Play Therapy

Founding Figure(s)

• Virginia Axline (1911–1988), Clark Moustakas, Garry Landreth, Sue Bratton, Dee Ray (US)

Timeline

• 1940s: Axline develops nondirective play therapy, based on Rogers’s newly emerging PCA.

• 1987: Centre for Play Therapy established at University of North Texas.

• 1992: British Association of Play Therapy established.

Develops Rogerian Principles of…

• Actualising tendency.

• Non-directivity.

Other Influences

• Early child psychotherapists (e.g., Anna Freud). Attachment principles.

Key Concepts

• Belief in child’s inner capacity towards growth and healing, through natural media of play and creativity.

Key Practice(s)

• Accepting, warm, respectful, permissive relationship in which child can take lead.

• Empathy: looking at the world through the child’s eyes and reflecting back feelings, perceptions, and behaviours.

Client Populations

• Children. Some application also with adolescents.

Evidence base

• Well-established evidence of effectiveness across multiple, rigorously-conducted trials (e.g., Lin & Bratton, 2015).

Current Dissemination

• Moderate-sized community of professional play therapists, and training programmes, in UK, US, and other regions of the world.

Examples of Practice

• Garry Landreth, Child-Centered Play Therapy DVD Preview

• See also CCTP Play Therapy Session, Play Therapy Session

Further Resources

• Core text: Axline, V. (1971). Dibs in Search of Self. Harmondworth, Middlesex: Penguin.

• Core text: Landreth, G. (2012) Play Therapy: The Art of the Relationship, 3rd ed. NY: Routledge.

• Website (US): Centre for Play Therapy, University of North Texas.

• Website (UK): British Association of Play Therapists.

Focusing-Oriented Therapy

‘Process directive’ practice, based on the method of focusing, in which clients are encouraged to bring awareness to—and articulate—their bodily ‘felt senses’, such that there is a ‘carrying forward’ of experiencing.

Founding Figure(s)

• Eugene Gendlin (1926–2017, American).

Timeline

• 1953: Gendlin joined Rogers’s group at University of Chicago.

• 1960s: Gendlin increasingly articulated own ideas and practices, following ‘Wisconsin project’ (client-centred therapy with schizophrenics).

Develops Rogerian Principles of…

• ‘Experiencing’ as basis to human being and growth.

Other Influences

Phenomenological and existential philosophy, especially Merleau-Ponty.

Key Concepts

• Clients with low levels of ‘experiencing’ less likely to make good progress ∴ may be helpful for therapists to encourage/facilitate clients’ experiential awareness.

• Felt sense: a bodily, implicit, not-yet-fully-articulated sense of what is ‘right’ (i.e., fits) or ‘not right’: a ‘gut feeling’, at the edges of awareness.

• ‘Carrying forward’ of felt senses can be blocked/stuck/interrupted.

Key Practice(s)

• Focusing procedure (client-led, but with varying degrees of therapist encouragement/guidance/instruction): bringing awareness into the body, noticing concerns, articulating ‘felt sense’ in words/images, noticing when it brings relief, ‘receiving what has come from that experiential shift’ (Purton, 2012, p. 50).

Client Populations

• Focusing method widely used in self-help and by lay people in ‘focusing partnerships,’ as well as in professionally-delivered therapy.

Evidence base

• Limited trials of effectiveness; but good evidence that deeper experiencing is associated with better outcomes (Hendricks, 2002; Krycka & Ikemi, 2016).

Current Dissemination

• Large international focusing community, inclusive of focusing-oriented therapists.

• Focusing method incorporated into wide range of person-centred, humanistic, and integrative practices.

Examples of Practice

• International Focusing Institute (2015) What is Focusing?

Further Resources

• Introductory chapter: Purton, C. (2012). Focusing-oriented therapy. In P. Sanders (Ed.), The Tribes of the Person-Centred Nation (2nd ed., pp. 47-70). Ross-on-Wye: PCCS Books.

• Introductory book: Cornell, A. W. (1996). The Power of Focusing: Finding Your Inner Voice. Oakland, CA: New Harbinger Publications.

• Core book: Gendlin, E. T. (1996). Focusing-Oriented Psychotherapy: A Manual of the Experiential Method. New York: The Guilford Press.

• Website/Training: www.focusing.org/

Emotion-Focused Therapy

‘Process-directive’ practice in which clients are invited to deepen emotional processing through a range of tasks (e.g., two-chair work), grounded in a collaborative and empathic therapeutic alliance.

AKA

• Process-Experiential Psychotherapy. Note EFT ≠ Emotional Freedom Technique. Also, distinct from (though springboard for) Sue Johnson’s Emotionally Focused Therapy for couples.

Founding Figure(s)

• Laura Rice (1920–2004, Canada), Les Greenberg (Canada), Robert Elliott (US/Scotland).

Timeline

• Mid 1970s: Rice and Greenberg identify particularly helpful change events in therapy (e.g., two chair technique to resolve intrapersonal splits, Greenberg, 1979).

• ·   1993: Publication of key text, Facilitating Emotional Change.

• 2011: Foundation of International Society for Emotion Focused Therapy.

Develops Rogerian Principles of…

• Centrality of emotions to experiencing.

Other Influences

• Focusing, Gestalt therapy, contemporary psychological theory and research (e.g., cognitive neuroscience, attachment theory, emotion theory).

Key Concepts

• Emotion schemes: synthesising structures that process cognitive, affective, and sensory information—at a pre-conscious level—to create meaning (cf. CBT’s cognitive schema). Schemes can be dysfunctional, such that we respond in maladaptive ways >> poor ‘emotion regulation’. Emotion schemes can be restructured if evoked, symbolised, and ‘worked through’.

• Primary and secondary emotions: latter are feelings about feelings (e.g., shame about feeling angry), and may be problematic: blocking natural, organismic emotional response. 

Key Practice(s)

• Range of therapeutic ‘tasks’ proposed where ‘task markers’ present—though practice always grounded in empathic attuned, accepting, and collaborative alliance. Tasks include: focusing for unclear felt sense, two-chair dialogue for self-criticism/conflict splits, empty chair work for unfinished business (Elliott et al., 2004) >> re-establish adaptive emotions/emotion regulation.

Client Populations

• Diverse. Evidence based for depression (in US). Tailored treatment models/tasks being researched and developed for range of other difficulties (e.g., generalised anxiety, trauma).

• UK: Person-Centred Experiential Counselling for Depression (prev. ‘Counselling for Depression’) is NICE-approved, combines elements of EFT with Classical CCT (Murphy, 2019).

Evidence base

• Substantial, and growing, body of rigorous research demonstrating effectiveness of EFT, and EFT tasks, for depression and other problems (Elliott et al., 2013).

Current Dissemination

• Active, and growing, international community of practitioners and trainers.

Examples of Practice

• See various texts. Range of videos available for purchase: Counselling Channel, APA.

Further Resources

• Introductory book: Elliott, R. & Greenberg, L. S. (2001). Emotion-Focused Counselling in Action, London: Sage.

• Key book: Greenberg, L. S., Rice, L. N., & Elliott, R. (1993). Facilitating Emotional Change: The Moment-by-Moment Process. New York: Guilford Press.

• Website: International Society for Emotion Focused Therapy.  
  

Dialogical/Relational Approaches

Variant of classical client centred therapy that puts stronger emphasis on interactional, two-way encounter between therapist and client, as contrasted with wholly non-directive stance.

Founding Figure(s)

• Peter Schmid (1950–2020, Austria), Dave Mearns (Scotland).

Timeline

• 1990s/2000s: Peter Schmid publishes range of papers describing the essence of person-centred therapy in ‘dialogical’, ‘encounter-based’ terms: ‘the unfolding of interpersonality.’

• 2005: Publication of Working at Relational Depth (1st ed.).

Develops Rogerian Principles of…

• Relationship, encounter.

Other Influences

• Existential/relational philosophy: Martin Buber’s I and Thou, Emmanuel Levinas.

• Relational perspectives in wider therapy and psychology field: e.g., attachment, relational Gestalt therapy, interpersonal neuroscience.

Key Concepts

• Intersubjective ontology: human beings dialogically intertwined with others, not isolated entitles.

• We are always, unavoidably influencing others: ‘non’-directivity is never wholly possible.

• The client as Other: ‘infinitely foreign,’ ‘infinitely distant,’ ‘irreducibly strange’ (Levinas, 1969). Dialogue as welcoming/openness to encounter with Other.

• Relational depth: ‘a state of profound contact and engagement between people’ (Mearns & Cooper, 2005, p. xvii).

Key Practice(s)

• Flexibility and range of therapist responses, above and beyond empathic understanding response process: bringing therapist’s own responses, questions, reflections, perceptions in (without taking focus off client). Directivity (to a limited degree) is not taboo.

• Focus of work is on establishing connection, being together, co-presence—allowing the emergence of relational depth.

Client Populations

• General.

Evidence base

• No trials of effectiveness, or comparison against classical approach

• Good evidence that range of relational factors are associated with positive outcomes (Norcross & Lambert, 2019), with preliminary evidence relational depth is too (Wiggins, 2012).

• Current body of research looking at experience of relational depth, its measurement, impact, and facilitating/inhibiting factors (see Cooper, 2013; Mearns & Cooper, 2018).

Current Dissemination

• Loosely disseminated across person-centred practice and training in UK—and, to some extent, internationally—to varying degrees.

Examples of Practice

• Mick Cooper: Counselling Session Demonstration: Julie.

Further Resources

• Core paper: Schmid, P. F. (2006). The challenge of the other: Towards dialogical person-centered psychotherapy and counseling. Person-Centered and Experiential Psychotherapies, 5(4), 240-254.

• Core book: Mearns, D., & Cooper, M. (2018). Working at Relational Depth in Counselling and Psychotherapy (2nd ed.). London: Sage.

• Websites: http://pfs-online.at/ , www.mick-cooper.squarespace.com/relational-depth
  

Creative Person-Centred Practices

A range of practices that use creative media—such as movement, dance, painting, sculpting, music, and creative writing—in a non-directive and non-interpretative way to facilitate self-discovery, spontaneity, healing, and growth.

Founding Figure(s)

• Natalie Rogers (1928­–2015, US); Liesl Silverstone (1927–2013, UK).

Timeline

• 1970s/1980s: Natalie Rogers (Carl Rogers’s daughter) develops person-centred expressive arts therapy and establishes training and community.

• 1985: Liesl Silverstone establishes the Person-centred Art Therapy Centre in London.

Develops Rogerian Principles of…

• Creativity, as pathway towards healing and growth.

Other Influences

• Arts, performance, and creative practices.

Key Concepts

• Creativity is an expression of our organismic actualising tendency: our movement towards healing and growth.

• Creative methods can be a powerful means of helping clients express feelings and discover hidden aspects of ‘self’.

Key Practice(s)

• Creative media (e.g., paints, clay, musical instruments) made available to client, and client invited to express emotions and experiences through them.

• Client provided with a permissive, supportive, non-judgmental environment in which they can express themselves spontaneously and freely.

• Reflection back to client of emotions, perceptions, actions, words, and artwork. Focus is on creative process, creative work, and meaning (rather than outputs).

• Clients’ creative processes and work not interpreted, directed, or judged. Trust in client’s own path.

Client Populations

• Adults, young people, and children. Individual and groups.

Evidence base

• None.

Current Dissemination

• Small community with handful of training courses in the US and UK.

Examples of Practice

• Expressive Arts Therapy Video with Natalie Rogers

• Liesl Silverstone: Art Therapy the Person Centred Way

Further Resources

• Introductory chapter: Rogers, N. (2013). Person-centred expressive arts therapy: connecting body, mind and spirit. In M. Cooper, P. F. Schmid, M. O'Hara & G. Wyatt (Eds.), The Handbook of Person-Centred Psychotherapy and Counselling (2nd ed., pp. 237-247). Basingstoke: Palgrave.

• Core text: Rogers, N. (1993) The Creative Connection: Expressive Arts as Healing, Ross: PCCS.

• Core text: Silverstone, L. (1997) Art Therapy—The Person-Centred Way: Art and the Development of the Person, 2nd ed., London: Jessica Kingsley.

• Website (UK): Association for Person Centred Creative Arts

• Website (US): Person-Centered Expressive Arts

Pre-Therapy

A form of non-directive practice specifically developed for people with psychosis and other ‘contact impairments’, aiming to facilitate re-connection through very close, ‘mirroring’ reflections.

Founding Figure(s)

Garry Prouty (1936–2009, US), Dion Van Werde (Belgium).

Timeline

1966: Garry Prouty gives ‘birth’ to Pre-Therapy, working with mentally ill clients in Illinois.

1970s: Prouty starts to publish work.

1985: Pre-Therapy International Network established.

Develops Rogerian Principles of…

• Psychological contact, as the first condition for therapeutic work.

Other Influences

• Gendlin (who mentored Prouty), phenomenology.

Key Concepts

• ‘Contact’ = contact with the world (reality contact), contact with emotions (affective contact), or contact with others (communicative contact).

• Contact needs to be established before therapeutic work can progress. But helping clients re-establish contact functioning (as expressed in ‘contact behaviours’) can be valuable in itself.

Key Practice(s)

• Contact reflections: very concrete, literal, ‘duplicative’ reflections that closely mirror the client’s actions and aim to re-establish a ‘web of contact’ with the client:

• Situational reflections of client’s behaviour in context, e.g., ‘Rana is touching the table’.

• Facial reflections: reflective expressions and affect, e.g., ‘You are looking sad.’

• Body reflections: e.g., ‘You are rocking,’  ‘You are holding your arm out.’

• Word-for-word reflections, even if not fully clear or coherent, e.g., client says, ‘Fast… very fast… very fast’; therapist repeats ‘Fast… very fast... very fast’.

• Reiterative reflections: repeat of reflections that have previously established contact.

Client Populations

• People with ‘contact impairment’ and ‘grey-zone’ (i.e., partially impaired) functioning; for instance schizophrenia, learning disabilities, organic impairments, autism, dementia.

• Practiced both as formal one-to-one therapy, and in more informal/everyday care interactions (e.g., as part of nursing practice). Also group/ward practices to establish ‘contact milieu’.

Evidence base

• Very limited body of controlled, pre-/post-, and case studies; but showing some evidence of positive effects (Dekeyser et al., 2008).

Current Dissemination

• Small international network. Training at post-qualification level. 

Examples of Practice

• See example dialogues in Sommerbeck, L. Beyond Psychotherapeutic Reach.

Further Resources

• Introductory chapter: Van Werde, D., & Prouty, G. (2013). Clients with contact-impaired functioning: Pre-therapy. In M. Cooper et al. (Eds.) The Handbook of Person-Centred Psychotherapy and Counselling (2nd ed., pp. 327-342). Basingstoke: Palgrave.

• Introductory book: Sanders, P. (2007) The Contact Work Primer. Ross: PCCS.

• Core book: Prouty, G., Pörtner, M., & Van Werde, D. (2002). Pre-Therapy: Reaching Contact Impaired Clients. Ross: PCCS.

• Website: Pre-Therapy International Network

Motivational Interviewing

Person-centred style of guiding, developed for people with substance use problems, which specifically aims to elicit and strengthen motivation for change.

Founding Figure(s)

• William Miller, Stephen Rollnick.

Timeline

• 1983: Motivational Interviewing (MI) first described by Miller.

• 1991: Publication of comprehensive guide.

Develops Rogerian Principles of…

• Empathic, accepting, collaborative relationship (cf. authoritarian, pathologising approach to people with substance use problems).

• Aimed at eliciting client’s own desire for change and growth (cf. persuasion, confrontation).

• (MI/Miller explicitly claims Rogerian heritage, see Miller & Moyers, 2017).

Other Influences

• ‘Stages of change’: precontemplation, contemplation, preparation, action, maintenance, termination (Prochaska & DiClemente, 1986). Empirical research. Behaviour change principles.

Key Concepts

• Change talk: person’s own statements that favour positive change (e.g., ‘I want to stop drinking’); cf. sustain talk, statements favouring status quo. Ambivalence (existence of both change and sustain talk) is the norm. MI specifically sides with change talk (cf. classical CCT).

Key Practice(s)

• Guiding principles: express empathy, develop discrepancy (i.e., elicit client’s desire for things to be different/change talk), avoid arguments, ‘roll with the resistance’, support self-efficacy.

• Four processes/steps:

  • Engaging: establishing relational foundations—listening, understanding, open questions.

  • Focusing: establishing orientation, direction, goals towards positive change.

  • Evoking: inviting and supporting client’s change talk (desires, abilities, reasons, needs, importance); using open questions, affirmation, reflection, and summaries.

  • Planning: establishing specific, concrete strategies; supporting confidence, persistence.

Client Populations

• Primarily used as brief intervention for people with alcohol and other substance use problems, across a broad range of settings (e.g., addition treatment, healthcare, social work); but can be used with other client populations or incorporated into more general therapy.  

Evidence base

• Vast body of rigorous trials show effectiveness of MI for substance use problems, at level equivalent to CBT and AA (DiClemente et al., 2017; Project MATCH Research Group, 1997).

• Process evidence supports MI claim that more change talk >> more change.

Current Dissemination

• Extensively used, across globe, in range of addiction and treatment settings. Less common as one-to-one counselling/psychotherapy. Somewhat outside of global PCA community.

Examples of Practice

• Motivational Interviewing – Good Example – Alan Lyme (and numerous others on YouTube).

Further Resources

• Introductory text: Motivational Interviewing—Wikipedia entry.

• Core book: Miller, W. R., & Rollnick, S. (2012). Motivational Interviewing: Helping People Change (3rd ed.). New York: Guilford.

• Website: Motivational Interviewing Network of Trainers.

• Motivational interviewing in brief consultations. Free online module, BMJ learning.
  

Integrative Person-Centred Approaches

Range of both general integrative frameworks (e.g., ‘pluralistic therapy’) and specific integrative combinations (e.g., ‘person-centred CBT’) which encourage the combination of person-centred principles and practices with other therapeutic ideas and methods.

Founding Figure(s)

Numerous, including Reinhard Tausch (German), Les Greenberg (see EFT, above), David Cain (American), Richard Worsley (British), John McLeod & Mick Cooper (Scottish/British).

Timeline

• Late 1970s: Greenberg researches effectiveness of Gestalt method two chair technique.

• Late 1980s: Tausch proposes ‘supplements’ to PCT.

• 2000s: McLeod & Cooper articulate ‘pluralistic’ variant of person-centred practice.

Develops Rogerian Principles of…

• Full functioning (in therapist) = flexibility, responsiveness, and openness to multiplicity of understandings and practices.

• Uniqueness of each individual client, their strengths, and their therapeutic needs.

• Uniqueness of each individual therapist and their strengths and abilities (Keys, 2003). 

Other Influences

• Specific integrative practices have combined PCT with numerous other approaches, e.g., CBT (e.g., Josefowitz & Myran, 2005), systemic (e.g., O'Leary, 1999), existential (e.g., Cooper, 2012).

• General integrative frameworks draw on postmodern rejection of singular ‘truths’: no one size fits all (including classical PCT concepts of ‘actualising tendency’ and ‘non-directivity’).

Key Concepts

• Core conditions can be useful supplemented (for some clients, some of the time) by understandings and practices from other approaches. Challenges PCT ‘purism’.

Key Practice(s)

• Diverse practices (alongside core conditions), depending on particular type of integration.

• Pluralistic framework emphasises shared decision-making/preference work.

Client Populations

• Diverse.

Evidence base

• No trials of effectiveness outside of EFT (see above).

• Good evidence for working with preferences/shared decision making (e.g., Swift et al., 2019).

Current Dissemination

• Numerous counsellors and psychotherapists, worldwide, integrate core person-centred practices with ideas and methods from other approaches (Thoma & Cecero, 2009).

• Integrative practices less clearly/confidently articulated in person-centred field, per se.

• Small but lively pluralistic community in UK, distinct from PCT community.

Examples of Practice

• See EFT (above). Working with Goals—pluralistic.

Further Resources

• Introductory chapter: Cain, D. (2013). Integration in person-centred psychotherapies. In M. Cooper, P. F. Schmid, M. O'Hara & G. Wyatt (Eds.), The Handbook of Person-Centred Psychotherapy and Counselling (2nd ed., pp. 248-260). Basingstoke: Palgrave.

• Introductory chapter: Worsley, R. (2012). Integrating with integrity. In P. Sanders (Ed.), The Tribes of the Person-Centred Nation (2nd ed., pp. 125-147). Ross-on-Wye: PCCS Books.

• Core debate: See Cooper & McLeod, ‘Person-centered therapy: A pluralistic perspective’ with critique by Ong et al., ‘Unnecessary and incompatible’.

• Website/Training: www.pluralisticpractice.com  
  

References

• Cooper, M. (2012). Existentially informed person-centred therapy. In P. Sanders (Ed.), The tribes of the person-centred nation: An introduction to the schools of therapy related to the person-centred approach (2nd ed., pp. 131-160). Ross-on-Wye: PCCS Books.

• Cooper, M. (2013). Experiencing relational depth in therapy: What we know so far. In R. Knox, D. Murphy, S. Wiggins & M. Cooper (Eds.), Relational depth: New perspectives and developments (pp. 62-76). Basingstoke: Palgrave.

• Dekeyser, M., Prouty, G., & Elliott, R. (2008). Pre-Therapy Process and Outcome: A review of research instruments and findings. Person-Centered & Experiential Psychotherapies, 7(1), 37-55.

• DiClemente, C. C., Corno, C. M., Graydon, M. M., Wiprovnick, A. E., & Knoblach, D. J. (2017). Motivational interviewing, enhancement, and brief interventions over the last decade: A review of reviews of efficacy and effectiveness. Psychology of Addictive Behaviors, 31(8), 862-887. https://doi.org/10.1037/adb0000318

• Elliott, R., Greenberg, L. S., Watson, J. C., Timulak, L., & Freire, E. (2013). Research on Humanistic-Experiential Psychotherapies. In M. J. Lambert (Ed.), Bergin and Garfield's handbook of psychotherapy and behavior change (pp. 495-538). New Jersey: John Wiley.

• Elliott, R., Watson, J. C., Goldman, R., & Greenberg, L. S. (2004). Learning Emotion-Focused Therapy: The Process-Experiential Approach to Change. Washington DC: American Psychological Association.

• Greenberg, L. S. (1979). Resolving splits: Use of the two chair technique. Psychotherapy: Theory, Research, Practice, Training, 16(3), 316-324.

• Hendricks, M. N. (2002). Focusing-oriented/experiential psychotherapy. In D. J. Cain & J. Seeman (Eds.), Humanistic Psychotherapies: Handbook of Research and Practice (pp. 221-252). Washington, DC: American Psychological Association.

• Josefowitz, N., & Myran, D. (2005). Towards a person-centred cognitive behaviour therapy. Counselling Psychology Quarterly, 18(4), 329-336. https://doi.org/10.1080/09515070500473600

• Keys, S. (Ed.). (2003). Idiosyncratic Person-Centred Therapy. Ross-on-Wye: PCCS Books.

• Krycka, K. C., & Ikemi, A. (2016). Focusing-oriented-experiential psychotherapy. In D. Cain, K. Keenan & S. Rubin (Eds.), Humanistic psychotherapies (2nd ed., pp. 251-282). Washington: APA.

• Levinas, E. (1969). Totality and Infinity: An Essay on Exteriority (A. Lingis, Trans.). Pittsburgh, PA: Duquesne University Press.

• Lin, Y. W., & Bratton, S. C. (2015). A meta‐analytic review of child‐centered play therapy approaches. Journal of Counseling & Development, 93(1), 45-58. https://doi.org/10.1002/j.1556-6676.2015.00180.x

• Mearns, D., & Cooper, M. (2005). Working at Relational Depth in Counselling and Psychotherapy. London: Sage.

• Mearns, D., & Cooper, M. (2018). Working at Relational Depth in Counselling and Psychotherapy (2nd ed.). London: Sage.

• Miller, W. R., & Moyers, T. B. (2017). Motivational interviewing and the clinical science of Carl Rogers. Journal of Consulting and Clinical Psychology, 85(8), 757-766. https://doi.org/10.1037/ccp0000179

• Murphy, D. (2019). Person-Centred Experiential Counselling for Depression. London: Sage.

• Norcross, J. C., & Lambert, M. J. (Eds.). (2019). Psychotherapy relationships that work (3rd ed. Vol. 1: Evidence-based therapist contributions). NY: Oxford University.

• O'Leary, C. (1999). Counselling Couples and Families: A Person-Centred Approach. London: Sage.

• Prochaska, J. O., & DiClemente, C. C. (1986). Toward a comprehensive model of change. In W. R. Miller & N. Heather (Eds.), Treating addictive behaviors (pp. 3-27): Springer.

• Project MATCH Research Group. (1997). Matching alcoholism treatments to client heterogeneity: Project MATCH posttreatment drinking outcomes. Journal of Studies on Alcohol, 58(1), 7-29.

• Purton, C. (2012). Focusing-oriented therapy. In P. Sanders (Ed.), The Tribes of the Person-Centred Nation: An Introduction to the Schools of Therapy Related to the Person-Centred Approach (2nd ed., pp. 47-70). Ross-on-Wye: PCCS Books.

• Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21(2), 95-103.

• Sanders, P. (Ed.). (2012). The Tribes of the Person-Centred Nation: An Introduction to the Schools of Therapy Related to the Person-Centred Approach (2nd ed.). Ross-on-Wye: PCCS Books.

• Swift, J. K., Callahan, J. L., Cooper, M., & Parkin, S. R. (2019). Preferences. In J. C. Norcross (Ed.), Psychotherapy relationships that work (3rd ed., pp. 157-187). NY: Oxford University.

• Thoma, N. C., & Cecero, J. J. (2009). Is integrative use of tehcniques in psychotherapy the exception or the rule? Results of a national survey of doctoral-level practitioners. Psychotherapy, 46(4), 405-417. https://doi.org/10.1037/a0017900

Wiggins, S. (2012). Development and validation of a measure of relational depth. (PhD dissertation), University of Strathclyde, Glasgow. Retrieved from http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.576407

Citation

This blog post can be referenced as: Cooper, M. (2021, Sept. 30). The branches of the person-centred tree: Some pointers. https://mick-cooper.squarespace.com/new-blog/2021/9/29/the-branches-of-person-centred-therapy-some-pointers

Credits  

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Non-Directivity: Therapeutic and Meta-Therapeutic Perspectives

What does it mean to be non-directive? Tony Merry, in his definitive introduction to classical client-centred therapy, describes it as respect for a person’s process of self-determination, and creating a relationship in which the sources for change reside in the person themselves.

In recent years, however, I think two different ways of understanding this non-directive stance have been articulated. The first is what we might call therapeutic non-directivity. Here, the therapist is not directive in the therapy session. They trust the client to talk about what is important to them, and to lead the way in finding answers to the question that they are posing. The therapist works mainly through empathic reflection and understanding.

The second is what we might call meta-therapeutic non-directivity. This is also a form of trusting the client’s own process of self-determination, but this time in terms of what they might want from therapy itself: that is, at a meta-therapeutic level. So, when the therapist is being non-directive at the meta-therapeutic level, one option might be to work in a therapeutically non-directive way. But there could be other options too—depending on what the client wants and what the therapist is skilled in and able to offer. For instance, if a client wanted to learn a particular mindfulness technique, or if they wanted advice on relationship problem, the therapist might input on these areas if they know how to. This wouldn’t, then, be therapeutic non-directivity, but it would still be non-directive at the meta-therapeutic level as it’s trusting that the client knows what is best for them.

It is often assumed, particularly in early stage person-centred trainings, that non-directivity means therapeutic non-directivity. So, for instance, if a client asks for guidance or suggestions, you reflect back to them that this is what they are looking for, and encourage them to find their own answers instead. But, in recent debates, many experienced person-centred practitioners have said that, in such instances, it may be quite appropriate for therapists to respond to the client’s wants: that is, to practice non-directivity at the meta-therapeutic level. Pluralistic therapy is a form of practice, emerging from the person-centred field, which particularly emphasises meta-therapeutic non-directivity. Some people have argued that pluralistic therapy is unnecessary because the person-centred approach, by its very nature, advocates this already. However, this criticism is very dependent on how the person-centred approach is defined. Given that, in many cases, person-centred non-directivity is understood at the therapeutic level alone, it may be useful to have a perspective that explicitly advocates a meta-therapeutic approach.

To a great extent, the stance that people take here may be dependent on how they understand the actualising tendency, and this is another person-centred concept that is open to a wide range of interpretations. In particular, do you understand the actualising tendency as something that lies deep within the person, outside of consciousness (what I have called an ‘essentialist understanding’ of the actualising tendency); or do you understand the actualising tendency in terms of the person knowing, consciously and here-and-now, what is best for themselves (an ‘existential understanding’)? If you take the latter perspective, you are more likely to trust that the person can, there-and-then in therapy, articulate something of what they want and need. But if you see the actualising tendency as something buried deeply away, you are more likely to feel that it needs time, space, and therapeutic non-directivity to be able to emerge.

At the meta-therapeutic level, we can also distinguish between active and reactive non-directivity. Reactive non-directivity is where we would respond to particular requests from the client if they made them (assuming, again, we were appropriately trained), but we wouldn’t specifically solicit meta-therapeutic suggestions or suggest options. Active non-directivity at the meta-therapeutic level, on the other hand, might mean that we would ask clients about the kinds of therapeutic inputs that they would want, or even make suggestions about what we believed might help them. Pluralistic therapy tends to advocate such an approach. The assumption here is that, because of the power differential between therapists and clients, clients may not feel able to say what they want unless they are asked. They might also not be aware of all the different options. But the danger, here, is clearly that clients may feel obliged to agree with therapists, and in so doing lose their own self-direction.

Of course, there are no rights or wrong here, and each of these forms of non-directivity may be very useful to clients. They are also not mutually exclusive. But what may be important is that therapists—and particularly trainees—are aware of what kind of non-directivity they are advocating and practising. The general definition of non-directivity is so broad, and so open to misunderstandings, that specifying what you, personally, mean by it is essential for anyone advocating such a stance (and particularly if you are trying to write about it in an assignment!). Non-directivity, as Tony Merry said, is about a deep respect for the client’s own process of self-determination, but how we manifest that respect in our client work is a complex and multifaceted issue that requires careful consideration and articulation.

This blog post can be referenced as: Cooper, M. (2021, Sept. 21). Non-directivity: Therapeutic and meta-therapeutic perspectives. https://mick-cooper.squarespace.com/new-blog/2021/9/21/non-directivity-therapeutic-and-metatherapeutic-perspectives