Personal Therapy: A Reflexive Account

What have I, as a client, found helpful in therapy? What have I found unhelpful? And, What, for me, has been the process of change?

We're currently working on an analysis of young people's experiences of school-based counselling in our ETHOS trial and, as part of the preparation for that, we wanted to look at our own. This reflexivity is an essential part of good qualitative research: the more we can be aware of our own experiences, the more we can bracket it and ensure that we don't impose it on what our participants are telling us.

So below is my summary based on those episodes of therapy, with therapists from a variety of orientations: person-centred , existential, psychodynamic, and cognitive-behavioural. Of course, this is just my experiences and perceptions, and someone else may experience therapy in entirely different ways (indeed, that's the whole point of the exercise).

---

I have had 12 episodes of therapy over the last 38 years, from 12 different therapists. These have practiced from a variety of orientations: person-centred, existential, psychodynamic, and cognitive-behavioural.

Helpful

In terms of the person of the therapist, I’ve found it most helpful when they’ve been warm, friendly, and showing genuine care and interest.  It’s been important to me that I feel respected by them: on a human-to-human, adult-to-adult level.  At the same time, I have appreciated some professional ‘distance’ rather than over-familiarity.  So someone who achieves a balance of being open and ‘human’, but at the same time capable of—and focused on—doing their job.  Not too ‘sloppy’ or unstructured or laid back.  Along these lines, therapy has been most helpful to me when I’ve felt that the therapist is someone who I can learn from, who ‘knows’ more than me in some area.  Not necessarily ‘sorted’ or without their own problems, but someone who can help me discover things I didn’t already know.

It’s been helpful for me when therapists give me space to talk through, at my own pace, my problems.  Also, it’s been really important to me that the therapist understands, deeply and fairly easily, how I experience the world.  That they ‘get’ what life is like for me—as it actually is—and that they can help me (for instance, through reflections or questions) go more deeply into my experiences: talking about areas that I might only be dimly aware of.

Sometimes, insights from the therapist have been helpful to me (for instance, in relation to my past): particularly where put tentatively, and where I’m given space to work out their meaning for myself.

I have sometimes found psycho-education, or information from the therapist, very helpful.  However, although this has often taken the form of specific guidance or exercises, it is generally the overall message that has been most helpful to me.

Unhelpful

In terms of the person of the therapist, I’ve found it least helpful when they show coldness, indifference, and a lack of care; and worse when they relate in ways that are aloof, arrogant, condescending, dismissive, and critical.  I have also found it unhelpful when therapists engage in mechanistic and ‘by rote’ ways.  Another thing I find very unhelpful is when the therapist seems to be making assumptions about who I am or how I experience the world, or wants to ‘impose’ their perceptions over my actual lived-experiencing.  Along these lines, I really react when therapists, through interpretation or guidance, seem more interested in ‘proving’ the truth of their particular therapeutic model or dogma, rather than listening to how I experience my world, and helping me work out what’s best for me.

 The other side of this is that, if a therapist is too vague, woolly, and ramshackle, I can end up feeling a bit lost in therapy and losing confidence in them.  As above, for therapy to be helpful, I need to feel that the therapist is someone I can learn from—and develop in relation to.

Process of Change

Most of my change in therapy has come through developing insights about what I am doing, why I am doing it, and how I am really feeling; and then finding ‘better’ ways of doing things—ways that are more satisfying, fulfilling, and rewarding.  This has nearly always come about through a two-way dialogue between myself and the therapist: questions, reflections, and gentle insights and interpretations from the therapist; space for me to reflect, process their perceptions, and disclose further; more input and encouragement from the therapist.

Sometimes, particularly when things have felt very difficult, it has been helpful just to have lots of space to talk and put everything ‘out there’.  This has made things feel less overwhelming and tangled up. 

Knowing that there is someone there who I can turn to for help and support—someone ‘solid’, dependable, and knowledgeable—has been really important at times.

Learning, mainly through cognitive and behavioural therapies, that it is better to face fears than avoid them has been very helpful for me. This guidance has been a constant companion throughout my life, and has helped me to live ‘out in the world’ as fully as possible. 

Sometimes, just being given accurate information by a therapist has allayed fears.

---

Exploring your own therapeutic experiences: A reflexive exercise

If you're interested in exploring your own experiences of therapy then you might be interested in the steps I used to do this for myself. These are as listed below. (Please bear in mind, of course, that this is at your own risk—it can be painful or upsetting to think back on therapy—and do ensure you keep anything you write down stored safely) :

1. List all the episodes of therapy that you have had (you can include group as well as individual, whatever is meaningful for you).

2. For each one, write down (approximating where you don’t know for sure):

• A title for it that’s meaningful for you (e.g., ‘Gestalt Therapist’, ‘College Counsellor’)

• Who the therapist was

• Dates

• Location

• Number of sessions

• Presenting issue(s) (what you came to address)

• ‘What I experienced as helpful in this therapy’

• ‘What I experienced as unhelpful in this therapy’

• ‘The process of change in this therapy, if any’

• A rating of overall helpfulness from 1 (Not at all helpful) to 10 (Extremely helpful).

3. Now go through your answers for the three penultimate questions (i.e., helpful, unhelpful, and change process) and try to summarise in a few paragraphs for each. So what, across therapists, you have experienced as helpful and unhelpful in therapy for you, and any change processes you went through.

As with reflexivity in research, perhaps a final step is then to consider how much your own perceptions might get ‘projected’ onto clients. The more we know what it is that we want and don't want from therapy ourselves, the more we may be able to step back from that and allow the genuine 'otherness' of the client to come through. For instance, if what we found was helpful was lots of space to talk, do we assume that all of our clients want that too? Are we open to the possibility that some clients may want something very different, for instance practical guidance? That doesn’t mean we then have to offer that, but it may be important to talk through with our clients what they do actually want (and not want), and what we can actually offer them: a process of metatherapeutic communication.

Critical parent or lazy slob? What's the real conflict at the heart of human being?

At the heart of each of the different approaches to therapy is an understanding of human beings in terms of a core inner conflict, and each one sees it in a slightly different way.

In the psychodynamic approaches, it's like a fight between a lecherous, aggressive drunk and a police officer who's wanting to keep the peace. And with a bossy, nasty magistrate pointing fingers over the police officer's shoulder.

In the humanistic approaches, it's like the battle between a free-spirited child and a critical, controlling parent who's worried what the neighbours will think.

In the existential approaches, it's like an argument between two disputants who cannot--and will not--seek a compromise. It doesn't matter what they're arguing about. You can guarantee that one of them will always disagree.

And in the CBT approaches, it's like a row between two flatmates: one a sensible, hardworking student (who's not averse to having fun), and the other a lazy slob who has never really developed the skills or confidence to make the most of things.

Which model is right? When you look at it this way, it's clear that there's no right or wrong, because all these different kinds of conflicts can happen between people--and within people--and there's no reason to think that only ever one of them is the 'right' one. Sometimes, we're lazy and need to give ourselves a kick, sometimes we clamp down on ourselves too much, sometimes we just can't stop arguing with ourselves and need to accept that there's always going to be some element of that. And when we view people in terms of all these possibilities, we get so much more of a richer view of human being than any one perspective can provide on its own.  All our theories are great, but they're even greater when we see them as a rich diversity of resources that we can draw on in helping to understand clients, rather than as exclusive truths. 

Choosing Your Research Topic: Some Pointers

If you're doing a research project in counselling, psychotherapy, or counselling psychology, choosing your topic can be one of the hardest things to get right. And often one of the things you get the least advice on. So how should you go about it?

Read through previous counselling/psychotherapy/counselling psychology research theses

Invaluable! Essential! Probably the most useful thing you can do to get you started. This will give you a real sense of the ‘shape’ of a research study in this field, what is expected of you, and the kinds of questions that you might want to ask.  Should be in your college library or ask a tutor.

originalITY is not everything

Often, in my experience, students come into Master’s or doctoral research projects thinking, ‘I must do something original… I must do something original.’ So they work away at finding some dark corner somewhere that no-one has ever looked into before. Of course, there does need to be originality in your research, but if you’re burrowing away into a corner somewhere then there’s a real danger that no-one else is going to be particularly interested in where you’re going—you’re off into a world of your own. So instead of asking yourself, ‘What can I do that no-one else has ever done before?’ ask yourself, ‘What can I do that builds on what has been done before?’ And that means…

…Get a sense of the field

What are the key questions being asked in your field today?  What are the issues that matter and that are of relevance to practice?  It’s great to draw on your own interests and experiences, but also make sure you develop some familiarity with the field as it currently stands.  This will help to ensure that your research is topical and relevant—of interest and importance to the wider field as well as yourself.  A great thing to do can be to find out what your tutors are researching and what they see as the key issues in the current field.  And do remember that there may be the possibility of developing your project alongside them in some way, so that you can contribute to a particular national- or international-level research initiative.

Also, right from the start, think about how your work and your research question might have the capacity to influence practice and policy.  This may be the biggest research project you’ll ever do.  So make it count.  Think about doing something that can really help others learn how to improve their practice, perhaps with a particular group of clients, or with respect to a particular method.  If it’s a doctoral level project, you’ll become a leading expert in that field, and you’ll be in a position to teach the rest of us how to be more helpful.  So think about what you’d like to find out about, which you can then disseminate to the field as a whole.

If you want to make your research count, have a really long think before you dive into doing research on therapists’ experiences or perceptions.  Lots of students study this: it’s reflexive, and it’s a relatively easy group to access.  But it also raises the question of how interested people are really going to be in how therapists’ see things.  After all, we’ve all been trained in particular beliefs and assumptions, so if we’re the subject of research, we’re often just going to reiterate what we’ve been taught to think.  Generally, clients make a much more worthwhile participant group, because you’re hearing first hand what it’s really like in therapy, and what works and what doesn’t.

Consult the literature

Once you’ve got some idea of what you’d like to look at, find out how other people have tried to answer that question. If no-one has tried to answer it before, that’s great, but you need to be really sure about that before going on to furrow your own path—after all, you don’t want to get to the end of your research to find out that somebody ‘discovered’ the same thing as you decades ago. So have a look on Google Scholar, and particularly on social science search engines like PsychInfo. Undertaking such searches also ensures that your research will be embedded within the wider research field, and it may well give you ideas about the kinds of questions that are timely to ask.

Make sure it's related to therapeutic practice

Choose a topic which is related, at least in some way, to the field of therapeutic practice. Most directly, this may include things like: clients’ experiences of helpful and unhelpful factors, how psychological interventions are perceived from those outside the field, or the applied role of counselling in such fields as education. Exploring people’s experiences of a particular phenomenon—for instance, women’s experiences of birth trauma—can also be related to therapeutic practice, but just be clear what the association might be. For instance, could that help therapists know how to work most effectively with that client group, or to know what issues to be sensitized to.

Find yourself a clearly-defined question

Try to find a single, clearly defined question as the basis for your study (see my Research Aims and Questions pointers). This can then serve as your title. If you can't encapsulate your research project into a single question/sentence at some point, the chances are, you're probably not clear about exactly what it is you are asking.

That's ‘question’, not ‘questions’

One of the biggest problems students face is that they ask too many inter-related questions, with too many constructs of interest, and therefore get very muddled in what they are doing. For instance, they’re interested in attachment styles, and how it relates to dropout as mediated by the client’s personality in EMDR for trauma. But that’s five different constructs (attachment styles, dropout, personality types, EMDR, trauma—and, indeed, a sixth implicit one, which is the outcomes of EMDR for trauma), and generally you want to focus down on just one or two constructs (particularly in qualitative research), or maybe three at most if you are doing quantitative. So, for instance, you could focus on how attachment style influences dropout, or how clients experience EMDR for trauma, or the role of personality styles in mediating outcomes in EMDR for trauma. Or you could even just focus down on how clients experience dropout. All nice, straightforward questions that you can really get into at Master’s or doctoral level depth. So think about the constructs that you definitely want to focus in on, and let go of those that are maybe less central to your concerns. Of course, that’s difficult, and three of the main reasons why are given below—along with the things you may need to remind yourself of:

'I won't have enough material otherwise.'  Your word limit may seem like a lot, but you'll be amazed at how quickly it goes. If you just focus on one question, you will be able to go into it in a great amount of depth—far more appropriate to Master’s or doctoral study than trying to answer a number of questions and subsequently coming away with numerous superficial answers.

'There's lots of different aspects of this area that I'm interested in.' That's great, but you won't be able to cover it all in this one project. You can always do further research after this one. In limiting yourself to just one question, you may well experience feelings of loss or disappointment as you let go of areas you're really interested in, but it's better to feel that loss now than after you've put months of work into areas that are just too dispersed.

'I've already started to ask this other question, and I don't want to lose the reading that I've already done'. Again, it can be painful letting go of things, but there is no value in ‘throwing good money after bad.’ Sometimes in research you need to be brutal, and cut out areas of inquiry that don't fit in—even if you've sweated blood over them. Remember what authors say: the quality of their book is defined by what they leave out!

That’s ‘question’, not ‘answer’

Some of the most problematic projects come about when researchers try to show that a particular answer is the correct one, and consequently won’t let anything—including their own findings—get in their way. So if you really believe something about psychological therapies, like ‘person-centred therapy is much more effective than cognitive-behavioural therapy’, or ‘women make much better counselling psychologists than men’ then you may want to steer clear of this topic. That is, unless you can really get yourself into a frame of mind in which you are open to the possibility that you might find the absolute opposite of what you want—and you can enthusiastically write about the implications of this finding. Good research is like good therapy: you put to one side your own assumptions as much as possible, so that the reality of whatever you are encountering can come through. So, in trying to work out your research question, here’s something to really ask yourself:

What is the question that I genuinely don’t know the answer to (but would love to find out)?

And ‘genuinely’ here means genuinely. It means you really, actually, don’t know what the answer to that question is. If you can find that question, it’ll help enormously in your whole research project, because it’ll mean that you’re genuinely open to, and interested in, finding out what’s out there. That’s research!

But make sure there’s not too much literature on it

If you ask a question on which much has already been written—like the effectiveness of person-centred therapy—then you’re likely to be drowned in material before you even get to the end of the literature review. So narrow down your question—e.g. the effectiveness of advanced empathy in person-centred therapy—until you’ve got a manageable number of references in your sights. Don’t worry if it seems too few, you’ll no doubt pick up more references as you go along. And remember, you need to have full mastery of the literature regarding the question your asking, and it is a lot easier to master the information in five or six papers than it is in hundreds.

What’s often ideal is if you can move one step on from some pre-existing literature: e.g. extending a study about depression in men to looking at depression in women, testing out a theory that you’ve found in a book, or using qualitative research to address a question that has previously only been addressed through quantitative research. So don’t get too hung up on being totally ‘original’: in fact, if you try to be too original you can end up in a sea of confusion with no theoretical or methodological concepts to anchor yourself to. Having an original twist is often much more productive—you’re saying something new, but you’re building on what’s already been laid down.

Think methodology from the start

It’s no good coming up with a brilliant question if there is no way of actually answering it, or if answering it is going to be such a headache that you’ll wish that you never started in the first place. So as you come up with ideas, think about how feasible it might actually be to put them into practice. This is something you may really want to discuss early on with a colleague or research tutor.

Respondents MUST be accessible

In terms of the feasibility of the study, probably the most important question is whether or not you are actually going to get anyone to participate—to respond to your interviews, questionnaires, etc. It is essential to the success of your study that you get a good response rate, so thinking about who you do research with is often as important as thinking about what you do (see my research pointers here on recruiting participants). A number of factors will determine how good your response is likely to be: how big the population is in total, their motivation to help you, how easy it will be for you to get in touch with them, how cautious you will need to be as a consequence of ethical safeguards. So don’t just come up with an idea and hope blindly that someone out there will be interested. However hard you think it will be to get participants, you can guarantee that it will actually be several times harder than that, so make sure this is something you think about, and address, at an early stage.

Ethics come first

The principles of non-maleficence—doing no harm to your respondent—and, ideally, beneficence—promoting the respondent’s well-being—should be an integral part of your research design. So, right from the very start of your project, think about ways in which your research might benefit those that are involved; and also make sure that you have read and familiarised yourself with appropriate ethical guidelines, as well as any other sets of relevant standards.

Aside from ‘doing the right thing’, the issue of ethics will be an important one for you because, in any research study, you will need to submit your project to an ethics committee (see above), and the more sensitive your work, the more committees and the longer the time this is likely to take. For instance, if you wish to carry out research in the National Health Service, you will almost certainly need to go through an NHS ethics committee, which can take many months to consider and respond to proposals. So, as you start to develop your research ideas, be aware of the ethical issues and processes that it might raise, and try to find out about the ethical submissions that such a study is likely to entail. That way, you won’t suddenly find yourself facing a long and uncertain wait before you can proceed with your work -- or, if you do, at least you’ll be prepared for it.

Feeling good means 'actualising' our directions in life

A lot of contemporary models of human being suggest that we are basically 'directional'. What that means is that we are always 'going to somewhere', always pointed in particular directions. We're striving, trying to improve things, trying to be something and somewhere more than we are: even if it's more chilled out! If that's the case, then we can understand wellbeing in terms of how much we're able to 'actualise' this direction: how much we're aligned with where it is that we want to go.

This actualisation process can be understood in terms of six As. First there is awareness: knowing what our goals are and where we are trying to get to. Second there is anticipation: having a sense that our goals are possible and things that we can achieve. Third comes approach: progressing towards the things that we want; and then comes acceleration: moving towards our wants at an increasing speed. Importantly (but maybe not the most important thing) is then achieving our goals. Finally, and particularly one that may become more important with age, is appreciating what we have achieved.

So, viewed from this perspective, the 'good life' is one in which we have things in life we're striving towards which are important to us, and we have a sense that we're making some kind of progress towards them. We don't have to get these goals all the time, or move rapidly on to other things, but just a general sense that we're pointed in a direction and that we're able to attain it in some way.  And from this perspective, psychological problems are associated with not being clear about what we want from life, or knowing what we want but feeling that it is impossible to get there--or not making any progress at all. Or even it might be about getting to our goals but then not taking the time to appreciate what we have achieved and just rushing on to the next one.

Last thing: if we think about wellbeing in this way, it also shows how what we feel is both about ourselves AND our social and political environment. I might not progress towards the things I want because I don't have good strategies for getting there.  But I also might not progress towards the things that I want because the world is telling me about all these amazing things I should have (a perfect body, the latest phone, a devoted partner) and then not providing me with any possibility at all of getting there. So helping people change the way they go about things can be important--through therapy or self-development work--but what can also be really important is focusing on social and political change. If we create a fairer world with more resources for everyone, then more people can move towards more of what they want more of the time.