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.

'Advice' in Counselling and Psychotherapy: What is it Good For?

From a person-centred standpoint, advice is very much a no-no. Indeed, it’s virtually a taboo in the person-centred field: the first thing you learn when you learn about practising non-directively. That’s not surprising given where Carl Rogers, its founder, came from. He wanted to counteract the expert-led tendency of the therapies of his day (the 1930s and 1940s), which involved the therapist telling the client how to solve their problems. It assumed that the clinician knew: about the client’s life, about the best way forward for them, about how they should live their life. Rogers reacted, and many of us still baulk today for these same reasons: who gives the clinician the right to think they know better than the client about the client’s own life?

Given that advice-giving is so intrinsic to how many us learn to ‘help’ others, it seems essential to me that counselling trainings should start with learning how not to give advice: to bracket that need and to learn to just be with clients so that they can develop their own skills in problem solving. If we just ‘leap in’ all the time, we may really get in the way of that. It’s also important for trainees to recognise that, in many cases, giving advice can be more about the ‘kick’ we get from being smart and showing that we know things, rather than coming from a genuine desire to help the other. Amongst the many different forms of therapy responses, research shows that advice is rated as one of the least helpful.

I know that for myself, as a client. If a therapist tries to give me advice, I nearly always feel patronised, directed, belittled. It makes me feel like, ‘Why the hell do you think you can tell me what to do, after years of me trying to sort it out for myself.’

But sometimes, actually, I have found it helpful. One of the most helpful things a therapist ever said to me, and actually probably one of the least humanistic, was this: ‘Why don’t you think of what a “normal” person would do in those circumstances and try and do that.’ On pretty much every index that’s a ghastly intervention, but actually it was incredibly helpful for me and something that supported me through a lot. And I think the danger in dismissing all forms of advice is that we may actually then not see when it can be helpful—as us pluralists say—for different clients at different points in time. So there is another side to this.

For a start, we’ve found in our research with young people in school counselling that, again and again, they say that they value the advice that they get from the counsellor (and you can see a great review of the evidence here). And this is kids in person-centred counselling. Of course, I’m sure sometimes what they are calling advice is actually the therapist reflecting back to them what they, themselves, worked out; but the point is that they see it as advice, and they love it. Along similar lines, we’ve found in our surveys on therapy preferences that about two-thirds of individuals want a therapist to give them advice, against about a quarter who don’t (see chart below). You could say, ‘Well, that’s because they don’t really know what therapy is or what’s really going to help them’; but then, paradoxically, that’s the essence of a therapist-expertise stance: saying what clients really need even if clients are saying something different.

Participants preference for advice vs not advice from a therapist, using the C-NIP form

Part of the issue, I think, is that the word ‘advice’ tends to be used in a very generic and non-specific sense, when actually it can cover a whole spectrum of different responses to clients. It’s one thing to say to a client, ‘You really ought to be kinder to your mum and, if you aren’t, you should feel ashamed of yourself’ (which, of course, no therapist would ever say); and quite another to say something like, ‘I wonder if you have ever thought about telling your mum how you’re feeling.’ So while the first kind of pressuring, very rigid advice might be unhelpful for nearly all clients; something much softer and more tentative may be of greater therapeutic value, and not have the effect of pressuring the client in any one way. So we need to nuance what we mean by ‘advice’.

Closely related to that is the fact that we are always influencing our clients—just by being there in the room with them—so there isn’t really any such hard division between ‘influence’ vs. ‘non-influence’. Rather, there’s different degrees of influence and some of the most powerful ways may be the most implicit. For instance, if we smile when a client tells us about their feelings we are implicitly conveying to them that they are doing something of value. Or, if we encourage them to think about their genuine needs, we are conveying that it’s good to be authentic. That maybe isn’t explicit advice but it is a valuing of one particular way of being, and can have, effectively, pretty much the same impact. Indeed, you could argue that, by being implicit, it’s actually more coercive—perhaps giving direct advice is more congruent and transparent.

There’s also good reasons why clients might value advice. Sometimes, as I’ve argued in my latest book, we’re just don’t know the things we need to do to get to where we want to be. If my car breaks down, I need someone to tell me how to fix it. I don’t have some inner organismic sense of what I need to do. And, similarly, clients may need some guidance on how to make friends, or overcome anxieties, or give up alcohol. That’s not such a terrible thing to acknowledge, is it? The positive effects of psycho-educational approaches like social skills trainings show that clients can really gain a lot from such direct education.

Conclusion

I think there’s some very good reasons why therapists should be trained out of automatically giving advice; and it’s certainly not a response mode we should use more than sparingly—unless a client has specifically signed up for a psychoeducational approach. Helping people work things out for themselves is, I’m sure, generally a more sustainable form of learning. It’s also important that, if we’re giving advice, we’re skilled and knowledgeable about what we are saying: none of us want to be telling clients to do things that just aren’t helpful. So just to be really clear, I’m not saying in any way that we should just break with our training and start advising our clients, willy-nilly, on how to live their lives, what to do, what they should wear, etc. But I am saying that, in the person-centred and humanistic therapies, I think we have tended to get a bit ‘phobic’ about advice; and turned something that was a counteraction to some over-directive practices into a rigid ‘law’ about what we can and cannot do. From a pluralistic standpoint, and based on the evidence, advice can be helpful for some clients some of the time. And perhaps it would be better to be working out when it might be helpful, and what are the best ways of giving it at those times. For instance, I’m sure that tentative ways of advising, rather than impositional ones, are of greatest value to most clients. And asking clients whether they’d like advice or not is also, probably, a helpful practice so that clients don’t feel imposed upon. There’s also the question of what kind of advice is most beneficial? For instance, from our research with young people, we’re finding that it tends to be in two areas—social skills and coping behaviours—and developing knowledges in such areas may be very helpful in terms of optimising the value of advice-type responses.

Perhaps the question we always need to ask, as Teresa Cleary notes in her comments below, is whether our responses is in the best interests of the client, or whether it’s to meet some personal need or agenda. The problem with giving advice is that it is, indeed, often more the latter than the former; but not giving advice can also be so—if, for instance, it’s about conforming to some inner set of ‘shoulds’ about how counsellors behave. So there’s no easy answers. It’s complex. And while having some basic rule about ‘not giving advice’ is a great starting point in training, like all skills and competencies, it is something that can get nuanced and developed over time.

[Spanish translation of this blog post]

Non-Directivity: Some Critical Reflections

The concept of non-directivity emerged in Carl Rogers’s work in the 1930s and 1940s as an alternative to the therapist-led counselling of his day. There, the clinician defined the interview situation, asked questions, diagnosed, and proposed particular activities (if you’re interested in its origins, do get hold of a copy of Rogers’s early work, Counseling and Psychotherapy). Rogers’s ‘non-directive’ approach was a radical innovation, which aimed to put the client’s own goals and understandings at the very centre of the therapeutic work. Underlying this was a humanistic ethic that placed ‘a high value on the right of every individual to be psychologically independent and to maintain his [or her] psychological integrity’ (p. 127).

Looked at today, it seems to me that there is still enormous value in emphasising the client’s right to direct their own therapy. Just as one example, for instance, when I’ve analysed interviews with young people in person-centred school counselling, it is clear that some really value not being told what to do by the counsellor. They say things like, ‘The counsellor asked me questions, but she didn’t push me. That felt calm and relaxed (and much better than the person I had before who was just talking all the time/getting me to do things).’ ‘Non-directivity’, then, can clearly be helpful for at least some clients some of the time; and, even without that, there would be an ethical argument for starting therapy with the client’s own directions. That’s why, perhaps, a ‘person-centred’ approach is becoming increasingly dominant in the health and social care fields. That doesn’t mean a strictly Rogerian practice, but one that aims to put the client right at the heart of the decision-making process. Health Education England, for instance, write:

Being person-centred is about focusing care on the needs of individual. Ensuring that people's preferences, needs and values guide clinical decisions, and providing care that is respectful of and responsive to them.

So, in that sense, Rogers’s basic principle of ‘non-directivity’ has been accepted as a starting point for the whole care field, and is, in many ways, incontrovertible. I think that’s great. I also think that it’s really important that, on counselling and psychotherapy training courses (pretty much of any orientation), trainees are taught the discipline of being able to recognise their own particular directions and agendas, and to try and de-prioritise these in favour of the client’s.

However, it’s worth noting the change in terminology — from ‘non-directivity’ to ‘person-centred’ — and to a great extent that is evident in Rogers’s work too. In his later books he uses the term ‘non-directive’ a lot less: indeed, it’s not even there in the index of his 1961 classic: On becoming a person. Personally, I think that’s a good thing: for me, while the ethos of non-directivity is incredibly important, the term is problematic for a few inter-related reasons.

First, from an intersubjective standpoint, it doesn’t make much sense to talk about being ‘non-directive’. Intersubjectivity is the philosophy that human beings only exist in relation to each other; and, if that’s the case, then simply being in the room with another person will have some influence on them. Here, then, we can never not direct another, and that’s what comes through in the research. For instance, some of the young people whose interviews I’ve looked at find it really awkward when the counsellor doesn’t say much, and particularly when there’s silence. I’m sure the counsellors, here, are trying to be non-directive and not leading but, actually, it has a very powerful effect on the client. So there’s no ‘neutral’ when it comes to counselling, no pure reflection; and it’s probably important that therapist know that so that they can think about the impact that their behaviours are having, whatever they do. If they try to direct, it will influence the client in certain ways; but if they try not to direct, it will also influence the client in certain ways. The term ‘non-directive’ seems to imply that we can act without influence, and that, I think, occludes rather than clarifies what happens in the counselling room.

Second, I think that the term ‘non-directivity’ can lead to a particularly passive understanding of person-centred practices — especially for trainees who are new to the field. What we see with young people is that, although most do really love their counselling, there is a significant minority (maybe 15% or so) who experience their person-centred counsellor as too passive: too quiet, too purely reflective — not offering enough input or advice. Again and again, too, when I ask my adult clients about their previous therapies I hear things like, ‘She was really nice, but she just didn’t do anything, and I am not sure I got much out of it.’ So I think that person-centred therapists need to be wary about ‘sitting back’ too much — at least with some clients. Person-centred therapy, per se, can be incredibly active and dynamic — the therapist fully present and immediate in the room. But I think the term ‘non-directive’, all too easily, points away from that: it infers not-doing, not-acting, not-taking initiative. ‘Person-centred’ or ‘client-centred’ or ‘client-oriented’ seem much better terms to me: that emphasise that the therapy is based around the client but don’t position the therapist as, inherently, non-active in that.

Third, the concept of ‘non-directivity’ throws up a paradox: because what does it mean to be non-directive with a client who wants direction? And it’s certainly the case that that’s what some clients wants. Take the graph below, for instance, from some research we recently conducted on individuals’ preferences for therapy. Respondents were asked to say what they would want a therapist to do, from a scale of 3 (Allow the therapy to be unstructured) to 3 in the other direction (Give structure to the therapy). Here, around 65% of respondents were saying that they wanted a structured, therapist-led approach; compared with around 15% wanting an unstructured approach: and that was similar on all our other therapist directiveness dimensions.

So, if a client is scoring a ‘3’ for wanting structure in their therapy, what is the ‘non-directive’ thing to do? You could say, ‘Well they’re asking for structure, but really they need to learn to live without structure and find their own direction,’ but that seems to be putting the therapist’s perspective before the client’s — hardly non-directive! So a more non-directive approach, it seems to me, is to try and accommodate the client’s preference and provide some structure (if we can and if we genuinely think it might be helpful for the client) — and this is what we’ve tended to advocate in pluralistic therapy (see here). But then the term ‘non-directive’ doesn’t seem to particularly fit any more. Not unless we say that being ‘non-directive’ can include such therapist-led activities as providing structure, activities, and guidance — but that’s really not what the term would seem to suggest. So, again, I think terms like ‘person-centred’ or ‘client-oriented’ are much better ways of expressing that desire to actively align ourselves with the client’s own directions: to put their wants and preferences right at the heart of the therapeutic work.

Finally, I think the term ‘non-directivity’ implies that, as therapists, we can act without directions when, actually, directions are inherent to all our actions. That’s something I’ve particularly focused on in my most recent book, which argues that ‘directionality’ is an essential quality of human being: that forward-moving, agentic thrust of being that can exist unconsciously as well as consciously. This means that, as therapists, we are never not trying to do something. We might want to be conveying empathy to our clients, or understanding them, or facilitating their own self-empowerment; but these are all directions in themselves, and recognising what these directions are is probably more important — in terms of our own self-awareness — than assuming (or hoping) that we’re acting without direction. This links to the earlier point that we’re always going to influence another, whether we like it or not.

I guess, in conclusion, what I am saying is that, although the thinking and ethics behind the term ‘non-directivity’ are of critical importance, the term, itself, is not always a helpful one. It’s good in reminding therapists to recognise, and de-prioritise, their own agenda; but it can imply an individualistic understanding of human being, and it points towards an interpretation of person-centred practice which is too passive and too non-engaged for some clients. In fact, I would say that it’s maybe time to drop the term from our training and literature, and instead to focus on being ‘client-’ or ‘person-’ centred, and what that really means. Or maybe we think about person-centred therapy as an approach which, fundamentally, strives to align itself with the direction of the client and to facilitate that. So not ‘non-directive’ but ‘client direction-centred’. Person-centred therapy, ultimately, isn’t about lack. It’s about dynamism, responsiveness, presence. And I think there are better terms that convey that deep engagement with clients. We’re not non-something. We are something. And emphasising what we are is, I think, a more constructive and positive way forward for the person-centred approach.

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[Image by Agnieszka Zapart: see https://www.facebook.com/PsychoterapiaGestaltAgnieszkaZapart/ for her wonderful illustrations]

[Spanish translation of this blog post]

Relational Depth in Online Therapy: Can it be Experienced, and What Facilitates and Inhibits It?

With recent developments around the coronavirus, many counsellors and psychotherapists are having — or choosing — to move to online or telephone-based therapy with their clients. But, for relationally-based practitioners, a concern can be that these changes will make it much harder to achieve a depth of connection.

Fortunately, a couple of years ago, Aisling Treanor, a trainee on the Doctorate in Counselling Psychology at the University of Roehampton, asked exactly such a question in her thesis. It was entitled ‘The Extent to Which Relational Depth can be Reached in Online Therapy and the Factors that Facilitate and Inhibit that Experience: A Mixed Methods Study’ and can be downloaded, in full, from here.

There were two parts to Aisling’s study. First, she conducted a small scale quantitative survey with 13 clients, looking at how much they had experienced a depth of relating in online therapy. Then, she conducted qualitative interviews with seven of those participants to explore their experiences in much more depth. All of the interview participants, and most of the survey participants, had received therapy via video conferencing (mainly Skype). Six of the seven interview participants were female, all were white, and their therapy tended to be long term: generally more than two years (though, in some cases, they switched to online part-way through the therapy).

So what did Aisling find?

Do Clients Experience Relational Depth in Online Therapies?

In her survey, Aisling used two quantitative measures to assess the extent to which clients experience relational depth (both of which can be downloaded from my page here).

The first was the Relational Depth Inventory, which asks respondents to identify an important event during a therapy session, and then to rate the extent to which they experienced specific qualities, associated with relational depth, during that event (for instance, ‘I felt a profound connection between my therapist and me’, ‘I felt my therapist trusted me’). The average score for the online therapy clients was approximately 3.7 on a scale of 1= ‘not at all’, 2 = ‘slightly’, 3 = ‘somewhat’, 4 = ‘very much’, 5 = ‘completely’. So that means that, in an important moment of therapy, clients experience relational depth to a considerable extent. That compares with a mean of around 3.3 from clients in face-to-face work, albeit using a different version of the RDI and with a different sample. So we can’t conclude that clients in online therapies have deeper connections in important moments than those in face-to-face therapies, but certainly the results aren’t too bad for online practices.

One of the limitations of the RDI is that it just asks about depth of connection in one moment of therapy, but what about the therapeutic relationship overall? This is the focus for a second measure the Relational Depth Frequency Scale (RDFS). This RDFS (client version) presents respondents with the following stem, ‘Over the course of therapy with my therapist, there were moments where…’ and then asks them to rate items related to relational depth (for instance, ‘It felt like a shared experience,’ ‘We were deeply connected to one another) on a scale of 1 = ‘not at all’, 2 = ‘only occasionally’, 3 = ‘sometimes’, 4 = ‘often’, 5 = ‘most or all of the time’. The average score for the 13 participants was 3.5, so somewhere between ‘sometimes’ and ‘often’. This compares against a mean of 3.5 in a survey of mainly face-to-face. Again, the measure used was slightly different and there’s no way of comparing the samples, but at the least we can say that the participants in online therapies did experience some depth of connection with their therapists.

In addition, five of the seven interview participants said that relational depth was experienced in their online therapy; and their descriptions of these moments of encounter was very similar to clients in face to face therapy (see, for instance, here). This included describing these moments as ‘beyond words’ and ‘liberating’. One client, for instance, said, ‘I think they are life changing moments those moments. They don’t come often, it’s like catching rainbows. You can’t catch a rainbow, it might land near you or something you know and in a sense these moments are I suppose miracles in a way, they are just extraordinary moments.’

So, in summary, Aisling’s research would suggest that clients can experience relational depth in online therapies. Bear in mind that all of the clients were in fairly long term work but that, in itself, would suggest that the level of relating was sufficiently deep for the clients. We also need to be wary because, of course, it’s a very small sample; and clients who were willing to take part in the survey may have been more likely to relate closely with their therapy and their therapists. Nevertheless, the findings strongly challenge the assumptions that relational depth can’t be achieved when working online—clearly it can, and for some clients in quite powerful ways.

What Facilitates Relational Depth in Online Therapy?

In the interview study, participants reported a number of factors facilitating a depth of connection that we’ve also found in face-to-face therapies (see here). First, the longer they were in therapy, the more depth of connection they tended to report. Second, there were personal and professional attributes of the therapist, such as being authentic, ‘holding the boundaries’, and being competent. There were also, however, two factors specific to online therapies.

First, and perhaps most interestingly, some of the participants said that the physical distance between them and their therapists enabled a more honest dialogue, and therefore deeper levels of communication. For instance, one client said, ‘I find it easier to communicate because there is that distance. I find one-to-ones intimidating and therefore that slight distance releases that tension.’ Another client said, ‘I’ve felt quite, like, relaxed and very free to express what I might want to, being on Skype rather than being face-to-face.’ A couple of clients also talked about the intimacy of the video conferencing encounter because participants are, perhaps ironically, more ‘face-to-face’ with a therapist (quite literally) than when they are in a room together. One client said, ‘it can feel more intimate than being in a session, em, in the same room, ’cos you kind of forget- you almost forget the kind of physical, kind of, conditions and you’re just purely focused on the conversation and content of that.’

The second factor that participants said could make for deeper relationships in online therapy, as compared with face-to-face therapy, was the ‘convenience’ of the encounter. Aisling writes, ‘Being at home in a comfortable and relaxing environment may allow clients to talk about distressing or painful experiences more quickly than being face-to-face with a therapist, and therefore enabling a deeper connection to exist.’ After sessions, too, knowing that you can just ‘flop into bed or onto the couch’ helped some clients feel safer to express more in-depth material. Some clients also felt that the offer of online therapy, when face-to-face was no longer possible, was experienced as a caring gesture by the therapist, and taking their specific needs and circumstances into account. The fact that therapy was cheaper (saving on travel costs, in particular) and available at a wider range of times also meant that clients were more likely to engage with therapy in the first place. There was also a vastly wider choice of therapists, thus meaning that clients were more likely to find someone they could connect with.

What Inhibits Relational Depth in Online Therapy?

Not surprisingly, perhaps, the biggest obstacle to experiencing relational depth in online therapies was technical difficulties. Most often, this was simply to do with problems in the online connection, for instance the internet cutting out or a poor signal. One client stated:

The only thing that ever frustrated me was when there were connection problems. It didn’t hinder the relationship as such as I knew it wasn’t anyone’s fault, it was just exasperating when you were mid sentence and spilling your heart’s secrets out and then all of a sudden I couldn’t hear what the therapist was saying or there was a delayed reaction or the camera would freeze.

Participants also spoke about the visual distraction of seeing themselves on screen (usually in a little box). One client said, ‘I find it really difficult, I didn’t like it at all, especially being able to see myself, I don’t even- I never really like it, I find it really impersonal and quite awkward using Skype’.

The second inhibiting factor, mentioned by a couple of participants, was the lack of non-verbal cues. One client described how this meant moments of deep connection could get missed:

The picture’s not terribly good and the sounds not terribly good and, em, I guess that I was a bit slow on picking it up [that the therapist was emotionally connected] because of the lack of body language to go with it. You know she [the therapist] had to say to me, ‘Oh my God, I’m finding this very emotional’, before I really picked it up and saw that she was crying, em, whereas if I’d have been sitting in the same room, I’d have noticed it straight away’.

Then there was the physical distance which, while disinhibiting for some (see above), could also be experienced as a barrier to relational depth. One client, for instance, who had experienced relational depth in face-to-face therapy, felt that he could not experience it online because of the sense of detachment that the physical distance brought. Other clients felt that the lack of physical proximity made it difficult to really feel that ‘the other person is with you’. Similarly, while some participants felt that the home setting was conducive to relational depth, others felt that it could get in the way: distracting, creating a sense of ‘lethargy’, and not bringing about the focus and ‘mindset’ that a specifically therapeutic context could bring.

Conclusion

Overall, what the findings from Aisling’s study show is that it is possible to experience relational depth in online therapy, though there are aspects of this medium that may make it less (as well as more) likely to occur. This is consistent with the broader research on relating in online therapies (see, for instance, here), which suggests that its quality does not plummet when therapy is conducted online, though it may be less than face-to-face in some instance.

What Aisling’s research also shows, however, is that there were large differences between clients. Some were absolutely fine with online therapy and found that they could relate deeply and intensely: perhaps even more so than in face-to-face therapy. Others, however, did find the medium inhibiting, and couldn’t experience the depth of relating that they would if they were in a room with their therapist.

For therapists who need to switch to online work, one obvious implications is that it’s ideal if you can get the technicalities as finessed as possible. Sometimes, there is not much you can do about poor signals and weak connections; but knowing how Skype or Zoom works, and learning how to be confident with them, is critical in being able to deliver therapy remotely. Also, given the lack of non-verbal cues, explicitly communicating to clients what you are experiencing and feeling may be of considerable value.

Developing the competencies to deliver therapy online, and issues of data security and confidentiality, is beyond the scope of this research and this blog. BACP have some good guidelines here; and Ruth Allen has posted some very useful guidance here. There is also a freely available online short course from Kate Anthony here. And the good news coming out of Aisling’s research is that delivering, or switching to, online delivery of therapy doesn’t necessarily mean compromising the depth of therapeutic relating. Clients can still have powerful, intense moments of deepened therapeutic connection via Skype or other video conferencing platforms.

[Spanish translation of this blog post]

The Chronic Strategies of Disconnection Inventory: A Practice Example

Chronic strategies of disconnection (CSoDs) is a concept developed by the feminist psychotherapist Judith Jordan. It refers to patterns of behaviour that we may develop to protect ourselves from hurt or anxiety in close relationships, but which may now be redundant: i.e., we tend to do them automatically when, in fact, it may be more beneficial for us to stay in closer connection with another person. It is a concept I have written about in relation to relational depth: looking at the ways in which people may, consciously or unconsciously, undermine their own ability to relate at depth.

The Chronic Strategies of Disconnection Inventory was a self-reflective checklist of different CSoDs developed by Rosanne Knox and myself. We developed the inventory based on data from workshops with counsellors and psychotherapists, in which they were asked to identify their own CSoDs (see our paper here). The checklist presents various different CSoDs (e.g., ‘Pushing others away,’ ‘Not expressing your wants’) and invites respondents to indicate on a 0 (Not at all) to 3 (A lot) scale, the extent to which they tend to adopt these CSoDs.

Originally, the inventory was designed for counsellors and psychotherapists to use. The aim was to help us identify our own CSoDs, so that we could explore the extent to which these might ‘leak’ into our therapeutic work, attenuating our ability to relate deeply with clients.

However, the inventory can also be used with clients to help them identify their own CSoDs.

Recently, I received an email from Simon Hughes, a trainee on the first year of a person-centred diploma, who also works in a homeless charity and housing trust. He wrote about his experience of using the inventory in a community of seven people who have come from residential rehab or detox units. I found it so interesting how he had used it that, with his permission, I have reprinted his email (with details anonymised). Simon writes…

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As part of the house, we run groups twice a week, and Wednesday's groups are about psycho-social education to build skills for relapse-prevention and help the guys in their recovery. The house are a community who challenge each other and support one another in their recovery—they have strong connections together and this is one of the best things about the project. I have been in this role since September, and decided to use the CSoDs Inventory for a house group on the fourth week I had been in the role. Relationships at this stage were still forming.

First, I spoke to the group for around five to ten minutes to explain what chronic strategies of disconnection were and gave a disclaimer about how they are not diagnostic, but just to raise awareness. I had read the Mearns and Cooper book on relational depth earlier that month, and explained how relationships can help us grow as people, but also how relationships can be risky and that we can develop strategies to protect ourselves from deep ways of relating. I then read out the blurb at the top of the CSoDs Inventory page and we had a discussion about relating deeply to people and how that is helpful (e.g. in the group talking about recovery) but can also be vulnerable and different to how we tend to relate to others outside of the group and places like Narcotics Anonymous. 

I was conscious that reading the CSoDs Inventory was not everyone’s style, so I read through the 40 strategies of disconnection aloud, giving examples of how each one might look. After that, we had the choice to either fill in the form with a pen and tick what seemed like a strategy we employed, or else to sit and think if any of them had resonated with us. We discussed what we had said and then had a cigarettes break.

After the break the group said they would like to look at the inventory again, and challenge each other on what strategies they believe the others used. I spoke briefly about how just being aware of them won't change things, but that these things tend to decrease in therapy because of an accepting relationship where people feel able to be themselves truly. I said for example, that my wife and I had been watching too much TV and not relating, and being aware of this helped us relate deeper by doing things like going for walks—but it needed to be followed by more than just being aware of it. We discussed framing how we would challenge each other and its usefulness, then the group decided they would like to proceed. People went round saying what CSoDs they felt others used, and I was surprised that the challenges were empathic and encouraging the others to become more part of the community—no one seemed upset, surprised, or offended.

At the end, the group said they felt that this had been the best ‘house group’ yet. I felt a real sense of depth in the group, which I haven't felt to that extent in a house meeting and the majority of the house seemed really able to use the inventory. I also felt a benefit in taking part in this exercise with them.

Feedback

I feel that the CSoDs Inventory was a hugely useful tool to promote conversation and deepen relationships in the context of a therapeutic group. It provided a space for residents to talk about each other’s behaviour (e.g. isolating in rooms) in a constructive way, in order to promote connection. The inventory worked for people from various educational backgrounds, literacy skills (originally said literally abilities), and at different stages of recovery. The group were able to use the inventory and engage with it, with only a small introduction, and I was able to facilitate the group whilst still being in counselling training. Honest discussion promoted relational depth in the group and the group liked this inventory more than any other Wednesday group I have since co-facilitated.

The CSoDs Inventory might be used by professionals and trainees as a therapeutic tool or outcome measure—it is reasonably accessible in how it is written and works well in a group setting, as well as for individual reflection. The inventory was applied to a group focused on recovery from substances, and provided a format to discuss tensions in the house in easy accessible language without members feeling accused or insulted.

I find the weakness in the inventory is that, while it is graded, there is no interpretation or use for the grading (e.g., no interpretation of what a total score might mean).

It may be that the inventory could be used like other outcome or process forms (e.g. CORE-OM, PHQ-9). For instance, a CSoDs Inventory could be completed at sessions 1 and 10, and the results compared. The assumption would be that people would let go of disconnection strategies within therapeutic relationships, and their score would likely decrease.

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Simon’s experiences identify some very interesting possibilities for use of the CSoDs Inventory, and the concept more broadly. As with any therapeutic method, however, the inventory should only be used following consultation with supervisors/trainers, and in-depth discussion of its appropriateness to the particular therapeutic context. It is essential, too, that clients are invited to consider whether or not they would like to use the CSoDs form prior to its use.

Why I Love Qualitative Research

I’ve just come off an hour’s Skype on a qualitative research project. We’re looking at clients’ experiences of preference accommodation. Do clients want therapists to ask them about their preferences? Do they find it helpful having them accommodated? Do clients preferences change over the course of therapy? We’re engaging in a research process called Consensual Qualitative Research (CQR), and have the privilege of having one of the developers, Sarah Knox, on our research team. It was an hour, also with Gina di Malta and Hanne Oddli, going over the first part of an interview transcript and trying to put into ‘domains’ what the participant was saying about preference accommodation. Were they saying that their preferences had come from their previous therapy, or were they saying that the therapist just intuitively knew what they wanted? Back and forward: dialoguing and disagreeing and trying to make sense of things. CQR is a fascinating qualitative method where you work together on the analysis as a team. It really gets to the heart of qualitative research: working to make sense of what people are saying and experiencing in their lives.

Working on this project has really reminded me of the extraordinary things that can be achieved through qualitative research. Of course, being a pluralist, I love quantitative research too, but there’s something about the qualitative process that gets to the depth of things in a way that numbers never really can. When you’re interviewing someone, when you’re asking them about their lives and perceptions, you’re getting straight into the process by which someone comes to do the things that they do. And what things mean for them. You can look at numbers, and you can say that, for instance, ‘School counselling leads to reductions in distress’ but you don’t really know why. It’s like looking at the world through a mesh. But with qualitative research, you can really ask people about things, and then ask them again. And ask them in different ways that mean that you can build up such a rich picture of what’s going on.

Interviewer: What was it like seeing the school counsellor?

Young person: Well I- I really liked how she talked to me about things.

Interviewer: So you liked talking about things. Can you say more?

Young person: It was, I felt that the more I talked about things the more I kind of felt relieved. Less stressed.

Interviewer: So the stress came off as you talked. Is that right?

Young person: Yes, I felt a weight coming off. I talked about things and, as she listened, I felt at least someone else knew what was going on. I wasn’t alone. And I got some ideas about how to talk to my mum…

Of course, qualitative research doesn’t do everything. It’s not great if you want to compare between groups, and it’s hard to generalise too widely from it. But generalisation is based on the assumption that everyone acts according to the same laws and, actually, what qualitative research helps you to see is just how different everyone is. One participant says that they really loved going to see the school counsellor. Another says that they hated it. Taken quantitatively, you can end up averaging these two things out so that, on average, people feel fairly neutral about seeing a school counsellor; but actually that’s not the reality at all. The reality is that some loved it and some hated it. And qualitative research can really help us to hold on to, and prize, those differences.

It’s for reasons like these that so many counsellors, psychotherapists, and counselling psychologists would rather be doing qualitative research than quantitative. It’s not a million miles from being with a client: listening, understanding, deepening an empathic attunement with another’s world. A key difference though is that we’re also taking that out of the therapy room and telling others about it: so that, for instance, clinicians can use that knowledge to inform and develop their practice. That’s why one thing I am really passionate about is trying, wherever possible and ethical, to do qualitative research with clients rather than therapists. I know, I know… it’s more difficult often to find clients to do research with, and there’s additional ethical considerations. But when you’re talking to clients about what they feel about therapy, when you’re asking them what was helpful and not helpful and then bringing it all together into a coherent whole, there’s something amazing you’re learning about what we do. It’s ‘straight from the horses mouth’: deeply, profoundly affecting how we can think about the people sitting opposite us.

Just today we published a study on clients’ experiences of working with goals. Again, in many ways, it was a really simple study: we talked to clients about how they felt about working with goals in therapy. Yet I feel like I learnt so, so much to help me in my clinical work. For instance, I’m a real advocate of goal-oriented practices, but clients were also saying that, in some instances, goal setting could feel premature. They really didn’t know what they wanted. And there was some clients who felt it was mechanistic, and demotivating at times. Sure, you can say, ‘Well, I could have told you that without interviewing 22 clients,’ but then there were also some very positive things clients said about working with goals, like they could bring focus and help them progress forward step-by-step. So qualitative research, particularly with clients, can help us out of rigid positions of ‘clients want this’ or ‘clients want that’ towards an appreciation of the complex, heterogeneous, and multifacted world of clients’ experiences of therapy. A few years back, John McLeod and I published a protocol on conducting qualitative research into clients’ experiences of what is helpful in therapy, and I think it’s still a very useful framework for conducting research that can really contribute to the development of our knowledge and practice (see here).

I wish qualitative research played more of a role in informing clinical guidelines and policy. But I think it’s up to us involved in it to try and sketch out what that might be. The great thing about randomised clinical trials is that they give very clear results, and you can bring them together to produce specific and definitive guidelines for policy and practice. How do you do that with qualitative research? I am sure you can, but we need to work out how. In the meantime, though, I hope that more of us can get more time really talking to clients about what therapy is like, and learning more and more about what’s working and what’s not. It’ll never give us definitive answers, but it’ll help us build up a richer and richer picture of how, where, and why we can be most helpful in our work.

Is Person-Centred Therapy Effective? The Facts

Are you sick and tired of people telling you that ‘person-centred therapy doesn’t work’? Does your manager try and convince you that there’s no evidence for the approach? Would you like to scream at the next person who tells you person centred therapy is ‘just the basics’ and that ‘everyone does it all anyway’? If so, here’s ten facts about the evidence base for person-centred therapy that might just keep you sane… and everyone else that better bit informed.

1. Humanistic and experiential therapies, of which person-centred approaches form a substantial part, bring about large and significant reductions in psychological distress (see Elliott et al.’s 2021 comprehensive meta-analysis for the definitive review).

2. The effects of humanistic and experiential therapies, overall, tend to be similar to other therapies, including CBT. This is particular true when the allegiance of the researchers is taken into account (see Elliott et al., 2021). However, a major recent study did find that, 12 months after assessment, person-centred experiential counselling for depression had slightly poorer outcomes than CBT (see here). There is also some evidence that non-directive therapy may be a little less effective than other therapies for depression (see here). Overall, what the research shows is that the more active, process-guiding forms of person-centred therapy are as effective as other therapies, but a strictly non-directive approach may be marginally less effective than most.

3. Studies which compare the outcomes of person-centred therapy in real world settings (e.g., IAPT) show that these are very similar to CBT and, indeed, may be achieved in a shorter period of time (see Pybis et al., 2017).

4. There’s no consistent evidence that CBT or psychodynamic therapies have longer lasting effects than person-centred therapy, or that they ‘work’ more quickly. Indeed, in the recent major study (see #1), person-centred therapy actually seemed to act more quickly.

5. It’s the dodo bird, stupid (though maybe don’t say the ‘stupid’ bit to your manager!). Again and again, what the research tends to show is that ‘everyone has won and all must have prizes’—all therapies, overall, do about as well as each other.

6. There is an overwhelming body of data to show that Rogers’s three ‘core conditions’—empathy, unconditional positive regard, and congruence—are all associated with positive outcomes (see Norcross and Lambert, 2019).

7. Studies which ask clients what they found helpful in therapy (whether CBT, psychodynamic, or humanistic) show, again and again, that much of what they most value is relational qualities closely associated with a person-centred approach: e.g., therapist warmth, caring, and trustworthiness (see here for one very recent example).

8. Consistent with person-centred theory, research shows that, by far, the largest contribution to therapeutic outcomes comes from clients: their levels of motivation, involvement, engagement. It’s clients that make therapy work, not therapists (see Bohart and Wade, 2013).

9. Person-centred counselling with children, and with young people, also shows good outcomes, at a level generally consistent with other therapeutic orientations.

10. Even if there are small differences in the overall effectiveness of different orientations, this doesn’t take into account the fact that different clients do better or worse in different therapies (and at different points in time). Research shows, for instance, that clients who are more independent, who deal with issues in a more ‘internal’ way, and who particularly want space to talk are likely to do very well in a person-centred approach (see my Facts are Friendly).

The bottom line… be proud of being a person-centred practitioner and all the evidence behind our approach. But be informed as well (see here for an overview of all the evidence). There’s every reason to challenge someone who belittles the evidence base for person-centred therapy, but you need to know your research and what it all means.

What do clients want from therapy (and is it what person-centred therapists might want them to want)?

In a research paper published today (see here for journal version, and here for author final version), we found that a majority of clients wanted a more directive approach to therapy. Our data shows, for instance, that over 70% of clients wanted their therapist to focus on specific goals in therapy, to give structure to the therapy, and to take the lead. Clients expressed a particularly strong preference for therapists to teach them skills to deal with their problems. By contrast, only around 15% of clients wanted a more non-directive approach.

What we also did in our paper was to compare these preferences against therapists’ preferences, themselves. Not surprisingly, perhaps, we found that counsellors and psychotherapists—mainly of a person-centred orientation—wanted a lot less direction. So if we’ve used our own preferences as a guide to what clients are likely to want, it may come as something of a shock to see that, in fact, clients tend to want a lot more structure and leading. But that’s what we found, in two pretty rigorous surveys, and it’s matched by previous findings in the field (see, for instance, here).

These findings may be pretty challenging to those of us, from person-centred, humanistic, and relational orientations, that tend to work in more non-directive and unstructured ways. It suggests that what clients want is sometimes (perhaps often) different from what we tend to offer.

We could try and dismiss these findings by arguing that what clients want is not necessarily what they need. And, indeed, there’s good evidence that people don’t always know what is best for themselves (see, for instance, here). Two problems though. First, the evidence shows that there is quite a good association between what clients say they want from therapy, and how well they end up doing in it (see, for instance, here). So clients’ explicitly-stated preferences do indicate, on average, what works better for them, and also the kind of therapy that they are more likely to stick with. Second, if we start saying that clients don’t really know what they need (and we do), then we’re moving dangerously close to an ‘expert-driven’ perspective which holds that, as therapists, we know what’s best for clients. Not a good place for person-centred therapists to find themselves at!

Maybe it’s a case that clients’ preferences change over time. That is, they start off wanting more therapist direction but, once they get into therapy, they get more used to taking control for themselves. That may also be true in certain instances; but our data suggests that, across therapy, clients’ preferences don’t change too much. Certainly, in my own experience of using a preference inventory, I’ve found that what clients want stay pretty consistent. That is, at the start of therapy, clients are often saying things like, ‘Mick, I’d like this therapy to be fairly task-oriented,’ and after a few sessions they are saying, ‘So come on, when are we going to start on tasks!’

Perhaps clients’ desires for goals, tasks, and CBT is a consequence of neoliberalism, with the promise of an easy fix around every corner: someone who can always sort you out. Maybe. But, in my experience, when clients are asked why they want direction they come out with pretty cogent rationales: for instance, ‘Goals give me a sense of what I can focus on,’ or ‘I’d like to see things from a different perspective.’ And it’s a bit patronising, too, to assume that, because clients may want things different from us, it’s because they’ve been socialised into ‘faulty’ ways of thinking. Again, if we’re coming from a person-centred perspective, and trusting in the client’s own wisdom, surely we should be valuing how they see things from the start.

Does this mean that clients don’t want empathy, or acceptance, or an intense relational encounter as well? Not at all. In fact, we didn’t even ask about those relational qualities because we figured that, for most clients, the choice between an ‘empathic’ or a ‘non-empathic’ relationship would just be a no brainer.

And does this research suggest we should all re-train as CBT therapists? No, of course not. For a start, there are clearly some clients who do want a less directive approach, or who have tried CBT and are now wanting something different.

More importantly, perhaps, I think that the kinds of qualities that clients are asking for are all things that can be incorporated into a person-centred, humanistic, or relational practice. What, I think, a lot of clients are saying is something like this, ‘I want a therapist who is going to be active, who is going to do things, who is going to “sit forward” rather than “sit back”’. It’s like what I’ve wanted when I’ve been for a massage. It may feel less painful if the masseur is soft and gentle, but what I really want is someone who is going to be digging their knuckles in, making things happen. Clients invest a lot in therapy—time, emotionally, and financially often—and I think what many of them are saying is, ‘I want you, as a therapist, to be really involved here. To do things. Not just to sit back and let me do all the work.’

So I do think these findings challenge some ways of being a person-centred, humanistic, or relational therapist (or psychoanalytic, for that matter). I think they challenge a fairly ‘passive’, non-involved, ‘neutral’ style—or one where the therapist sticks mainly just to reflecting the client, and doesn’t add too much beyond that. The limitations of such a style are also very evident from research we’ve done with young people, as well as findings from adult clients: that a passive, non-involved stance can really ‘freak’ some clients out. They want to feel that the therapist is a ‘real person’, with real thoughts and ideas. And if everything is just focused on them, it can feel very unnatural.

More than that, from a pluralistic person-centred stance, goals, structure, and skills training can all be part of our therapeutic work—if that’s what clients are wanting, we’re appropriately trained in it, and we’re happy to work in that way. So while we can’t ever be everything to every client, a pluralistic PCA always tries to put the needs and wants of the individual client before any rigidity or dogma of method. If a client wants it, and we can do it, and we can both see how it might be helpful, then why not!

One of the nice things about a pluralistic person-centred stance is also that we can be really open to whatever the research says, and not having to reinterpret it to fit our own needs and agendas. As Carl Rogers so beautifully puts it (and there’s a great book of this title :-) ):

…[T]he facts are always friendly. Every bit of evidence one can acquire, in any area, leads one that much closer to what is true. And being closer to the truth can never be a harmful or dangerous or unsatisfying thing. So while I still hate to readjust my thinking, still hate to give up old ways of perceiving and conceptualizing, yet at some deeper level I have, to a considerable degree, come to realize that these painful reorganizations are what is known as learning, and that though painful they always lead to a more satisfying because somewhat more accurate way of seeing life.

Finally, just to say, the whole point of this blog isn’t to argue that we should all, now, work in more active and directive ways with every client. From a pluralistic standpoint, different clients need different things at different points in time; so there’s undoubtedly some clients out there who really want—and need—us to be quieter and more sitting back. Rather, the point of this blog is to say that we should always try and stay open to each individual client, and not prefigure what they want or need. In fact, if I think about myself, I tend to prefer a therapeutic style that gives me lots and lots and lots of space. But then, I’m a therapist.

Carl Rogers's 'core conditions': Are they necessary and sufficient?

It’s the essay title just about every person-centred student has to address at some point in their training: Was Rogers right to claim, as he does in his classic 1957 paper, that the therapist’s (a) congruence, (b) unconditional positive regard, and (c) empathic understanding are necessary and sufficient conditions for therapeutic personality change to occur (along with (d) therapist—client contact, (e) client vulnerability, and (f) the therapist’s communication of these conditions)? Rogers’s hypotheses were based on the available research of his time, and were an amazingly insightful and succinct reading of it. But over 60 years have elapsed since Rogers put forward his position: Does it still stand up to the evidence?

Let’s start with 'necessary’. That means that those first three ‘therapist-provided’ conditions (along with the three ‘relationship’ and ‘client’ conditions) needs to be there for therapeutic personality change to occur. Here, the research suggests a resounding ‘no’. The problem is, it’s evident that therapeutic personality change can happen through a variety of mechanisms where there really isn’t much of a relationship at all. For instance, James Pennebaker has shown that writing about emotional experiences (as with keeping a diary) can be a profoundly therapeutic experience; and there is good evidence that online therapies can be as helpful as face-to-face therapies, often with minimal interpersonal contact. Have you ever watched a film that has had a profound effect on you, or read a book that has moved you to see life in a really different way? If so, it’s really not possible to claim that any kind of relationship factors are necessary conditions for therapeutic personality change.

What about ‘sufficient’? Well, yes, the very latest research does show that each of Rogers’s core conditions are associated with positive therapeutic change. But it’s not necessarily the case from that that they are causing the change. It may be, for instance, that clients who improve then start to feel that their therapists are more accepting and empathic. I know, for instance, that if my doctor gives me some good news, I tend to like them more. And what the evidence also shows is that Rogers’s core conditions are just three of many different relationship factors that are associated with positive outcomes. For instance, alignment on the goals of therapy also seems to be important, and then there’s the therapist’s capacity to deal with ruptures in the alliance, and the use of systematic client feedback. All of these factors are closely related to Rogers’s conditions, but it suggests that the ones Rogers identified don’t have some kind of ‘magical significance’: they’re three factors amongst a sea of inter-related relational variables that all, together, are associated with positive outcomes. Add to that is the problem that, for different clients, Rogers’s therapist-provided conditions may be more or less helpful. For instance, research into empathy shows that, for some clients—highly sensitive, suspicious, and poorly motivated—very high levels of empathy may be counter-productive. Certainly, some clients can feel that a therapist is just too positive, or too in their shoes, or too present and full on. And, finally, there’s some very good evidence, both quantitative and qualitative, that clients can really value, and benefit from, ‘non-relational’ interventions, like normalisation through therapist’s expert knowledge, or ‘behavioural activation’. Maybe the relational elements of these therapeutic encounters are sufficient to bring about some degree of change, but to just focus on that would be to ignore what some clients, themselves, are saying matters most.

The problem with Rogers’s hypothesis is that, in many ways, they’re not very ‘Rogerian’: in the sense that they assume everyone responds in the same way, without taking into account individual differences. When you say things are ‘necessary and sufficient’, the inference is that this is going to be true for us all, and that doesn’t allow for people to respond to therapies in different ways. That’s why John McLeod and I have been arguing that one way of really embodying person-centred principles is through a pluralistic approach to therapy: acknowledging the many different ways in which clients can be helped and the individual differences in what works for each of us (see blog on Person-centred therapy: A pluralistic perspective). I’m sure that Rogers, like most of us in the person-centred field, would have wanted to respect those differences; and no doubt his ‘conditions’ were an attempt to speak the language of his times: scientistic, nomothetic (i.e., universal), and absolute. In fact, I remember reading somewhere that he does acknowledge that it probably wasn’t the best way of phrasing things. If he’d said something like ‘congruence, empathy, and unconditional positive regard are incredibly important elements of therapy for many people, much of the time’, he’d have been absolutely spot on. It’s a bit less snappy, but 60 years later he would have still been absolutely spot on with what the evidence is telling us, and that’s an amazing thing.

So what would Rogers say now. Reading the evidence, very closely as he did, I’d like to think he’d say something like the following:

What we know is that the quality of the therapeutic relationship is one of the best predictors of outcomes; and a growing body of research is beginning to show that it does, indeed, have the capacity to bring about positive change. For lots of clients, having a good quality therapeutic relationship—empathic, trustworthy, and caring, for instance—can have an enormous impact, just in itself; and for others, it can be an essential vehicle through which other change processes can happen. However, different clients need different things: and it may be that some clients need more: more psychoeducation, or more challenge, or more interpretation. Different people are different. So nothing is necessary and sufficient for everyone. But if you want to practice therapy in a safe and effective way, then establishing an empathic, honest, and unconditionally accepting relationship is, for most clients, one of the best things that you can do.