How to Explain Integrative Practices: A Directional Account

Let’s say you’re writing a case study or essay for an integrative or pluralistic course on counselling, psychotherapy, or counselling psychology. You’re using a range of different therapeutic methods and theories—for instance, person-centred practices with attachment-based ideas and some mindfulness techniques—and you have an intuitive sense that it all goes together somehow. But how do you put that down on paper? That is, how do you explain a range of different ideas and practices in a way that is coherent and gives a deeper sense of integration in what you are thinking and doing?

My recent book Integrating counselling & psychotherapy: Directionality, synergy, & social change (Sage, 2019) is an attempt to provide a framework for doing just that (you can find an open-access summary here). And the framework is less of a new theory, and more a way of trying to articulate the implicit assumptions and understandings that many of us have about our work.

The framework starts with the idea that human beings are essentially directional. What that means, drawing on humanistic and existential ethics, is that we are always moving towards something in our lives: always purpose-oriented, always agentic. We’re not blank sheets that get written on (or, at least, not only that), and neither are we machine- or computer-like beings that are determined to act in certain ways. Rather, we act towards our worlds, try to make sense of things, try to do things rather than just being done to. A directional understanding of human beings is pretty much common to all our therapeutic approaches—whether the person-centred actualising tendency, psychodynamic desires, or CBT goals and drives—and is way of understanding our clients that expresses a deep respect for who and how they have come to be: something we would all want to do as the basis for our work.

From a directional standpoint, clients come to us because they are struggling to move forward in their lives. There’s things that they want—whether relatedness, self-worth, inner peace, or more happiness—and in some way, and for some reason, they’re not able to get there. Whatever theories or methods we use, what makes our work coherent is that these are all ways of trying to to help our clients get from where they are to where they want to be.

That’s why many of us are naturally integrative: because we have a sense that there are different ways, from a range of different therapeutic approaches, that can help in that process. For those of us at the pluralistic end of the spectrum, we’re also interested in talking to clients about how they, themselves, think that they can get there: because we want to draw on the wisdom and resources of the client, as well as bringing our own into the mix.

This integration, however, goes deeper than just wanting to help. The directional framework suggests three basic reasons why things can go wrong with people, and hence three ways in which we might try to make it right.

Finding Synergies

The first is that people sometimes struggle to move forward in their lives because there’s other parts of them wanting to go in different directions. For instance, a client wants to deepen their trust and love for their partner, but there’s also part of them holding back: scared of letting go and allowing themselves to be fully in their relationship. Or a client wants to feel better about who they are, but there’s a ‘driver’ or a ‘critic’ part of them that is pushing them to be strong, or more successful—saying that they are never good enough. All the time as therapists we work with these conflicts, and what we do, whatever orientation we are from, is to help clients find more synergetic ways of meeting their needs. What that means is that we try and help clients to find ways in which they can get, for instance, the love that they want, but also feel safe in the relationship; or to feel good about themselves, but also to allow themselves to push forward. Synergetic means ‘win-win’ between our different wants and needs: it means getting A and B, rather than A or B. Our roles, as therapists, is not to take sides in these internal disputes, but to help the client find their own positive reconfigurations. And there’s many, many ways we can do that. So, for instance, our person-centred, listening work might be about providing a client with the space to lay out all the different things they want, but then psychodynamic interpretations might add in some ideas about what they are really striving for and how they go about doing that. For instance:

I can really hear how scared you are of trusting your partner, and I guess that might link to the hurt and rejection you experienced as a child. You knew what it was like to be abandoned, you knew how painful that was, and I can totally see why you would want to protect yourself now. But I guess the cost of it is that you’re finding it difficult to let your partner in.

There’s other idea and practices that we might bring in to support this process of reconfiguration, given the appropriate skills and training. For instance, we might encourage the client’s trusting and distrusting parts to have a dialogue using two-chair work from Gestalt therapy; or we might use creative methods like artwork to help the client express other feelings and strivings. Behind it all, though, is a desire to provide clients with a space to explore their ways of doing things and to help them find better possibilities: more rewarding and more satisfying ways of living, where they are getting more of what they most fundamentally want more of the time.

Being Effective

Sometimes, people just don’t have the best ways of getting to where they want to be. For instance, they want to overcome their anxiety but they do it by drinking or being promiscuous; or they want to improve their relationship but they do it by criticising their partner. Of course, ‘best’ here isn’t some judgement from an external standpoint, and there’s no one best thing for all clients all of the time: some people, for instance, might find promiscuity really helps with their anxieties. But it’s just that, for ourselves, and by our own standards, we don’t always do things in the ways that are going to help us most. So, from the directional framework, the second thing that a therapists can do is to help clients learn more effective ways of getting to where they want to be.

Just to reiterate, as a person-centred-ish therapist, I do hate to use the word ‘better’. I know it can seen really judgmental and inconsistent with the idea of a person as an actualising being. But it depends a lot on how we understand actualisation. From a directional standpoint, we do always understand people as striving to maintain and enhance themselves (as Carl Rogers would say), and there’s a strong sense of the person as an ever-growing and evolving organism. But, as even most person-centred therapists I’m sure would acknowledge, the fact that we are always striving to do our best doesn’t mean that what we are doing is, genuinely, the best thing for us. Indeed, if it was, there wouldn’t be any point to therapy at all.

So, as integrative or pluralistic therapists, there’s various ways in which we might help clients find better ways of doing things. And this might range from very client-centred ways (for instance, providing the client with a space to talk and reflect), to more therapist-led and psychoeducational ways: for instance, suggesting mindfulness exercises or coping strategies. This is where CBT methods and techniques can come in as particular helpful. And although such practices might seem diametrically opposed to person-centred approaches; from a directional standpoint they’re simply different ways of helping clients to ‘find better’. Just like if we were learning a new language: some of the learning comes from outside (discovering, for instance, new Spanish words for things), but also time to process internally and to make sense of things ourselves.

Social Change

The third reason we don’t always get what we want, in the directional framework, is less something we can do about as therapists, but nonetheless important to acknowledge. Sometimes, clients don’t get where they want to be because of social impediments. For instance, a woman wants to feel successful at work but actually there’s a ‘glass ceiling’ that stops her from being able to reach the level she should. Or a black person feels unsafe walking around the streets because of the very real racism that is out there in the world. As therapists, we can help clients work out what is best for them to do within these limitations, and we might also help them feel more personally empowered. But, to a greater or lesser extent, what these problems call for may be wider social, political, and economic action—and that’s perhaps something we can only facilitate from outside of our therapeutic role.

Conclusion

Sometimes integrative and pluralistic practices can feel fragmented, and we’re not always clear why we’re doing what we’re doing. That can be particularly hard if we have to explain (or justify) it to someone else. The point of this blog is not to create some new account of integrative practices that therapists can hang on to. Rather, it’s to try and dig down and to articulate what some of our implicit assumptions and practices might be if we’re working integratively or pluralistically. Some of the language of the directional framework is a bit technical (‘synergies’, ‘directionality’, etc), but the basic idea is very simple: that all of us, as therapists, are trying to help clients get from where they are to where they want to be, and when we’re integrating we’re drawing on different ideas and methods to try and do that as best as we possibly can.

Reference

You can reference this blog post as:

Cooper, M. (2021, April 10). How to explain integrative practices: A directional account. https://mick-cooper.squarespace.com/new-blog/2021/4/10/how-to-explain-integrative-practices-a-directional-account

[Photo by Stephen Hocking on Unsplash]

Person-Centred Therapy: We Need to Talk About Research

Carl Rogers was way ahead of his time when, in 1957, he published his ‘necessary and sufficient conditions’ for therapeutic personality change. He and his research team were amongst the first counselling and psychotherapy clinicians to use research data as a way of informing their practice.

But, since then, many elements of the person-centred field have stalled. We don’t know the latest research findings, we don’t evaluate our approach, we don’t consider research as a useful source of information in developing our practice. How many person-centred counselling trainings, for instance, teach students about the latest evidence on empathy, congruence, and UPR, as detailed in the APA books on Psychotherapy Relationships that Work, or David Rennie’s research into client deference in person-centred therapy?

Research evidence is not the only valid source of guidance on how to practice—far from it—but it is one very valuable guide. Why? First, it’s a way of systematically generating knowledge so that, at least to some extent, we can stand back from our own biases, wants, and assumptions and see what is ‘out there’. We all, of course, believe our approach to practice is effective (and perhaps the most effective one) but research can help us see it from different angles, so that we discover, for instance, what clients experience, think or do, rather than just seeing a reflection of our own wants. Second, and even if we don’t value research evidence, commissioners and funders do. It’s just no good, these days, going to commissioners and saying, ‘I think you should fund me to do person-centred therapy because Carl Rogers said it was effective back in 1957’. What’s needed is contemporary, high quality evidence that can really convince those with the money that investing in what we think is worth investing in really is.

So without research, and without a research-informed mentality, I think there’s a very real danger that the person-centred approach may die. Die because it stops growing and learning and evolving; and instead stagnates in what was discovered over 60 years ago and refuses to move on. Die because it’s no longer fitted to the world around us and the kinds of things that clients, today, actually want and need. And die because no-one any more is willing to pay for it.

Very recently, we published the findings from our large-scale ETHOS trial of school-based person-centred counselling; and there’s the results of the PRaCTICED trial soon out, comparing person-centred counselling for depression against CBT in IAPT. Both of these sets of findings, which we’ll be presenting at the forthcoming BACP Research Conference, provide an invaluable opportunity to learn more about the processes and outcomes of person-centred therapy; and to look at how we might grow and evolve our approach. And there’s so much more research out there that has been done, and can be done, to really help us nuance, refine, and update our person-centred ways of working to maximise the benefits that we can give to clients.

For me, a lot of the responsibility here comes to person-centred trainers. I think people who run person-centred courses need to teach a form of person-centred that is open, flexible, and research-informed. That doesn’t mean abandoning principles like non-directivity or the ‘core conditions’—students need to learn a particular, specialised practice—but it does mean that all this is taught within a critical understanding of what the latest research evidence says, and an open-minded welcoming of multiple positions and perspectives. I know that isn’t easy—many counselling trainers aren’t that familiar with research terminology and methods—but having some knowledge and understanding in this area seems an essential competency, to me, of a training position. Would we be OK, for instance, if people who trained nurses or doctors had no knowledge of the latest research evidence in their fields? If we want counselling to be treated as a mature, serious profession, then we have to recognise the role that research plays—and will be expected to play—from the very inception of practice.

And, for trainers, I think we need to consider carefully how we define what it means to be person-centred. If we define it, for instance, in terms of the ‘core conditions’, then what do we do if the research shows that those relational conditions aren’t actually, that important to change; or that there’s other relational or technical factors that are most closely associated with growth? The more we define our approach in terms of particular methods or stances that we ‘know’ work, the more closed we are likely to be to the evidence and to revising our thinking and practice as new findings come in. I don’t think there are easy answers here but if, for instance, we defined person-centredness in terms of listening deeply to clients’ perspectives, or in terms of an ethic of respect and care, we might allow ourselves more space to incorporate new discoveries and findings as we continue to grow.

‘The facts are always friendly,’ writes Rogers. He states, ‘in our early investigations I can well remember the anxiety of waiting to see how the findings came out. Suppose our hypotheses were dis-proved! Suppose we were mistaken in our views! Suppose our opinions were not justified!’ However, he goes on to say:

 At such times, as I look back, it seems to me that I disregarded the facts as potential enemies, as possible bearers of disaster. I have perhaps been slow in coming to realize that the 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.

[Image: johann-siemens, Unsplash]

Working with Client Preferences in Counselling and Psychotherapy

Mick Cooper, University of Roehampton, London; John C. Norcross, University of Scranton, PA, USA

Client preferences can be defined as the specific conditions and activities that clients want in their therapy. The literature suggests three main types of client preferences [1]. First are treatment preferences: the desires that clients have for specific types of intervention, like person-centred or psychodynamic. Second are preferences about the therapist. This is the kind of counsellor or psychotherapist that the client would like to work with; for instance, lesbian, Asian, or an older adult. Third are activity preferences: the specific actions that clients desire to engage in throughout the therapy process. This can include the frequency and format of therapy (for instance, online therapy), the methods and techniques to be used (for instance, two-chair work), the preferred topics to focus on (for instance, early childhood), and the therapist’s particular style (for instance, focusing on emotions).

In preference work, we can also distinguish between preference assessment—the identification of clients’ strong likes and dislikes—and preference accommodation—the therapist adjustment of their way of working to the client’s expressed desires [2].

There are both ethical and empirical reasons why therapists should concern themselves with client preferences. Research shows that clients are as much as 50% less likely to drop out of therapy when the treatment matches their preferences, and also show somewhat better outcomes. So, for instance, a client who wants a warm, supportive, client-led therapy style may be particularly likely to drop out—or show relatively poor outcomes—if they are given a highly directive and therapist-led CBT [1]. Ethically, preference assessment and accommodation can convey a deep respect for our clients and their ways of seeing their worlds: a core requirement of any ethical framework [e.g., 3]. It also means respecting our clients’ rights to be autonomous, self-governing agents; and recognising that they are not uniform, ‘machine-made’ products, but individualized beings with distinctive wants. Such honouring of difference is also important across cultures. A White male counsellor, for instance, who does not ask his female Pakistani client about her particular preferences may end up imposing European, ‘male’ assumptions on her. When we ask, therefore, we share power; we move away from a comparatively authoritarian, expert-led stance towards a more egalitarian and democratic one.

Addressing Common Concerns

Therapists, quite rightly, have a number of concerns about working with client preferences, and these are worth addressing up front.

‘Most of my clients don’t know what they want’

It’s certainly true that some clients don’t have strong preferences, particularly if they have not been in counselling or psychotherapy before. But preference work is not an all-or-nothing thing: it’s about gently and sensitively offering clients an opportunity to share their preferences, if and when they have them and would like to do so.

‘What clients want isn’t necessarily what they need’

That can be true. A client, for instance, might want warmth and reassurance from their therapist when, actually, what would help them is to learn to tolerate anxieties and tensions in interpersonal relationships. But, as we have seen, research shows that, overall, clients succeed better in therapy when they get the approach they want. Moreover, when therapists think that what a client requests will not prove helpful, then can then raise that concern with them. It’s not about handing over responsibility to clients, but working collaboratively with them—‘shared decision making’, as they call it in the medical field—to work out, together, the best way forward.

‘Clients preferences can change over the course of therapy’

 Yes, some do and some don’t (though our research shows that most client preferences are pretty stable over time). That means that assessing client preferences is not a ‘set-and-forget’ process. It’s often more tentative and recursive: opening up the discussion, trying things, and being willing to change the way of working if clients are not finding it helpful or want something else.

‘Does that mean I have to offer every therapeutic methods to every client I meet?’

No, we can only learn so many approaches, and we have to practice within our competencies. Thus, sometimes, working with client preferences means recognising that what they want is not what we can competently offer (and referral to another may be indicated). But, generally, it is much better that clients and therapists have that discussion early on, rather than discovering incompatibilities months into treatment.

‘I already have an intuitive sense of what my clients want, so why bother asking?’

Intuition is a valuable skill; but research shows, again and again, that therapists’ and clients’ perceptions of what is going on in therapy are often mismatched. For instance, one study found that, in about two-thirds of cases, clients and therapists had somewhat different views about the goals for therapy [4]. Moreover, there is a risk that therapists’ intuitive sense of what clients want are biased by the therapists’ own therapy preferences. Our research shows that there are quite large and systematic differences between what therapists and laypeople want, as clients [5].

‘I already work with clients’ preferences. I don’t need to do more’

Interestingly, in the medical field, doctors tend to think there’s more shared decision making going on than patients [6]. The difference may come down to power. If a doctor says, ‘Why don’t we try treatment X’, and a patient nods their head, the doctor may feel it’s a shared decision; but, for the patient, it may be more a case of compliance for fear of appearing ignorant or rude. Given that a similar power dynamic can exist in therapy—with research showing that client deference frequently occurs, even in person-centred approaches [7]—it behoves all therapists to reflect on their practice and think about how frequently they provide clients with opportunities to express their preferences. It may be less than we think.  

Assessing Client Preferences

So how should you go about assessing client preferences?

Almost certainly, the first step is a reflexive one: asking yourself, What is my scope of practice? That is, what are you (a) competent and (b) willing to offer to your clients? For instance, are you able and willing to offer transference interpretations, anxiety-management skills, or methods to discover meaning in life? What about individual, couple, group, or family therapy? Recognising what you can offer clients is essential in responding effectively to clients’ stated preferences—you will need to know whether what they ask for is something you can adopt or not.

Assessment of client preferences most commonly takes place at initial, or intake, appointments. It is probably best if this assessment takes place towards the end of that session—clients often come to therapy anxious, or with their own accounts that they want to offload—and it may be a few sessions before clients are ready to say something of what they prefer. We recommend that the clients’ treatment goals (the ‘where’) be established before ascertaining their preferences (the ‘how’).

 There are many ways that clients can be invited to express their preferences, for instance:

•  What do you think that we can do here that might be helpful to you? Do you have any sense of what wouldn’t be helpful?

• What would you like in our work together? What kind of preferences do you have?

• Try this brief exercise. Close your eyes, breathe deeply a few times, and imagine in your mind’s eye what you would strongly like to happen in here. What would I ideally do? What would I not do?

• Let’s think together about how you might get what you want from therapy. Which treatment method? What type of therapy relationship? What type of out-of-office activities: self-help, exercise, apps, and so on?’

 Assessment of client preferences can also take place before that intake meeting. For instance, on an initial phone conversation, a prospective therapist may ask about particular treatment preferences or preferences about the therapist to ensure there is a basic compatibility before moving forward. Scheduled review sessions are another point at which clients may be asked about their preferences, and whether the therapist’s methods and style seems to be of help. And, of course, throughout the therapy sessions there may be occasions where it is appropriate and helpful to discuss client preference: for instance, at the start of sessions, when the therapy is not progressing well, when there is an alliance rupture, or when the ending approaches. In fact, recursive assessment of preferences often becomes part of routine outcome monitoring.

Based on the research and our clinical experience [2], we offer several principles of good practice in preference assessment:

• Focus on strong preferences—what clients might really want and really dislike—rather than milder or more moderate preferences; it’s the former where accommodation or non-accommodation is most likely to count.

• Ask clients what worked and did not work in previous therapies, if they have had them. It’s often the most simple and natural way in to helping identify what might be helpful now.

• ‘It’s the relationship, stupid’: preference assessment needs to be framed within the context of a respectful, warm, collaborative therapeutic relationship; if not, it may be little more than a sterile data gathering process.

• Make it clear that asking about preferences is a normal part of counselling and psychotherapy. Clients may be surprised to be asked, and assume that therapy is like other, practitioner-led ‘treatments’.

• Actively invite clients to share their preferences: given client deference (see above), it’s not enough just to assume that, if they have preferences, they’ll verbalize them.

• Be part of the dialogue yourself: shared decision making means shared—you need to work with the client to help decide, together, what might be best for them.

• Be confident: at its worst, preference assessment can communicate to clients that we don’t know how to help them, and that it’s their responsibility to decide. So the message we want to communicate to clients is, ‘We’ve got lots of ideas about how to help you, but we’re really interested in your ideas too. I am the expert on therapy and you are the expert on you.’

• Suggest alternatives through ‘scaffolding’: clients can easily feel overwhelmed if they’re presented with a ‘blank sheet of paper’ and asked, ‘What do you want?’ Rather, it is often helpful to suggest 2 or 3 specific possibilities, for instance, ‘We could talk about your grandmother this session, or perhaps you would like to focus on your boyfriend?’

• Don’t ‘overcook’ it: if clients do not have ideas about will help them, or seem reluctant to talk about it, then move on. You can come back to their preferences later on in the therapeutic process, if it seems appropriate.

• Tailor the tailoring: some clients, some of the time, want to have their preferences assessed and accommodated; others, do not. Hence adjust the amount of preference work to the individual client—there is no one size fits all, even when it comes to the client’s preferences.

Through our research, we have developed a tool to assess strong client preferences, the Cooper-Norcross Inventory of Preferences (C-NIP) [8]. This measure, now translated into over ten languages and freely available for use digitally or on paper (see c-nip.net), invites clients to express their preferences for therapy along four dimensions: (a) Therapist directiveness vs Client directiveness, (b) Emotional intensity vs Emotional reserve, (c) Past orientation vs Present orientation, and (d) Warm Support vs Focused challenge. The measure takes clients about five minutes to complete and can be immediately scored in session to indicate whether the client has strong preferences on any of these dimensions. This then serves as the basis for discussion about how the therapist and client can work together. Our research suggests that clients generally find the C-NIP helpful, supporting their ability to articulate how they want to proceed in treatment. And, they say, it feels good to be asked.

Working with Client Preferences in Therapy

Once clients’ preferences are assessed, there is the question of how they are accommodated—or not—into the therapeutic work. In our book, Personalizing Psychotherapy, we suggest four possibilities: adopt, adapt, alternative, or another.

Adopt means that we integrate the client’s strong preferences, pretty much as they are, into treatment—bearing in mind, of course, that these preferences (and our scope of practice) may change over time.

Adapt is offering something along the lines of what the client wanted, but adjusted to take into account our own views of what might prove most effective, the research evidence, ethical considerations, or the limits of our own scope of practice. In the case of Hamza, for example, there was a small but significant mismatch between what he wanted from treatment and the therapist’s (Mick’s) understanding of what might be most helpful for him:

Hamza presented with high levels of depression and anxiety and was becoming increasingly withdrawn from his college and social environment. The therapist view, based on an understanding of core behavioural principles, was that Hamza needed to be encouraged to get out and re-engage with his world. The more he withdrew, the more anxious and isolated he became. Hamza sensed this pattern as well. However, he also indicated that, based on a previous episode of CBT, it was unhelpful for him to be told by a therapist, ‘If you don’t do what I’m suggesting, you’re not going to get better.’ He related that it left him feeling guilty, ashamed, and even less confident to go out into the world. The adaptation challenge was to find methods of communicating to Hamza that he could change his behaviours, without implying that he was ‘bad’ or ‘wrong’ if he did not. A delicate balance needed to be struck between helping Hamza own some responsibility and, at the same time, avoiding his strong dislike of feeling blamed. [2]

 The third option is to respectfully propose alternatives to patients’ strong likes and dislikes. This would be when we believe their preferences will not be most suited to the particular context, or when we do not think it will produce the desired results. Just because clients want something does not mean that we should automatically provide it. Ethical, legal, and clinical constraints still bind us to responsible and effective practice. In some cases, for instance, clients may be unconsciously trying to recreate problematic relationship or to test the therapy’s frame. Three ‘E’s may be helpful when proposing alternatives to clients [2]:

• Explain your reasoning for not accommodating or adapting.

• Empathize with probable patient disappointment.

• Educate the client about the proposed alternative, so that they understand why it is being proposed.

When a client’s strong preferences prove congruent with the research evidence and best practices, but not our own scope of practice, then referral to another becomes a strong possibility [2]. This is a practice that students often receive little training in, but it is an essential competence, given our inevitable limits and our desire for clients to have the best therapy possible. Some helpful pointers for therapists may be:

• Accept your limits as a clinician: see onward referral as a sign of your commitment to your clients’ mental health rather than as an indication of your failings.

• Be aware that some clients may experience onward referral as a sign of rejection or an indication that their mental health problems are incurable. Make clear that it is due to your competency boundaries as a therapist, rather than their failure as a patient.

• Refer onwards in a collaborative way with clients so that it is experienced as a shared and empowering experience, rather than as something imposed on them.

• Provide concrete suggestions and specific sources in mind, as opposed to vague referrals to other services. This may mean being aware of other resources in your community—for instance, low-cost CBT practitioners or substance misuse programmes—before having these discussions with clients.

• Obtain proper permission or releases so that you can communicate with other clinicians or clinics; that will ensure continuity of care and help the treatment personalization forward. [2] 

Conclusion

Assessing and accommodating clients’ preferences constitutes a complex, nuanced set of practices and interactions that evolve over the course of therapy. It is, at heart, about creating a more egalitarian, empowering, and responsive relationship that enables clients to use counselling and psychotherapy most effectively. Both research and practice attest to the success of preference work.

But there is still much more to learn. Which clients in which situations, for instance, are most (and least) benefitted by preference work? How can we most effectively help clients articulate their preferences? Answering these kinds of questions is part of a wider movement towards personalised care, in which our clients are treated as more than just instances of a general class (for instance, ‘depressives’ or ‘borderline types’), but as unique human beings with specific and individual desires. When we ask clients about their preferences, as with Buber’s ‘I–Thou attitude’ [9], we affirm them as agentic participants or partners, who have the power—and right—to direct their own process of change. This is certainly not the only means of conveying such valuing and respect to our clients, but it becomes an integral part of a deeply affirming, empowering relationship. 

Further Reading

Our book, Personalizing Psychotherapy: Assessing and Accommodating Client Preferences, is now available from APA. For UK readers, a 40% discount is available for the book with free standard delivery. Please go to www.eurospanbookstore.com/personalizing-psychotherapy.html and use the ‘code Psychotherapy40’. This offer valid until at least 31/4/21 and open to customers based in the UK, Europe, Middle East, and Africa.

References

1. Swift, J.K., et al., Preferences, in Psychotherapy relationships that work, J.C. Norcross & B. E. Wampold, Editors 2019, Oxford University: NY. p. 157-187.

2. Norcross, J.C. and M. Cooper, Personalizing psychotherapy: Assessing and accommodating client preferences2021, Washington: APA.

3. British Association for Counselling and Psychotherapy, Ethical framework for the counselling professions, 2018, BACP: Lutterworth.

4. Swift, J. and J. Callahan, Early psychotherapy processes: An examination of client and trainee clinician perspective convergence. Clinical psychology & psychotherapy, 2009. 16(3): p. 228-236.

5. Cooper, M., et al., Psychotherapy preferences of laypersons and mental health professionals: Whose therapy is it? Psychotherapy, 2019. 56: p. 205-216.

6. The Health Foundation, Helping people share decision making, 2012, The Health Foundation: London.

7.  Rennie, D.L., Clients' deference in psychotherapy. Journal of Counseling Psychology, 1994. 41(4): p. 427-437.

8. Cooper, M. and J.C. Norcross, A Brief, Multidimensional Measure of Clients' Therapy Preferences: The Cooper-Norcross Inventory of Preferences (C-NIP). International Journal of Clinical and Health Psychology, 2016. 16(1): p. 87-98.

9. Buber, M., I and Thou. 2nd ed1958, Edinburgh: T & T Clark Ltd.

[Spanish translation of this blog post]

How to (almost) Fail a PhD: A Personal Account

The year, 1996, didn’t start well. My then-partner and I went to Spain, with three friends, for a Christmas break. For some reason we thought it would be shining hot. As it turned out, we spent a week in a wet, damp bungalow in the middle of nowhere. The main thing I remember were the Spanish tortillas on the few days we got out—wet and damp as well, with burnt soggy potatoes at the bottom.

My PhD viva was on Friday the 6th Jan—25 years from the publication of this post (more details on what a PhD viva is are available here). I’d read through my thesis a few times and felt fairly well-prepared. It was a somewhat unusual topic, Facilitating the expression of subpersonalities through the use of masks: An exploratory study. Basically, during my undergraduate studies I’d gone to a mask workshop run by a friend of mine at Oxford University and been amazed at the power of masks to bring out different ‘sides’ of my self (or ‘subpersonalities’). I researched it further for an undergraduate paper and then, in the early 1990s, applied to Sussex University to do a PhD on the topic. Basically, I wasn’t sure what I wanted to do as a career—either media (TV, journalism) or academia—and, as I couldn’t find a way in to media work, I thought I’d do the latter, particularly when I was awarded a grant from Sussex University to support me. That’s when I also started counselling training: I thought I better to do something practical alongside the PhD.

The internal examiner for the viva was a tutor of mine from my undergraduate days and someone who I knew fairly well. The external examiner was an academic in humanistic psychology I didn’t know much about, but had read a couple of her books and they seemed interesting. The three of us sat that Friday in the internal examiner’s office: dark and small, with his bike leaning against the bookshelves.

I remember more about after the viva than the viva itself. But the questions came quickly and they felt pretty intense from the start. ‘Why was I writing about subpersonalities?’ ‘What evidence was there for them?’ ‘What made me think they were a legitimate basis for a PhD?’ ‘Why was I so dependent on the work of John Rowan, what about my own thoughts?’ I answered the questions as best I could, wondering if that was how vivas were supposed to be—anxious that, perhaps, this was more critical than normal. After about 90 minutes I was asked to leave and sat in the Department common room—somewhere I’d spent many hours as an undergraduate socialising and relaxing in. I felt a rising anxiety from the pit of my stomach. I’d done my best, but something felt wrong. One of my other undergraduate tutors passed by and asked me how things had gone. He said he was sure it would all be fine: no one got failed for their viva. I wasn’t so sure.

Called back in the darkened room, like a death sentence. They had, indeed, decided to fail the thesis. Well, not quite fail it, but they were proposing that I resubmit for an MPhil: the next to lowest outcome. The main thing I remember was crying. I think it was an armchair I was sitting in, in a corner of the room. Sobbing away. Couldn’t believe it, even though I’d felt it coming. I went to see my supervisor and told him the news. Then I walked and walked and walked to a nearby village. Bought some cigarettes for the first time in years, rang my closest friend from a red call box and just smoked and smoked. There was nothing else I could do.

I came back to campus and went to see my supervisor again. He said that the examiners had decided that, in fact, I could have another chance to resubmit for a PhD: one outcome higher. But it would require a complete rewrite—four years’ work down the drain!

I met my partner at our house near Brighton station. Then we went to the pub. A few pints and I felt better, but I knew it was just temporary. Back home, as the alcohol wore off, the reality of the situation smashed back in my face. And so many questions: ‘Why had I failed?’ ‘Why had my supervisor said to me, just the day before the viva, that the work was “excellent”?’ ‘Were they ever likely to pass it even if I did spend the next three years rewriting?’ More than anything, I just didn’t understand what was wrong with the work, why they had failed it. The examiners obviously, clearly, really didn’t like it. But why?

That weekend was probably the worst of my life. I hardly slept the Friday night, just terrible feelings of anxiety and worry. Thinking over and over again what had gone wrong. A few hours sleep, then pub the next day and again some temporary relief. Then walking, walking, walking with my partner—along Brighton seafront—trying to make sense of things and work out ways forward. A game of pool in a pub in Hove. Slow walk back along the Western Road. I bought some aftershave at a chemist in Seven Dials that was my favourite for many years. Back home in the silence and the pain of it all. Moments alone were the worst, when my partner went to sleep. Several serious suicide attempts over the next few days. I won’t go into details, but suffice to say that it was just the terror of the pain, and the thought of having—and meeting my—children in the future, that held me back.

It wasn’t just failing my thesis. It was where I was in life. Basically, I was 30, had been struggling for years to work out what I wanted to do. Had been watching so many family members and friends succeed in their careers. I felt like I was going nowhere. The one thing I had was this PhD and the possibility of being an academic, and now even that was in tatters. It was the last closed door in a series of closed doors. The last possibilities I’d been hanging out for.

One of the worst things was that I had to run seminars for the psychology undergraduate students the next week. I felt so totally and utterly ashamed: surely everyone would know about my failure, and then how could they possibly take anything I said seriously? I drove in that Wednesday, facilitated the class as best I could. It didn’t help that the internal examiner was the module coordinator. I spoke to him as well on the phone on the Monday. He was sorry to hear I was feeling so awful. He tried to explain what had happened but it just didn’t make any sense. More questions, not less.

I was teaching psychology at Brighton University as well at that time, and was so grateful that the programme coordinator there didn’t seem to flinch when she heard the news. She still trusted me, let me continue my teaching. In fact, that summer, when she moved on, I was offered her job, and started in a more permanent position at Brighton University.

Something had already seemed to turn, though, before that time. I felt a bit better by April. I had a new supervisor now (one of the conditions for me being allowed to resubmit): a professor from my undergraduate years that I really trusted. He was down-to-earth, grounded, gave me hope. But it was a whole new thesis, and three more years before I finally completed.

What Went Wrong?

So why had things gone so badly wrong? Had my supervisor let me down, was it that the examiners had been unfair, or had I just done a really poor piece of work? It took me months, maybe even years, to work out. But now I’d understand it something like this: When I started the work, I was doing it in the field of cultural studies. It was about masks, and with a fairly relaxed design: I was drawing on literature, ethnography, drama therapy. There was no stringent method, but that seemed fine for that field of study and others who wrote a thesis in a similar way had done fine. But then, about halfway through my programme, we’d shifted my registration to Psychology. My supervisor, I think rightly, wanted me to come out with a doctorate in psychology so that I could use that if I wanted to go into psychology as a profession—for teaching or clinically. But the problem was, the focus or content of my thesis hadn’t really changed. So my examiners, who were fairly classical psychologists, thought the whole thing was just off the wall. Far too a-methodological, no real use of systematic methods or analysis. As a psychology thesis yes, they were right, it didn’t meet expected standards. But I had no idea what those standards were. And somehow my supervisor had never seen that coming. And I guess I hadn’t too. There were warning signs. For instance, I presented at my psychology department’s seminar series and I could see that they weren’t too taken by being asked to wear masks and to move around in them, but I hadn’t wanted to see the problems. And I should have pushed harder for a second supervisor. I did ask, and it was discussed, but I let it go and thought it would all be OK.

What’s the Learning?

I guess, as with all awful things, there was a lot of learning. That experience has stayed with me throughout my life. I still go back to that pub by Brighton station every so often to sit and reflect and thank something or someone for, in the end, making things OK. And I’d do that again tonight if it wasn’t for COVID. Somehow, amazingly, within ten years of that viva I was a professor of counselling at a prestigious university in Scotland: something, sitting back there in 1996, I could never have even hoped for. When I go back to the pub, I kind of ‘talk’ to my 1996 self and tell him that things are going to be OK in the end, and to hang on in there. And it’s nice, in some ways, to have that chat with him and reflect on where things ended up. He’d have been so happy and relieved.

As a Student

One thing that I really did that was wrong was to isolate myself away from any academic community while I was working on my PhD. I never went to conference, or engaged with departmental seminars, or submitted to journals. And just the one time I did present, as above, I didn’t stay open to how people were responding. I was in my own little bubble, and that wasn’t shattered until my actual viva. I think I did that because I was scared: worried that others wouldn’t be that interested in my work or feel it was good enough. But I made the classic mistake of avoiding, rather than facing up to, the thing I was afraid of.

As a Supervisor

I really try and be straight with my students if I think there’s problems. If I don’t think the work is at the right level, I’ll do my best to say it. Much better they hear it from me than from their examiners.

And when it comes to choosing an examiner for a student, I do think about the importance of ‘alignment’. This is not about finding someone who will simply waive the thesis through; but finding someone who has some of the same basic assumptions and expectations as the student and the supervision team. Most psychologists would probably fail a cultural studies PhD if it was submitted as psychology. And, similarly, I imagine that many cultural studies academics would fail a psychology PhD for reasons—like lack of epistemological, cultural, and personal reflexivity—that traditional psychologists might never consider. So there’s a reality that, in the academic world, there’s lots of different sets of expectations and assumptions; and it seems essential to me that students are assessed in terms of what they are trying—and supported—to do.

These days, most universities (certainly Roehampton) have a minimum of two supervisors for doctoral work, and that’s absolutely key to ensuring that it’s not dependent on just one academic’s views. We do our best, but our blind spots are, by definition, blind spots. Really getting an honest second opinion on student’s work—triangulation—makes it much less likely that things will go off track.

As an Examiner

I’m still angry at my examiners. Fair enough, they didn’t like the work and didn’t think it was at doctoral standards. But, they were so critical, so personal about the problems in the thesis. The external examiner, in particular, felt just ‘mean’ at times. When my new supervisor and I wrote to her, while I was revising, just to check I was along the right lines, she wrote a response that felt so demotivating and unclear. It just wasn’t needed. So when I’m a doctoral examiner now, even if I feel more work needs to be done, I try and do it supportively and warmly—with kindness, sensitivity, and empathy.

There’s also something about acknowledging the multiplicity of perspectives on things. As an examiner, I have to give my perspective on what I think is doctoral standard, I can’t ever be entirely objective; but I can acknowledge it as my perspective. You can criticise something without criticising the person behind it.

As a Person

I guess one of the best things that came out of this whole period of my life is that I’ve never taken my job for granted. I feel incredibly privileged to have had a chance to work and teach: just seeing students, writing emails—it’s amazing to have this role and this opportunity with others. I still, deep down, don’t believe that I would/will ever have it.

I guess the downside of this, which has not been so great for relationships and, perhaps, as a father, is that I’m still so focused on work. If I don’t do a set number of hours each day, I start to feel almost shaky and that I’m letting work down. I’ve worked, maybe, 55 hour per weeks for the last twenty or so years. Rarely taken my full annual leave. And that’s, in part I’m sure, because I’m still haunted by the ghost of that experience. My 1996 self still regularly tells me ‘You’ll never have a job’, ‘You’ll never be part of a work team,’ ‘You’ll always be a failure and outside of things.’

Something else at the edges of my awareness: when I look back, I realise how much I had to contribute at that time. So much passion, energy, commitment. I really wanted to make a difference. And it was so, so hard to—not just with the PhD but as a young person struggling through their 20s who didn’t quite fit into the social structures. And it makes me think about how much of that energy gets wasted in our young people: so much passion, drive, and creativity that is blocked, that doesn’t have an outlet. It’s such a burning frustration for those young people, and such a waste for our society as a whole.

Concluding Thoughts

I still feel shaky, and then some relief, reflecting on this time. I’ve never written about it before and perhaps there’s still more to process in therapy. Just that sheer, pounding, devastating sense of failure and shame. But there’s also something profoundly uplifting about it. How you can be right at the very bottom of things, utterly hopeless, but if you stick with things and keep going despite then it can get better and amazing things can happen. I’d love to say ‘trust the process’ or that, in some way, that failure led to subsequent successes; but in many ways I think I was just incredibly, incredibly lucky that things worked out ok. Part of me, maybe that 1996 part, believes (or, perhaps, knows) I could still be struggling away. And I do feel like I’ve been amazingly lucky and blessed in my career and in my life: more than anything, four beautiful, gorgeous children.

Out of the storm, chaos, and anguish of life, there’s still the possibility of some incredible things emerging. Things can change. Even when we’ve totally given up on hope, hope and possibility may still hold out for us.

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Acknowledgements

I am deeply indebted to Helen Cruthers, James Sanderson, and the friends and colleagues who helped me through that time in my life.

Very special thanks to Christine Aubrey—I will always be so grateful.

Thanks also to Yannis Fronimos for feedback and encouragement on this article.

A condensed version of this article was published in the BACP publication Therapy Today and can be downloaded here. Thanks to Sally Brown for her superb editing and condensing of the post.

Recruiting Research Participants: Some Pointers

Participant recruitment… it’s the make-or-break of many a research project, so it’s surprising that it’s not addressed more in the literature. It’s as if, once you’ve chosen your research questions, decided on your methodology, and obtained ethical approval, you just close your eyes and, as if with a sprinkling of fairy dust, your data appears….

If only! Truth is, finding people to take part in your study is often the hardest, and most gruelling—emotionally as well as physically—part of your research. And difficulties over recruitment are one of the main reasons why people have to extend their research projects—sometimes by years. So if you want to make sure your research project is a successful one, planning for recruitment is something you need to take seriously, right from the very start.

Who’s busy too?

Why is it so hard to recruit for your study? Well, first, there’s a good chance that most people aren’t really going to want to do it. Sorry. That’s not to say that they’ll be critical of your research or think it’s pointless. It’s just that so many of us are so incredibly busy these days. Think of how you feel when you see an email or a Facebook notice inviting you to take part in some research. ‘Mm, looks kind of interesting,’ but with a hundred plates already spinning in your life, do you really want to take on one thing more? Have you got a spare hour and time to read information sheets and fill in consent forms. With your kids screaming in the next room or your partner who’s just put dinner on the table! So however fascinated you might be with your own research topic; remember that other people are ‘outside’ of your head rather than ‘inside’ of it: caught up in their own world of worries, tasks, and goals.

Touching on sensitivities

Prospective participants may also be reluctant to take part because what we’re inviting them to do is hard, emotionally as well as cognitively. Counselling psychologist Jasmine Childs-Fegredo says:  

In a qualitative study for example, you might be asking people quite personal, and possibly even potentially distressing questions, about their past experiences. For a quantitative study, you might be asking participants to undertake a task or complete a survey which they might be worried about finding difficult in some way. 

Jasmine goes on to add:

So you need to approach your recruitment strategy really sensitively: from the wording in a recruitment poster to the emails you might send out to participants. Use warmth, empathy, and be professional; enabling people to feel safe and thereby prepared to be in a relationship with you as their researcher.

Rosie Rizq, a former Professor at the University of Roehampton, makes a similar point when she emphasises the importance of developing a collaborative relationship with (prospective) participants right from the very start:

In my experience, many trainees tend to revert to a 'helicopter in/helicopter out' approach to their participants, rather than approaching potential participants with a collaborative mindset that may require particular sensitivity and thoughtfulness. I guess I'm seeing participant recruitment as part and parcel of a wider mindset and epistemology required for projects that might involve highly personal, painful, or sensitive material. Some participants require very careful handling indeed prior to any agreement being signed off; they need to feel a sense of confidence in the researcher and that their material will be treated carefully and respectfully before, during and, most importantly, after interviews.

So recruitment is not something we do to prospective participants; it’s a way, if you like, of initiating a relationship. And as with the start of all relationships it needs to be done with care, sensitivity, and attention.

Awkward!

But there’s another, third, reason why recruitment can be so difficult: because, for us as researchers too, it can just feel so incredibly awkward. Maybe this is just for the introverts amongst us, but I remember, when running psychology experiments for my PhD, just how excruciatingly embarrassed I felt asking people to take part—I wanted to die inside. Perhaps it’s a fear of rejection; perhaps an anxiety about receiving without giving—kind of like ‘pleading’ people to do something. I remember, as a kid, having the same feeling when I’d spent all my money in the arcades and had to beg random strangers for the tube fare home (in fact, I found it so torturous that my best friend, James, always ended up doing the begging for us!). Seriously, though, that awkwardness can create real obstacles towards successfully recruiting for—and completing—a study. You can’t do recruitment if you’re metaphorically hiding behind a wall somewhere, secretly hoping that no-one will notice you.

Be Proactive

So, as a general principal for successful recruitment, a key thing is to be proactive. This doesn’t mean being pushy, demanding, or nagging people when they’ve clearly had enough of you. But it does mean taking active steps to make recruitment happen, being on top of it, and pushing through—where appropriate—your own embarrassment or awkwardness barrier. Remember… there’s no fairy dust. Recruitment will not happen to you. Over the years, I’ve just seen too many research projects fail, or severely stall, because researchers have sat back and waited for participants to arrive rather than actively seeking them out.

Planning recruitment from the start

All this means that a recruitment strategy should be built into your research project from the very start, not an add on once you’re through ethical approval. And if you can’t conceive of viable ways to recruit people to a particular study, it may well be that you need to do something else—there’s no point having a brilliantly designed study if no one is actually able or willing to do it. Those strategies need to be concrete, realistic, and well thought out; and ideally tried-and-tested. Has an organisation, for instance, given initial indications that they would be willing to support recruitment, or have other projects used similar strategies to good effect? Remember, too, that of the many people who are potentially available to take part, most won’t. So if you’re planning, for instance, to interview clients at a service that sees 100 people per year, you might have to assume that at least 80% or so of them won’t be interested—and then of those 20 remaining some will drop out before, or at, the interview. So is that going to leave you with enough participants? However many people you think are going to want to take part in your research, chances are, the final numbers will be even less!

Challenging groups

There’s no doubt that some groups of participants are more difficult to recruit than others. Practitioners are often the easiest to recruit, clients more challenging, and then some groups of clients (for instance, those in prison) next-to-impossible unless you have some specific ‘ins’. The challenges of recruitment with a particular group, however, do need to be weighed up against the value of what research with them will accomplish. So, for instance, although clients may be more difficult to recruit than therapists, they can give much more valuable answers to particular research questions (for instance, ‘How do clients experience therapists’ self-disclosures?’).

If you are planning to conduct research in England which potentially involves ‘research participants identified in the context of, or in connection with, their past or present use of NHS services’ (either as practitioners or clients), you are likely to need NHS REC approval. This can be a time consuming process (3-6 months or more) and one that should be built into any research timeline. Again, though, the value of conducting research with such clients may outweigh the additional demands.

Have a written recruitment plan

A really systematic way to think recruitment through is with a written recruitment plan. This can be done on software like Word or Excel and, in most cases, is something you should be detailing in your ethics submission. List each of the different strategies/channels you’re going to use for recruitment (for instance, Facebook posts, Twitter posts, emails, approaching voluntary organisations), what you’re going to say, when you’re going to do it, and any other relevant details. You can then use that to track recruitment once you’ve started. Are you hitting the timelines you set for your different strategies, and what kinds of responses are you getting? If strategies don’t seem to be successful, strike them out and, where relevant, develop others (but don’t forget that those new strategies might need ethical approval). And, at the end of it all, you can present that plan in the appendix of your thesis: an ‘audit trail’ evidencing how thorough and committed you were in the recruitment process.

Where to recruit from

There’s many different strategies through which you can try and recruit participants, and generally I’d say ‘over do it’ rather than ‘under do it’. That is, given the challenges of finding participants, explore and identify a wider range of strategies than you may actually need, rather than cautiously and conservatively just choosing one or two.

A good starting point is to think where the participants you are looking for may be most likely to ‘congregate’. For instance, do they tend to frequent particular locations (for instance, hospital waiting rooms), or particular online sites (for instance, Reddit ‘subreddits’).

There are numerous places through which you can recruit participants. Some of the most commonly used are:

• Social media:

  • Facebook: personal pages, or on the many counselling/psychotherapy groups

  • Twitter: use @usernames to add it to the Twitter feeds of organisations like @BACP and @BPSOfficial, or #hashtags (for instance, #counselling)

  • LinkedIn (widely used by professionals)

  • WhatsApp groups

  • Reddit: again, think about groups (‘subreddits’) that may be specific to the topic you’re focusing on.

• Professional counselling associations (e.g., BACP, UKCP, BPS, BPS divisions): website notice boards, magazines, or research networks

• Service user groups, networks, and charities—both national and local—like MIND or Triumph Over Phobia (see listing here)

• Email contacts

• Websites: personal, university

• Blogs: for instance, write a blog about your planned research, or the background literature to it, for a relevant site; with a link if people are interested in following up

• Students: there may be a system, for instance, for psychology undergraduates to participate in research

• Conference attendees

• Physical notice boards (for instance, at universities or GP surgeries)—although, in my experience, they are not a particularly fruitful method of recruitment

• ‘Snowball sampling’: asking your participants to recommend further participants

• Online recruitment sites (‘mechanical Turks’), like Prolific, where you pay people to complete your survey (this is mainly for large scale, quantitative (and funded!) studies).

Don’t forget that, if your research is conducted digitally (e.g., video conferencing interviews or a web-based survey), you might want to consider recruiting internationally. For instance, if you were looking at the experiences of clients with a particular condition (say counselling for sight loss), you might want to approach service user groups in the US, Canada, and Australia, as well as in the UK (with, of course, the necessary ethical approval in place).

Personally, I’d nearly always suggest to avoid recruiting people you know, and particularly those you know well (and even more particularly your clients). There’s just too many opportunities for biases and demand characteristics to creep in. If they know your a priori assumptions, for instance, it may be very difficult for them to provide a contradictory view. Jasmine Childs-Fegredo adds:

You also need to consider what it may mean to recruit participants from a place you have worked.  For example, if you know the staff and some clients in an NHS service which you now want to recruit from, you will need to make sure you are aware of this ‘dual-role’ you have, and approach things with due sensitivity and considering the ethics around that.

Approaching prospective participants

Some general pointers when approaching people to participate in your research:

• Be friendly. If you’re cold, disinterested, or aloof you’re likely to immediately put people off. And bear in mind that some times you won’t know that you’re coming across in that way, even if you don’t mean too. If, like me, you have a ‘resting bitch face’, or tend to write quite curt emails, then think about ways of conveying a warmer and more welcoming invite.

• It’s nearly always better to personalise your approach: to individuals, to particular groups, to sectors of the population. Most of us hate getting very generic research invites that have obviously just gone out to hundreds of people. It’s immediately off-putting: What’s my incentive to take part if there are hundreds of others like me who can do the same? But if it’s a personalised email, tailored to me (e.g., ‘Dear Mick, given your position as a counselling psychology teacher….’) then I’m much more likely to respond. That, of course, makes the recruitment process more time consuming, but it’s generally worth the payoff: more prospective participants, and prospective participants who feel welcomed into the research, respected, and understood.

• Communicate your passion and excitement for your work, and for learning from your prospective participants. If they see it means something to you, it’s more likely to feel meaningful to them too.

• It generally a good idea to find ways in which prospective participants can express a very preliminary initial interest before making a more definitive commitment. (In psychology, this is known as the ‘foot in the door’ technique). So, for instance, you could invite people who may be interested to click on a hyperlink (for instance, to a Google Doc) where they can leave their email address to be contacted (make sure it is all GDPR compliant), or you could suggest that they email you for more information before making any commitment.

REcruitment materials

Recruitment materials are, essentially, the ‘adverts’ that you put out there to attract interest. And like any adverts, they have to be carefully thought through. A good place to start might be to reflect on the question (and discuss with peers), ‘What kind of research recruitment materials make me more likely to respond?’ For instance, is it where there’s a more personalised approach, or where it feels meaningful to your own life and concerns? And, importantly, also ask yourself, ‘What kind of research recruitment materials make me instantly hit “delete”?’ For instance, is it when you’re not clear what they’re asking you to do, or if it seems to go on and on with ever-finer details?

Some general pointers about recruitment materials:

• Proof them, proof them, proof them… and then get a few friends/colleagues to proof them, proof them, proof them. If your prospective participants are anything like me, they’ll be really put off by misspelt emails or slapdash flyers which seems to change font half way through. After all, if you can’t put enough care into getting your spelling right, what’s that going to say about how you’ll treat your participants? As emphasised throughout this blog, trust is everything!

• So try to get a balance between being friendly but professional. You don’t want to come across as too mechanistic or formal (it can feel intimidating), but too informal can also feel overly-casual and potentially unprofessional.

• Be sensitive: for instance, putting a research request on Twitter for people who have been ‘traumatised’ could trigger all sorts of responses in some people—many of whom may never actually get in contact with you.

• Don’t be pushy. You don’t want to put people under pressure to take part, or feel coerced in any way. So avoid headlines phrases like, ‘Please take part in my research,’ or ‘Participants needed,’ or ‘Would you like treatment for your anxiety?’

• Having said that, help participants see the potential benefits of taking part: to themselves, to the therapeutic field, to their wider communities. Remember, chances are they’re looking for reasons not to take part rather than reasons to; so you need to consider what the incentives might be and make those explicit. Of course, as above, you don’t want to be pushy, and you also need to be explicit about any potential risks. But, for instance, many participants can find it really rewarding talking about their experiences, and this is a possibility you can highlight in your information sheet. Also, for many participants, there can be a great deal of value and meaning in contributing to the development of improved mental health treatments and services for all. So if that is a potential impact of your study (and you’ve got a coherent strategy for achieving it) you can make that clear in your recruitment materials.

• Length of notices and other written materials is another challenge. Ethically, there’s a lot that you may want/have to say, but it can easily be overwhelming and off-putting for participants if it’s too much, too soon. One option is to disseminate, in the first place, just brief notices or flyers, that prospective participants can then follow up to find out more detailed information.

• Tailor your materials to the specific audiences. For instance, a notice on the professional network LinkedIn might have a more serious tone than a post on Twitter, and a face-to-face invite may be framed in a very different way.

• Be clear and concrete about what people should do next if they’re interested. Have your email address, for instance, in big and bold on the recruitment email, or a hyperlink for people to click on to sign up. Make it as easy as possible for potential participants to follow through. A good option here may be to have a website that people hyperlink to from social media platforms, that then has more information about the study and clear details of how to contact you. Generally, try to ensure that prospective participants can reach you through hyperlinking—if they have to copy your email/phone number down from a jpg, for instance, they may be a lot less likely to get in touch.

• And finally, don’t be weird. It’s an obvious thing to say, and ‘weird’ can mean many different things to different people, but if a prospective participants wants to feel assured that it’s safe to take part, it’s best to keep quirkiness in how you approach people, and what you put on your recruitment materials, to a minimum.

people who know people

Understandably, people may be less likely to respond to your research request if they don’t know who you are. So if you know someone who has contact with prospective participants, you may want to ask them if they can help you in the recruitment process. A research or clinical supervisor, for instance, might have a wide network of people they’d be willing to forward an email on to, or to post on their social media sites. There may also be specialists in the field that you’re looking at who’d be willing to support you by forwarding on recruitment invitations. You can always ask. And you can also add some information about yourself on recruitment sites so that you are less anonymous: even a photo and a brief biography can help prospective participants feel that there is a real and friendly person behind the recruitment process.

If you are wanting to recruit clients into your study, one way of reaching them is through counsellors and psychotherapists. This has to be done with extreme sensitive, though, and without in any way breaching confidentiality. For instance, it would be entirely unethical to ask therapists to pass on contact details of their clients to you so you could email them directly! You also need to make sure that the therapists’ clients are not feeling under any pressure to participate: deference effects means that clients may feel obliged to say ‘yes’ to their therapists, even if they don’t want to. One workable option may be to ask psychotherapists and counsellors to pass on a flyer to their clients giving them information about your study, and then the clients can contact you, in their own time, if they are interested.

Making contact with prospective participants through professional, training, or service delivery organisations is another way of reducing the anonymity of your request and enhancing its ‘legitimacy’. Here, for instance, a counselling service might forward on a request from you to their counsellors or clients; or else they might make the request as an organisation themselves (with you identified as the researcher). In general, recruiting through an organisation can create quite a ‘containing’ frame for research, and in some cases—quite rightly—is the only way in which you would be able to access particular populations (for instance, service users of a domestic violence organisation). If you can align your research with the specific wants and needs of an organisation—for instance, if it will provide evidence on their service effectiveness—they may be particularly keen to support you in it.

Finally, on this point re anonymity, prospective participants may be much more likely to respond to you if they can get a sense of you, as a person, rather than as an unknown name on a flyer. So, for instance, if you can go along and do a talk—even 5 mins—at a service user group, or chat to people over a conference poster, that might really help with response rates. As Jasmine emphasised earlier, people need to feel that you’re safe to open up to: someone known and familiar rather than alien and strange.

Be responsive

If a prospective participant gets in touch with you, respond. Don’t leave it sitting in your email inbox for weeks. It’s an obvious thing to reiterate, but it’s essential to treat prospective participants with courtesy and respect.

If it’s not working…

If your recruitment strategies aren’t working, don’t panic! Give it a bit of time and see what emerges. But if, after a few weeks, you’re still not getting any eligible volunteers, it might make sense to start looking at what adjustments you might want to make.

First issue, of course, is where the ‘blockage’ might be. For instance, is it that no one is making initial contact with you about your research; or is it that they are, but then not following up when you reply. That should give you some clues about where adjustments may be required.

If no one is showing any interest, it generally makes sense—at least initially—to stick with your participant group and look at additional, or alternative, strategies for recruitment. Are there particular networks, for instance, you can make contact with; or alternative social media sites? Here, you may need to balance the coherence and homogeneity that comes from having participants from just one source, against the greater recruitment possibilities that come from broadening things out. With this issue, there’s no right answers; but one thing I would say is to try and have a few from each if you can. For instance, three participants recruited through Facebook and six from snowball sampling can be fine, and you might even be able to say something about the differences between them. But eight from Facebook and one from snowballing leaves the latter a bit of an ‘odd man out.’ We don’t know if their responses are specific to them or to the strategy they were recruited through.

If widening your recruitment strategies still isn’t working, you may need to revisit your participant group and, with it, the specific question you’re looking at. For instance, if you’re exploring the psychotherapy experiences of Kenyan men, would expanding that to East African men, or men across all of Africa, make for a more viable recruitment process? Here, as above, you’re striving to strike a balance between having a scope that is broad enough for successful recruitment, but narrow enough to make your research project meaningful and coherent. Again, no right answers; but being open to adjusting your design, where necessary, can be a real advantage.

Use supervision

Remember to make use of support from your research supervisor(s). Jasmine Childs-Fegredo says:

Should you be experiencing issues with recruitment, it’s worth getting in contact with your supervisor(s) in the first instance, to talk through what you could do going forwards, and then report back to them as and when things start moving or if you need further support. Supervisors generally have the experience to nip things in the bud early on, and may have ideas you have not previously thought of. It’s best not to just leave things, and expect things to get better without some support. Supervisors are busy people and may not be able to see you immediately, but it’s always worth getting an advance meeting in the diary with them to discuss where you are in your recruitment strategy.

What does the research say?

In thinking through strategies for recruitment, it may also be very helpful to consult the research on what works and doesn’t work, says our former PsychD Course Convenor, Mark Donati. For instance, you can find papers like, ‘Factors influencing recruitment to research: qualitative study of the experiences and perceptions of research teams’, or how about this one: ‘Swiss chocolate and free beverages to increase the motivation for scientific work amongst residents: a prospective interventional study in a non-academic teaching hospital in Switzerland’! There may also be papers on recruitment for your particular participant group, for instance, ‘Overcoming barriers to recruiting ethnic minorities to mental health research: a typology of recruitment strategies’ and ‘Recruitment and retention of older minorities in mental health services research’. When you write up your research project, being able to report that you used research, itself, to direct your methodological choices can look very impressive.

In conclusion

Plan, be realistic, be proactive, and flexibly adjust if things aren’t working out…. That sounds like the recipe for a successful life, so no surprises that it also holds for successful research recruitment. And, of course, as Rosie and Jasmine emphasised, be sensitive, collaborative, and kind. Even if that doesn’t get you the most participants, it’s the ethical and right thing to do. Remember that you’re part of a wider research community, and successful enquiry, across the board, requires research participants to feel like they are valued participants in that process—not just ‘subjects’ that get discarded when the research is done. So approach prospective participants with a spirit of genuine openness and dialogue.

Mark thought I should end this blog on an upbeat note, and he’s absolutely right. Yes, it’s hard work; yes, it can be a struggle; but the sense of satisfaction, excitement, and sheer relief you can get from having all your data finally collected—and in a robust, ethical, and caring way—is second to none. So, if it’s seeming (or feeling right now), like an uphill struggle, keep your eye on that prize. With proactiveness, persistence, and creativity, you’ll get there for sure.

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Acknowledgements

Thanks to trainees and tutors on the PsychD Counselling Psychology Programme at the University of Roehampton for suggestions and advice. Photo: Maya, by Daniel Walford.

DISCLAIMER

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

Applying for a PhD in Counselling and Psychotherapy: Some Pointers

I’m sometimes asked about the process of applying for a PhD in counselling and psychotherapy and whether it’s worth doing, so I wanted to put together some pointers. Just to say, this blog is written from a personal perspective, for study within a UK context, and the focus is on research-based PhDs rather than professional doctorates. More on that distinction below.

Why should I want to do a PhD?

There’s probably a good chance that you shouldn’t. Yes, it’s pretty cool being able to write ‘Dr’ before your name when you fill in forms (at least for the first few times) but a PhD is nearly always a long, hard slog of 3 to 4 years or more (mine took about eight!): moments of insight, excitement, and achievement interspersed with long periods of boredom, frustration, and sheer hard work. Then there’s the emotional toil; and, like your original counselling or psychotherapy training, it can play havoc with your relationships. So don’t ask yourself whether you want to do a PhD when you’re feeling inspired, eager, and motivated. Ask yourself after a long, hard day’s work when all you want to do is pour yourself a glass of wine and flop down, mindlessly, in front of The Great British Bake Off. And, if you are going to try and do a PhD, make sure you really know why. I’d say that doing a PhD makes sense if you:

• Want to go into academia/teaching as a career.

• Want to go into research as a career (though there are very limited options here).

• Really, really love research and want to spend a long period of time immersed in it.

• Have a specific area of interest that you are really committed to making an original and significant contribution to.

I’m sure there are other reasons, but they need to be really good ones, and ones that are going to sustain you over the course of the programme. If your reason for applying is just that you’re not really sure what to do next, there’s a good chance that the hard slog of a PhD is not for you.

So what actually is a PhD in Counselling/Psychotherapy?

A PhD is generally a series of research studies, culminating in the writing of a dissertation (or ‘thesis’) of 80,000 words or so. Essentially, you’re writing a book, but one based on some systematic research process. Before you do anything else, have a look at some counselling or psychotherapy PhD theses to get a feel for what you’ll need to do: for instance, Adam Gibson’s Shared decision-making in counselling and psychotherapy (2019, University of Roehampton) or Katie McArthur’s Effectiveness, process and outcomes in school-based humanistic counselling (2013, University of Strathclyde).

A PhD programme doesn’t generally have a clinical component, and there’s often only a small amount of structured teaching—usually around research methods. Generally, the bulk of the work is self-study, alongside regular meetings with your supervisor(s) (perhaps 1-2 hours, once a month or so). PhDs can usually be undertaken on a full time basis (taking around 3 to 5 years) or part-time basis (4 to 6 years, and sometimes more).

A ‘PhD’ is generally a wholly research-based program of study, and is different from a ‘professional doctorate’, which tends to have a more clinical, professional, and/or reflective element (see, for example, the Metanoia Institute Doctorate in Psychotherapy by Professional Studies, or the University of Chester Doctor of Professional Studies in Counselling and Psychotherapy). These latter courses offer a more holistic programme of development for qualified counsellors or psychotherapists and often make more sense to undertake—unless your interest is solely on the research side of things.

A PhD is also very different from a doctorate in counselling psychology or clinical psychology, like our PsychD in Counselling Psychology at the University of Roehampton. These courses are for graduates in psychology and offer a full professional training from start to finish.

What should i focus on?

Generally, it’s good to start the process of exploring PhDs with some idea of what you want to look at (pointers on choosing a research topic can be found here). This doesn’t need to be fully formed—indeed, it’s important that you’re open to input from prospective supervisors—but having some sense of the field that you want to look at, the kinds of questions that you want to ask (and, perhaps, the method you might adopt) is important in being able to take things forward. So, for instance, you might want to look at something like, ‘Autistic children’s experiences of counselling,’ or ‘The role of empathy in psychotherapy with older adults,’ or ‘A phenomenological analysis of transference.’ Ideally, it’s good to write this up as maybe a page or so of ideas, so that it’s something you can send out to prospective supervisors to start a discussion about your ideas.

Should I approach potential supervisors?

Yes. You don’t have to, but I would generally suggest you find the leading academics in your subject area, or the particular method you’re wanting to adopt, and email them to find out if it’s something that they might, potentially, be interested in supervising. When you do that, it’s important to have some idea of what it is that you want to do; and the brief, one page sketch, as detailed above, is the kind of thing you can send them to let them know more. That’s the kind of thing that works for me if someone approaches me in this regard: if it’s very vague and open (‘I’m thinking of doing a PhD, sort of, maybe, what do you think?’) it can be a bit frustrating; if someone sends through screeds and screeds of an extremely detailed proposal, it can feel a bit overwhelming and like there’s not much flexibility there (but better the latter than the former).

Bear in mind that, generally, academics will only take on a small number of PhD students, so for them to want to work with you it has to be very much in their subject area. For instance, I’d be interested in PhD proposals on subjects like relational depth, or humanistic counselling in schools, or existential therapy; but if someone approached me with a PhD proposal for Transactional Analysis, even if I might think it was a great idea, I wouldn’t feel able to take it on. If you approach someone, though, you can always ask them to let you know other potential supervisors who might be more appropriate.

Can I Apply Directly to a University?

Yes, you can do it that way too. For instance, you could directly apply to the University of Roehampton here. (In fact, even if you have spoken to an academic who’s expressed interest in working with you, you would still need to formally apply through such channels.) If you’ve got a strong PhD application a university will probably give it close consideration whether or not they’ve got a specialist in the specific area. However, the advantage of approaching an academic first is it gives you some time to refine your proposal in line with what they may see as the key, or best, questions in that area. Often, there’s an iterative process of some initial informal discussion with an academic, maybe a refining of the research question, then a formal application—after which, of course, there’s further refinement and development of the research plan.

Where should I apply to?

There’s lot of different universities where you can do PhDs on counselling and psychotherapy topics. Sometimes that will be in a department of psychology, sometimes within a particular counselling or psychotherapy unit. Sometimes as part of an educational degree. In theory, pretty much any university should allow you to apply there for a PhD in the counselling and psychotherapy field.

Given that research meetings often aren’t that frequent, and can often be conducted online, geographical proximity needn’t be a major consideration. For instance, I’ve worked well with PhD students at the other end of the UK, as well as in mainland Europe. PhD programmes that have some taught elements will require some face-to-face attendance though. Also, at least a little face to face meetings with a supervisor—even if it’s only once a year or so—is generally a good idea (excepting COVID-19!).

So I’d tend to say apply to a university based on where the best supervisor(s) is going to be. That is, someone who knows the areas (or methods) you’re interested in and has published in it, has shown interest and motivation if you’ve approached them, and feels able to support you in your research programme. One thing you really don’t want is to end up with a supervisor allocated to you who feels that they’re having to take you on. That’s rare: but being proactive in identifying the right supervisor, liaising with them, and then applying to the respective university is generally the best way of ensuring you’ll get the support you need.

Also, there may be advantages in applying to a university which has a group of students doing PhDs in related areas, so that you have a community around you to discuss your work with, learn from others, and get support. That’s something you can find out from the academics there, or ask on interview. If the university has an active culture of psychotherapy and counselling research, that’s also probable good sign. Do they have a research centre in this area, for instance (like our CREST Research Centre at the University of Roehampton), or seminars, or do academics and students from this university regularly attend conferences like the annual BACP Research Conference? Having that active, engaged community around you may be really important in sustaining your interest and motivation over the course of the programme. You really don’t want to do this all on your own.

What qualifications do I need?

In most instances, the main thing to show is that you have experience of research, ideally in the counselling and psychotherapy field. So a Master’s in the area (for instance, an MSc in Research Methods) would be ideal, or a Master’s in counselling or psychotherapy which involved some significant research component. If you don’t have that, then experience of research in the workplace could count: for instance, if you have been working for several years in an evaluation capacity. Demonstrating motivation and interest in research, as well as a viable research proposal, is also very important. For the institution and supervisors, taking on a PhD student is a big commitment, so they really need to feel that you will be in it for the full long haul.

who’s going to pay me to do it?

Probably yourself. Unfortunately, there’s very little funding available for PhDs in the counselling and psychotherapy field, and most students do pay for it themselves. There are some exceptions—for instance, universities may have scholarships that they award on an intermittent basis, and there are grant funding bodies like the ESRC—but it’s generally extremely competitive and if you go down these routes you may have to do your PhD about a particular topic that the institution is interested in.

What happens once I’ve applied?

The academics at the university you’ve applied to will consider your application, in the light of the kinds of criteria discussed above, and may well invite you for interview to discuss your application further. If you’re accepted, you can then get going with refining your research project, and preparing to run your study.

In conclusion

I wouldn’t want to put anyone off applying for a PhD in counselling or psychotherapy. It’s got the potential to be an amazing journey: with discovery, in depth engagement with your topic, and the opportunity to make a unique contribution to the counselling and psychotherapy field. Relationally, too, it can be a unique opportunity to engage with peers, academics, and participants. You become a world-leading expert in your field; and if you want to go into academia or a research job, it’s pretty much essential. But it is a massive commitment, and you really need to be realistic about what you are letting yourself in for before you embark on it. As a PhD student recently said to me:

The ideal position to do a PhD is one where you know the route is hard, less than ideal, uncertain, but it is also the necessary route.

Very best of luck with it.

Further Reading

Hayton, J. (2015) PhD: An uncommon guide to research, writing and PhD life. James Hayton PhD. Suggested by a PhD student as very realistic and enjoyable.

Acknowledgement

Thanks for the guidance from current and former PhD students on the content here.

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Disclaimer

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

Just to add, no liability will attach to the University of Roehampton as a result of the training and consultancy work presented on this website, which I am carrying out in a private capacity.

Online Counselling: A Review of Two Brief CPD Training Courses

With COVID-19 and social distancing, online counselling has become much more of a consideration for counsellors and psychotherapists—and sometimes a necessity. Fortunately, quite soon into the pandemic, professionals in this field made freely available (or at low cost) CPD programmes to support therapists working in this modality. This blog gives a brief review of two of the main provisions now available for therapists in the UK. Just to say, it is an entirely personal review of the programmes, and based on a ‘looking over’ rather than a full and in-depth engagement with either.

Three important things to note. First, both programmes indicate that they are for qualified therapists rather than those in training. Second, they are also for therapists transferring their work with clients online, rather than commencing with new clients in online therapy. Third, both make it clear that they are not offering a full or qualified online therapy training (some suggestions for that are at the bottom of this blog).

How to do Counselling Online: A Coronavirus Primer

This programme was jointly developed by The Open University (OU) and the BACP as a response to the coronavirus (COVID-19) pandemic. It was written by Naomi Moller and Andreas Vossler who, for me, are amongst the most trustworthy and informed voices in the counselling field in the UK (both academics at the OU).

The programme is estimated to take six hours of study, and you can gain a ‘digital badge’ and ‘statement of participation’ on completion.

On the positive side, the programme gives some clear, useful, and evidence-based tips on the different forms of online therapy. It’s experiential as well as didactic, with lots of quizzes, exercises, and space for open reflection. I found it, in general, put together in a very professional way. A number of transcripts of online counselling are provided to concretely ground what is being presented. I found it generally quite helpful and learnt from it, both around practical areas like GDPR consideration and skills, like the online disinhibition effect. There’s a wide range of useful resources that it links to, like online client information sheets. Feedback I’m seeing suggests that many counsellors have found it very helpful as a basic introduction to the area.

Some of the issues I had with it, a number of which are generic to online training:

• I found the registration quite challenging, which wasn’t a great start, and ended up somewhere on the OU site trying to register for their university. In the end it was very simple but I did get lost along the way.

• Some of the open-ended reflective activities, to me, felt a bit ‘empty’, in that I wasn’t really sure what to say or what was being asked, and ended up completing them with just a few lines. From what I could work out also, there also wasn’t any way of downloading what I had written (I was expecting to be presented with it all at the end, and wasn’t), so my reflections all seemed lost in cyberspace somewhere.

• With the quizzes, some of the answers seemed a bit simplistic or random, and I wasn’t entirely sure that the ‘right’ ones were right. Having said that, I remember, when working on the Counselling MindEd e-learning programme that there were similar challenges, so this is not an easy one to get right.

• If someone wanted to, they could zip through the programme pretty quickly. There’s no way of telling how long someone’s been on it, and it’s pretty easy to ‘game’ the answers on a number of the quizzes and exercises. So there’s the possibility of people saying that they’ve completed it and getting the certificate without having really engaged, though there is a quiz at the end which does require some engagement with the course to successfully complete.
  

COVID-19 Telehealth course

This programme was developed by Kate Anthony, probably the foremost figure in the online therapy field in the UK for many years, and colleagues in the Online Therapy Institute. It’s indicated as 8 hours CPD. The programme can be freely undertaken (and they indicate that students, volunteers and unwaged do not need to pay); but otherwise it requests a contribution from users: up to £110 for full time/waged, and £10-25 for part time/low waged. Whereas the BACP/OU programme focuses on a range of non-face-to-face counselling methods (e.g., text-based asynchronous counselling, phone counselling) the focus of this programme is primarily on video conferencing-based therapy. 

The strengths of this programme is that it gives very clear and helpful guidance on a range of contractual, ethical, and practical issues when working online rather than face-to-face. It’s all very directly applicable to therapeutic work. There’s a specific section on working with children and young people, which is great to see.

Some of the issues I had with it, though:

• The programme is very text based/didactic, with long screens of writing: to a great extent, it felt more like reading a book than engaging with a mulitmodal, interactive online programme. Compared with the OU/BACP programme, there are only a small number of reflective exercises and limited case examples—though there is an extended video discussing online work with young people.

• Again, there’s no way to record how long someone has been on the programme, and here there’s no test at the end to assess engagement.

• In a few instances, some of the content seemed to be dated, or badly laid out, and some of it seemed a bit confusing.

Conclusion

It’s fantastic that both the Online Therapy Training Institute, and the BACP/OU team, have been so generous in making these programmes available. Both give essential information for qualified counsellors who are moving work with clients online. If you have had to do so, and you haven’t engaged with one of these programmes yet, I would definitely suggest you do. There’s a wealth of information on both programmes that can help to ensure ethical, effective, and informed online practice. Between the two programmes, if you like something more interactive (and don’t mind some of the over-simplification that that can involve), and if you are working online in ways other than video conferencing, then the BACP/OU programme may be more suitable. But if you prefer text-based learning, and particularly if you are moving to video conferencing rather than other forms of digital contact, then the Online Therapy Institute course may be more suited.

There are a number of more extended courses for a comprehensive training in online therapy. Ones that I am aware of are:

• Counselling Tutor’s Online and Telephone Counselling Course: 80 hours, and I’m receiving lots of incredibly positive feedback from people who have done it;

• Online Therapy Institute’s Certified Cyber Therapist Training;

• The Academy for Online Counselling and Psychotherapy’s Diploma in Online Counselling and Psychotherapy;

• Online Training for Counsellors’ Diploma in E-Counselling Theory and Practice.

You can find out about these and other training programmes at the website of the Association for Counselling and Therapy Online (ACTO). Needless to say, I am just listing the programmes above and am not endorsing them in any way. Having said that, I’d love to know what other people think of these programmes, or other one that might be out there that support this move from face-to-face to online. Do write in the comments below.

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[Image: Vector Background CC BY (https://creativecommons.org/licenses/by/3.0)]

'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]

SMART Goals for Counselling and Psychotherapy? Try HEALING CRISPS

It’s often stated that people should aim for SMART goals (Specific, Measurable, Assignable, Realistic, and Time-related). However, most of the research and theory for this comes from the field of profit and productivity maximisation. So while SMART goes might help people to hit performance targets, they’re not necessarily the ones that are going to maximise wellbeing and help clients overcome psychological distress. A person, for instance, might achieve a SMART goal of increasing their earnings by £5,000 within a year but, as the research shows, such ‘extrinsic’ goal achievement is not actually associated with greater happiness. 

So what kind of goals might clients be encouraged to consider if goals are going to be used in the counselling and psychotherapy work (and research suggests that most clients do like having goals). This is a question that I asked in my new book, Integrating counselling and psychotherapy: Directionality, synergy, and social justice (Sage, 2019) and will be explored in a one-day CPD workshop on ‘Working with Goals in Counselling and Psychotherapy’ on Sunday 5th July. It’s also a question I would have loved to come up with a brilliant new acronym for. Unfortunately, after many hours on acronym generator programmes, the best I could come up with was ‘HEALS CRISPS’: that clients’ goals should be: Higher-order, Effective, Approach, Longer-term, Synergetic, Challenging, Realistic, Intrinsic, Small steps, Process-focused, and Specific. Sorry!

‘Higher-order’

Generally, clients should be encouraged to identify goals that relate to those things that are most, fundamentally, important to them: for instance, relatedness, self-worth, or safety. As discussed below, goals also need to be relatively specific and realistic, but ensuring that they link up to something of ‘higher-order’ value is essential in making them meaningful to the client.

Effective

A client’s goals need to be credible ways of actualising their highest-order wants and needs, rather than random strategies; so it may be important to reflect with clients on how, and whether, their goals are really going to help them get to where they want to be. If a client, for instance, says that their goal is to lose weight, because they wants to be happier, some discussion might be needed about whether this is actually going to get them there.

Approach

Research suggests that it is better for clients to be oriented towards positive, promotion goals (for instance, ‘Increase my social networks’), rather than negative, prevention goals (for instance, ‘Stop feeling so alone’). The latter may be particularly problematic if all of a client’s goals are avoidant rather than approach: essentially, this means that they are asking the therapist to help them ‘go nowhere’. For Elliot and Church, therapists should be ‘discussing the ineffective and potentially problematic nature of avoidance goals [with clients], and working to reframe these goals in terms of approaching positive possibilities’. Similarly, where clients want to reduce ‘unhealthy negative emotions’, such as anxiety, it may be helpful to refocus them on increasing ‘healthy positive emotions’, such as concern.

Longer-term

Many psychological difficulties may relate to the prioritisation of very short-term goals over medium or longer-term ones. It may be helpful, therefore, to encourage clients to look towards longer-term objectives, as well as short- and medium-term plans, so that there is a focus beyond immediate obstacles or rewards. At the same time, however, clients’ goals need to be realistically attainable (see below). Again, then, it may be important that clients strive for goal balance, where they are pursuing a range of short, medium, and long term goals. 

Synergetic

Goals should be supportive of other therapeutic goals or, at least, not in conflict with them (for instance, ‘I want more time on my own,’ when the client has already stated ‘I want to be closer to my partner’). Therapists should be particularly mindful of ‘rogue goals’: where the client’s stated objective seems to run against many other wants in their lives. An example of this might be a client who wants to get fitter; but where time spent at the gym is damaging their family, relational, and work life. Generally, clients should strive for goal balance, where they are pursuing a broad number of goals, through a range of strategies, rather than being too focused in any one area.

Challenging

While clients seem to benefit from realistic, small steps; therapists should also bear in mind the psychological research that difficult goals tend to lead to greater overall progress. A client whose goal, for instance, is to cut down to six units of alcohol a day might be encouraged to consider whether two units might be a better objective. For Ford (1992), this is the ‘optimal challenge principle’: working with clients to set goals that are difficult but still attainable.

Realistic

Clients’ goals need to be achievable within the therapeutic time frame. Goals that are based on unrealistically high expectations should be challenged, especially when these are expectations of feelings or other ‘metagoals’ that may fuel vicious cycles (for instance, ‘I want to feel calm all the time’). Equally, therapists should challenge goals that are unrealistic because they are dependent on others, or the world, doing something (for instance, ‘I want my girlfriend to stop criticising me all the time’). These should be reframed in terms of what the client, themselves, can do (e.g., ‘I want to feel confident to challenge my girlfriend when she criticises me’). Therapists should also be mindful of the number of goals that clients are setting: are there too many to be realistically achieved (or too few to be sufficiently challenging)? If, as the work proceeds, it becomes apparent that clients’ goals are unattainable, it may be important to support them in the process of disengaging. 

Intrinsic

Closely related to the above, clients’ goals should be directly related to their own, personal higher-order desires and values—such as connectedness, autonomy, or self-worth—rather than contingent on the attitudes or actions of others (‘extrinsic goals’). Clients who are oriented towards such ‘intrinsic’ goals are likely to be more committed to those goals, take greater ownership of them, and experience them as more appealing.

‘Small steps’

Although, ultimately, clients should be aiming towards higher-order, longer-term goals; in many cases, the importance of being realistic means that it may be most therapeutically beneficial to set smaller subgoals with clients. These are objectives that they can succeed in, one step at a time. This process, also referred to as ‘goal stepping’ or ‘goal laddering’, can help boost clients’ self-efficacy and hence their ability to achieve subsequent goals, in a virtuous cycle. For instance, if a client wants to develop relatedness in their life, an initial goal might be to join a club, followed by a goal of forming a friendship, followed by a goal of sharing more personal narratives. Research suggests that this process of breaking down superordinate goals into more manageable tasks is experienced by clients as helpful: facilitating both a sense of achievement and relieving pressure. Given such perspectives, Ford (1992) suggests that the best approach to goal setting may be to have a, ‘strategic emphasis on attainable short-term goals combined with a periodic review of the long-term goals that gives meaning and organization to one’s short-term pursuits’ (p. 99). 

Process-focused

Goals that extend over time (for instance, ‘enjoy my final year at college’) rather than a single endpoint (for instance, ‘get a good final grade’) may support a more ongoing sense of wellbeing and be less pressurised.  As Miller et al. (1960), for instance, write:

successful living is not a “well-defined problem,” and attempts to convert it into a well-defined problem by selecting explicit goals and subgoals can be an empty deception.... it is better to plan towards a kind of continual “becoming” than towards a final goal.  The problem is to sustain life, to formulate enduring Plans, not to terminate living and planning as if they were task that had to be finished. (p. 114)

Specific

Goals that are specific: clearly-defined, concrete, verifiable/measurable, and simple (e.g., ‘Talk back to my bully at work’); may be preferable to goals which are vague, abstract, and complex (e.g., ‘Be assertive’).  In part, this might be because they are easier to monitor.  However, the specificity of goals needs to be weighed against their relative order (see above).  Also, goals that are too specific may lack flexibility, and make it difficult for the client to revise their goals to a more meaningful, or realistic, objective.

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In day-to-day counselling practice, it is not easy to remember all these characteristics. But perhaps the three standout ones are approach, intrinsic, and small steps: helping clients establish goals that are positive strivings, towards things that they really want, and that are manageable within a relatively well-defined time frame. A lot of this is about fostering the hope-generating element of goal-oriented practices: where goals work (and not all clients want, or benefit from, goals), it is often because they can help clients feel more about positive about where they are going—and their possibility of getting there.

[Adapted from Cooper, M. (2019). Integrating counselling and psychotherapy: Directionality, synergy, and social change. London: Sage. Image by Marco Verch (CC BY 2.0)]

A Chinese translation of this blog is available here

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What is Evil? A Directional Perspective

I had an email recently asking me what I thought about ‘evil’.

It’s hard not to see evil at the moment. The violence of police officers against people of colour. Members of the ‘English Defense League’ defending racism and racists. I wrote a Facebook post about the sheer stupidity of the EDL fighting for English rights but at the same time pissing on a statue of a defender of English democracy but then took it down. Just too negative and angry.

Maya, my 20 year old daughter, and I watched Othello last night (a brilliant 2013 production by the National Theatre). Partly just that we’re working our way through Shakespeare. Partly it seemed relevant to everything going on. Iago is one of Shakespeare’s greatest sh*tbags — maybe one of the greatest in all of literature. It’s almost too painful to watch as he manipulates Desdemona, Othello, and everyone around him to destruction. Othello, too, an appallingly vicious act of domestic violence.

Evil everywhere. And yet, just calling it ‘evil’ doesn’t seem to do much to address it, or change it. Or make things different. And it creates the kind of splitting that seems to just keep an unbridgeable gulf between ‘us’ and ‘them’. In an era of #BLM how do I, for instance, as a White person, address my own racism if it’s something ‘out there’? And where does this evil come from? Do we just look at the man urinating over PC Keith Palmer’s memorial and see it as some deliberate act of viciousness? Is it a choice? Or is it the expression of some innate, inborn tendency to evil? If the latter, then that would seem to go against everything that, as a therapist, I’ve learnt to believe: about the need to understand people and make sense of their lives and actions in their own personal context.

Iago, perhaps quite uniquely, talks his thoughts. He takes the audience through all the machinations and the reasons why he’s doing what he does. Iago (brilliantly portrayed by Rory Kinnear in the NT production as the kind of man not a million miles from the EDL), hates Othello for all that Othello has achieved. He feels belittle by him — by his very existence. And he fears, without any justification, that Othello has slept with his wife. And then there’s the underlying streams of racism that fuel his hatred: that a man, but not just any man but a black man, could be his superior.

There’s no sympathy watching Iago, and there’s no taking away from the horrors of what he brings down, but there is understanding. There’s reasons for why he’s doing what he’s doing; and, ultimately, I want to say that those reasons are reasons that, to some extent, we all share. That, and to be absolutely absolutely clear, doesn’t justify in any way what he does, but it might help us understand it and ultimately tackle and change it.

In my latest book on directionality and social change, I talk about the idea that we are all directional: meaning that, as human beings, we are fundamentally purpose-oriented beings: striving towards particular wants, needs, and goals. And that, across all of us, there are certain wants and needs that seem to be ‘highest order’: that is, that we all, in different ways, seem to be striving for. Certainly there will be individual and cultural variations, but different psychological theories — from Maslow to the behaviourists — have identified such needs as pleasure, growth, self-worth, relatedness, freedom, meaning, and psychological and physical safety. Everything we do, from this perspective, is a means towards these ends.

From this perspective, there’s nothing here in these highest order ‘directions’ that is, in themselves, intrinsically evil. No one, ultimately, strives to be bad. But how people act towards these ends can be very destructive of others. Iago seems to be striving, ultimately, to maintain some semblance of self-worth. In itself, it’s something many of us share; but what he does to get himself there takes his down a path that destroys many others. The evil then, from this perspective, is not intrinsic or inherent to Iago, but in how he chooses to actualise his most fundamental desires.

Why does he do it that way? One of the things that I talk about in my book is the idea of rogue goals. These are directions that take over the person to the exclusion of the rest of the system. Iago gets overtaken by his desire for revenge, and anything else that might do him good in his life gets sidelined by it. it’s an obsessiveness. Othello even more. When he kills Desdemona, he is so caught up in a jealously about her — a desire too, perhaps, for self-worth — that he cannot see anything further into his desire for relatedness or care or compassion. He’s taken over to the detriment of himself — let alone to Desdemona and their community. And, at an interpersonal level too, Iago’s desire for revenge becomes ‘rogue’: it takes over the whole interpersonal system in a way that is to the detriment of everything and everyone around it. That, in a way, is what we mean by evil: that a person acts towards their own highest-order directions in a way that savages across the needs and wants of others. As in racism, or homophobia, or other forms of bullying: one person, or one small group, allows their needs and wants to dominate to the exclusion of the whole. And when they have the power to enforce that, it becomes a systematic and endemic form of abuse.

Human beings may not be born with a tendency towards evil, but I do think we are born with a tendency towards narrowing of focus. To become oriented towards specific goals without being able to keep the wider whole in mind. John Bargh, one of the leading researchers on unconscious goals, writes about the way that, while we think ‘we’ have ‘goals’, it’s actually goals that have us. We are the vessels through which multiple goals act: and bringing those goals into some kind of coherent whole — whether within people or between people — requires a conscious effort. Otherwise, there is fragmentation and dis-coordination… and evil. Evil is where things act apart from, and against, the wider whole. I was talking to my 12 year old son, Zac, about this during the recent #BLM march. He asked why people could be racist and we were talking about the research that the difference between prejudiced and non-prejudiced people is not in their initial thoughts: we all, to some extent, have stereotypes, prejudices, and biases which pop up in response to certain groups. But the difference is non-prejudiced people then put those to one side and go on to act in equitable and non-discriminatory ways. It’s an effort not just to go rogue: not to let our thoughts and actions go down whatever prejudiced road they like.

When people talk about the stupidity of evil, then, in many ways I think it is. It’s a laziness in thinking that follows fragmented, unprocessed thoughts rather than staying with the complex whole. Urinating on a memorial of a man who protected British freedom while claiming to fight for British freedom: that’s the kind of un-joined up illiteracy that, perhaps, is at the heart of evil.

But it’s more than that, of course. Iago is brilliantly clever. So why is Iago ‘evil’ and not others? Why doesn’t he join himself up, and join himself to others, in a way that so many other people do. A deeper need or a deeper wound than most, perhaps. And a socialisation that leads him to believe that his means are acceptable to those ends. Not learning the values of fairness and equality as highest-order goals, in themselves. Perhaps, alongside self-worth and relatedness and freedom there are highest-order, value-based ends for democracy and equality that we need to learn: and that, without those ends, it is all too easy to fall into fragmentation. And choice? It’s an interesting question of where choice comes in and whether, amidst all of this, there is also a person choosing not to act towards the interests and concerns others. Yes, I do absolutely think there is a choosing being — not just a determined mechanism — acting towards these ends. But a choice ‘to be evil’? In my experience, it’s very rare choose deliberately towards this end, in itself.

Many years ago, in fact on my first counselling training, I wrote an essay about the difference between intent and effect, and I think that is so important to hang on to. Iago, Othello… racists in our society, the effects of their behaviour is incredibly, incredibly destructive on the lives of our black communities and also on so many other aspects of societies. It’s a privileging of one very small element at the expense of so many. And yet, to infer from that effect a particular intent isn’t, I think, that helpful. The reality is, people can behave in ways that are very destructive for reasons that, ultimately, may be fairly ‘normal’: and I am suggesting here that the massively destructive acts of racists, ultimately, come back to the same human needs as the rest of us: self-worth, freedom, probably even relatedness and community. That doesn’t make it right. That absolutely, absolutely doesn’t make it right — just as we can’t infer intent from effect, we also can’t say that because someone did something for intelligible reasons it couldn’t have been harmful — but it does mean that we can see the humanity behind the destructiveness.

Why should we want to do so? Why not just denounce these acts? Because, I think, we can denounce but also understand; and doing that, rather than just denouncing, gives us greater leverage to be able to change it and create a more tolerant and equitable society. If we understand, for instance, that at the root of Iago’s behaviour is a desire for self-worth we can think about how we bring up children in our society to ensure they feel of value. If we understand, in it, an inability to see the whole, then we can think about how we help children develop more holistic, comprehensive thinking: ways of being able to empathise and reach out into other minds and feeling. None of this means we shouldn’t be going out and marching and defending, actively and vigorously, the rights of all our communities: but it does mean that we can also work at more psychological levels to accelerate the pace towards a juster and fairer world.

Relational Depth at a Time of Coronavirus

It is one of the strangest and most unnerving times in our history. We are at the peak of the coronavirus crisis: locked away in our homes, terrorised by a microscopic parasite that destroys lives indiscriminately. We are watching as many of our most treasured social practices—going to work, eating at a restaurant, seeing friends—have been taken away. People are dying.

And yet, relationally, there is much that we might learn from the coronavirus crisis.

First, that we are all so much more connected than we thought. Practices at a wet food market in Wuhan bring London to a standstill; death rates in Italy determine social policies across Europe. We are not isolated, separate communities (however much BREXIT tried to make us be) but intimately tied together as communities and peoples around the world. A sneeze in one country, literally, triggers a tornado of fear and grieving in another. Human interconnectedness, then, is not something we create, but something we are. It is our natural state: to live in this web of human relationships.

Second, that we need social connection. As people become more and more physically isolated, so they find new and innovative means of connecting with others. The evening ‘Zine’ has become popular: a Zoom webchat accompanied by a glass (or two) of wine. A few night ago, I spoke to my eldest sister who I haven’t talked to, properly, for several years. I’ve learnt the name of my neighbour’s dog (‘Zorro’). We stand outside at 8pm each Thursday to the clang of cheering and banging pans to show appreciation for our NHS. The human being, pushed inwards, forces outwards: to new connections, new possibilities, new relationship and ways of relating.

Third, that, at heart, we are not destructive or antisocial beings, but deeply compassionate and caring. Faced with this threat, human beings—almost exclusively—have not turned against each other, but towards each other: with kindness, neighbourliness, and love. The heroism of health staff: working on the frontlines to battle the virus, all the time knowing their own vulnerability to infection. In the UK, we have seen millions of people sign up as volunteers to help and care for others.

The concept of relational depth is intimately tied to each of these three premises. It starts from the assumption that, as human beings, our natural home is with each other. That we do not come into the world as separate, independent organism, but rather as nodes in a complex network of social and community relationships. Here, at the heart of our being, is love: a reaching out and tying in to the other. A need for the other. A being-togetherness that extends and transcends our individual identity.

Yet that deep human need for connectedness can be thwarted. We fall outside of relationships, of community, and become cut off from the love that is needed to feed our bones and our soul. We become, as the great Jewish philosopher Martin Buber puts it, ‘individuals’ rather than ‘persons’. This is the state that many of our clients come to us in. Maybe not explicitly. And certainly not entirely. But for lots of our clients—whether depressed, anxious, or hopeless—it is a cut-offness from others that is at the heart of their difficulties. That does not mean that they are alone and without others. It means that their heart is no longer able to reach out to the hearts of others. Their truth lies inside only. The bonds of human connectedness and embeddedness have become torn away.

Relational depth is a form of human engagement with the capacity to repair those bonds (see the most recent edition of Dave and my book, Working at relational depth in counselling and psychotherapy, Sage 2018). It is not something that counsellors and psychotherapists can, or should, strive for; but it is a state of relating that therapists can open themselves up to. And, in doing so, they can create a space in which clients can both reach out to others and reach in to their own deepest truths. Relational depth is a being-with-self while being-with-others: it is a state in which someone, in their deepest, most authentic being, is in touch with another authentic being. It is, as the research shows, a profoundly healing experiences: and one that can touch clients’ lives for many years to come.

Healthcare systems across the developed world have moved towards the prioritization of cognitive behaviour therapy (CBT) and other psychological approaches that can be delivered in brief, easily measurable packages. Certainly, these therapies can be of great value to many clients. Yet we must never forget the deep human connectedness that is at the heart of so much healing. There is another approach to mechanized and technique-centred interventions which is based on a relational reaching out to clients, and calling them back into connection and community. During the current coronavirus crisis, it is certainly true that people are turning toward technology to address their difficulties (Zoom has never been so popular, and I love it dearly!), but these tools are only a means and not an end. No-one wants technology for technology’s sake: we use it to reach out, to connect, to be back in relationship with others. Similarly, whilst technologies and manualized practices may be useful in psychotherapy, it is often—as the evidence shows—the relatedness running through them, between therapist and client, that is the true agent of healing and change. Buber said that we cannot spend all our lives in ‘I-Thou’ relatedness to others; but if we have none of it at all, if we only live in the world of the ‘I-It’, we will suffer. Developing our capacity, as counsellors and psychotherapists, to relate at depth means that each of our clients, however isolated and cut off they are in their hearts, have the possibility of reaching back into connectedness: to be back, once again, in the loving holding of community. Whatever skills, practices, and manualized practices we have acquired and can deliver, it is this offering of relational depth to our clients that may be of most therapeutic value.

[Image: CC2.0 by DFID - UK Department for International Development at https://www.flickr.com/photos/14214150@N02/15455192817. Thanks to Dr Yukishigie Nakata to reprint the above from the Preface to the Japanese translation of Working at relational depth]

[Spanish translation of this blog post]

How to Record a Lecture in Powerpoint

With the sudden urgent need to deliver non-face-to-face teaching due to the coronavirus crisis, it’s an opportunity to learn how to develop online teaching resources. Developing a Powerpoint lecture, with audio, is actually incredibly simple (see my first video here). Below is how I did it. What you’ll need for this is a web camera, or something plugged in to your computer to record audio; and then a YouTube (or other video platform) account (see Step 13).

1. Open the Powerpoint slideset you want to turn into a video.

2. Go to the ‘Slide Show’ tab.

3. Click on ‘Record Slide Show’, then ‘Start Recording from beginning’.

4. Click on ‘Start Recording’…

5. …And there you go. Talk through your presentation as you would to a group of students, moving through the slides as you go. You can pause recording if you want—there’s a little box that comes up to click on.

6. Woah… Actually, maybe before you do the whole thing, just do one or two slides to make sure it’s all working. You use the ‘Esc’ button to get out of it. Then click on ‘From Beginning’ in the Slide Show menu to check that what you’re doing is all OK (if you can’t hear any audio, check your speakers are on. If they are, and you can’t hear audio when you play the presentation, you may need to fix your recording device). And assuming all OK, off you go again (from the start).

7. One thing I learnt is that you should give a little bit of time before you end talking on a slide, then go on to the next slide, then give a little time, then start talking again. Otherwise, if you talk too close to moving between slides, your audio seems to get a bit cut off.

8. When you’ve finished your talk, click on the ‘Esc’ button on your keyboard. You’ll now see that there is a little speaker sign in the bottom corner of each of your slides. So the software has recorded your talk per slide. If you click on it, you can hear the audio for that slide (and re-record it if you want).

9. Now go to the ‘File’ menu, click on ‘Export’, then ‘Create a Video’. The default settings there seem to be fine so you can then just click on ‘Create Video’.

10. It will ask you where you want to Save the video. Just put it somewhere you can remember, like in the folder where your talk is. Saving it in the default MPEG-4 format seems fine.

11. The next stage may take some time, maybe 20 minutes or so, so get yourself a cup of tea and sit back, relax, read BBC News online.

12. Now you’ve got your video in the folder you saved it in. Fab. You might want to click on it just to make sure it’s all OK.

13. Now’s the slightly trickier bit, if you don’t have a YouTube channel or other place to upload your video. YouTube, I think, is easiest, though bear in mind that it will be publicly available (and therefore not appropriate for confidential material). So what you need to do is to set up a YouTube channel, and you can do that by going to https://www.youtube.com/ and then using your Google Account (and set one of those up if you don’t have one)

14. Once you’ve got a YouTube account, you just click on the camera sign in the top right hand corner to ‘create a video or post’. Then you click on ‘upload video’, access your file, and it’ll be uploaded to YouTube. Again, this step might take a few minutes so another cup of tea (try a mix of Assam, Darjeeling, and Lapsang Souchong… gorgeous).

15. Then it’s there, and you’ve got a YouTube video. Just click on the address now and you can send it to your students, or embed the video in Moodle or other learning platform.

Probably the only downside I can see to doing videos this way, aside from confidentiality issues (but at Step 13 you can always upload the video to somewhere secure) is that students don’t get to see you talking. They just see the slides. So it’s a bit impersonal and probably less interesting than it could be if they were seeing you. There’s certainly other software out there that can do that, like Panopto. But if you’re used to Powerpoint, and want to do something relatively straightforward, the steps above seem ideal to create an online learning resource that students can access as part of non-face-to-face learning. It might be a substitute for a lecture or, even better, you could ask students to watch the video, then discuss it with them (for instance, via Zoom video conferencing, or Skype).

Good luck with it. Let me know if there’s anything here I should add or change.

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]

So you Want to be a 'Pluralistic Therapist'...

Say you’re applying for accreditation to a counselling or psychotherapy body (like the British Association for Counselling and Psychotherapy) or writing an essay on your model of therapy, and want to say that you’re ‘pluralistic’. What are the things that could help you put together a compelling and coherent case?

1. Be clear about the methods and ideas that your pluralistic work is based on. Pluralism is like the bread in a sandwich. It’s the framework within which you practice is based. But what’s the filling? Do you, for instance, offer person-centred methods of listening and reflection, or Gestalt two-chair work? And, obviously, what you offer needs to be what you’re trained in—so be clear where that knowledge and expertise comes from.

2. A ‘pluralistic perspective’ or a ‘pluralistic practice’? In the pluralistic field, we’ve distinguished between pluralism as a way of thinking about therapy as a whole (that lots of different approaches can be of value), and pluralism as a specific practice (where different therapeutic methods and ideas are drawn together to accommodate the preferences of the individual client). Both can be written about in any description of your therapy, but be clear about which one, and what you mean, when.

3. Understand the philosophical underpinning. Pluralism, either as a perspective or as a practice, isn’t just about chucking together lots of things and hoping for the best. It’s rooted in a deep, ethically-founded philosophy of how to relate to others and the world. Some of this philosophy is tough going but it’s essential to really understanding, in depth, what pluralism is about. Try, for instance, Connolly’s Pluralism or, for a really tough read, try some of Levinas’s work, like Totality and Infinity. There’s also some great stuff on the web, and a good place to start is with Wikipedia’s description of value pluralism, or the Stanford Encyclopedia of Philosophy’s entry on Isaiah Berlin.

4. Difference and diversity. Don’t leave it to last. At the heart of a pluralistic approach is a welcoming and celebration of diversity, so how do you address that in your own work: for instance, being aware of your own cultural background or positions of privilege? Some other questions: How do you actively strive to help clients from marginalised groups feel welcomed in your work, and how do you address power as a therapist? Pluralism welcomes everyone’s voice, but it also understands that some voices get more silenced than others. So how can we work to make sure that everyone feels really, genuinely heard in our work.

5. Why ‘pluralism’ rather than ‘integration’ or ‘eclecticism’? One of the first questions any assessor is likely to ask is why you’re describing your approach as ‘pluralistic’ rather than ‘integrative’ or ‘eclectic’, so you need to be clear about the differences (and the similarities). If you’re talking about pluralism as a practice, then you can describe it as a form of psychotherapy integration that orientates itself around clients’ particular needs and wants. Different integrative approaches do that, but it’s not inherent to integration, per se. ‘Integration’ can also refer to specific combinations of approaches, like cognitive analytic therapy, or mindfulness-based existential therapy, whereas pluralism as a practice isn’t aligned with any one model (combined or not). If you can get your head around the different forms of psychotherapy integration—like ‘theoretical integration’, ‘assimilative integration’, ‘common factors,’ and ‘eclecticism’—and where your pluralism sits with each one, that would really help (see the excellent Handbook of Psychotherapy Integration—pricey, but hopefully in your library). And remember that your approach doesn’t need to be one or the other: for instance, you might, ‘hold a common factors view of change, but practice pluralistically drawing on methods and ideas from specific theoretically integrative psychotherapies. If you’re writing about pluralism as a perspective, the differences are clearer as there’s isn’t really any integrative or eclectic equivalent. It wouldn’t really make sense to say, for instance, that you ‘practice as a person-centred therapist within an integrative worldview’, but saying that you do so within a pluralistic one makes total sense. And what, after all of this thinking, you decide that you’re maybe ‘assimiliative integrative’ or ‘common factors’ rather than ‘pluralistic’? Great, at the end of the day, what’s important is what you do with your clients, and being coherent in that, rather than what label you give to it all, per se.

6. Describe how, why, and when you make decisions about what you do in therapy. So right into the heart of pluralistic practice: How do you come to adopt certain ideas and methods? Yes, of course, it’s in collaboration with the client, but when do you talk about what you are going to do (for instance, at assessment sessions, the start of each session, review points); and what kinds of things do you talk about (for instance, goals, methods, formulations)? Are there, perhaps, some specific methods that you use to help identify what might be useful for the client, like timelines (see McLeod and McLeod in the Handbook of Pluralistic Counselling and Psychotherapy) or the Inventory of Preferences? And how, for instance, do you handle situations when a client wants something that you don’t think is best for them? Personally, I’d suggest emphasising dialogue, dialogue, dialogue (and, again read some in-depth texts on dialogue, like the paper here, so that your position is rich and philosophically-informed). Then, critically, you need to say something about why you are using the methods you do and the theories underpinning them (see, for instance BACP’s criterion 8.1, ‘Describe a rationale for your client work with reference to the theory or theories that inform your practice’). So, for instance, if a lot of what you can offer clients is a space to talk through their problems, why might that be helpful? What’s the theoretical and psychological basis for doing so? Here, for instance, you might draw on person-centred theory to say that, with space to talk, clients can connect more with their ‘organismic valuing potential’ and work out for themselves what is best for them to do. Or, if you work with clients to challenge their patterns of thinking, you might talk about cognitive theories of maladaptive thoughts. But, really importantly, make sure it’s logically consistent. If you say, for instance, that you trust in a client’s organismic valuing, you can’t then just describe their thinking as maladaptive. How can they be both? My latest book on an underlying integrative theory of directionality might be helpful here; or you could talk about the way that, from a pluralistic standpoint, different theories are ‘working narratives’ that suit some clients some of the time, rather than immutable truths.

7. Cite the evidence. There’s lots of empirical research related to pluralistic practices, and these can help to inform a critical exploration of your work. For instance, if you’re writing about accommodating clients’ preferences, you could cite the Swift et al. meta-analysis to show that preference accommodation is associated with reduced drop out and slightly improved outcomes. Or, if you’re writing about goals, have a look at the paper by Di Malta et al., which gives a rich, in-depth exploration of how clients experience goal-oriented practices: both the positives and the negatives. And, for evidence that a pluralistic approach to practice has decent enough outcomes, you can cite the paper here.

8. What about the problems? Pluralism is all about holding a reflective, self-critical stance towards the way that we work, so it’s essential to talk about some of the limitations of this way of working and thinking too. How much, for instance, can we really trust clients’ own assessments of what they want and need? So make sure you read some critiques of pluralism, for instance the recent paper by Ong et al from the person-centred field, or on our pluralisticpractice blog from Erin Stevens and Jay Beichman. Of course, you may well find things here that you disagree with; but what’s important is to be able to see pluralism from, well, a plurality of perspectives, and to be able to appreciate its limitations as well as the strengths.

9. Talk to us. And finally, do talk to us about how you’re getting on, and join in the debates. We have a website with regular blogs, and a Facebook page where some of these issues get discussed. Then, if you can make it, come along to our annual conferences which is the ideal place to talk to welcoming and like-minded people striving to develop new, open-minded ways of thinking about counselling and psychotherapy.

Just as a disclaimer, what’s here is obviously only suggestions and, if things do go ‘pear-shaped’, I’m sorry that I can’t take responsibility for that. On any application of assignment, the key thing is always to attend to the criteria set and, for instance, the BACP have some very valuable guidelines for their own accreditation process. Tutors, also, will have a much better idea of what you need to be saying; and any advice from them should over-ride what’s here.

Finally, we’d love to hear how you’re getting on: stories both of passing as pluralistic therapists, and any bumps along the way. Perhaps we can work together to iron them out. So do also share any advice you have from your own experiences of defining yourself as a ‘pluralistic therapist’. Good luck with it.

Essay Writing in Counselling and Psychotherapy: Top Tips

I’m a liberal when it comes to most things—except (as my students will know) fonts, formatting, and grammar. So why am I a fully signed-up member of the Grammar Police (or should that be ‘grammar police’)? Well, aside from my various OCDs (yup, that’s Oxford Comma Disorder), it’s a way that you, as a writer, can make sure that your beautiful, brilliant, creative writing is seen in its best possible light—not detracted by missing apostrophes and torturously convoluted sentences. So here are over 25 top tips for those of you writing essays and dissertations—at all levels—based on years of marking and encountering the same issues time after time. All of these tips are aligned with the Publication Manual of the American Psychological Association (7th edition), which provides an essential set of guidelines and standards for writing papers in psychology-related fields. There’s also a checklist you can download from here to go through your draft assignments to check everything is covered. (And just to say, by way of disclaimer, listen to your tutors first and foremost: if they see things differently, do what they say—they’re going to be the ones marking your papers!)

Puncutation

• Apostrophes. You just would not believe how many students working at graduate, Master's, and even doctoral level dont know when to put apostrophe's and when not to. Check out the rules on it—it takes two minute's on the web (try this site)—and you'll never drive your marker's crazy again (whose this Roger’s bloke that students keep writing about?).

• Single (‘ ’) or double (“ ”) quotation marks? For UK English it’s single; for US English it’s double. The only exception is when you give quotation marks within quotations marks, in which case you use the other type. So, for instance, in UK English you might write:

  • Charlie said, ‘I’ve often told myself, “buck up, don’t be stupid,” but I do find it hard.’ On the other hand, Sharon said…

  And while we’re at it, make sure those are ‘curly marks’ (or ‘smart apostrophes’), and not the symbols for inches (") or feet ('), which are straight.

• One space after a full stop. Not two. That’s for when we had typewriters.

• Colon (:) before a list, not semi-colon (;), and definitely not colon-dash (:-).

• Write out numbers as words if they are below 10 (except if they are to do with dates, times, or mathematical functions; or at the start of the sentence). So, for instance:

  • ‘Across the three cohorts there were over 500 participants.’

  • ‘In this study, six of the young people said…’

• Think where you’re putting your commas. They’re not sprinkles: something you just liberally and randomly scatter over your text. So check where you’ve put them, and that they meaningfully separate out clauses, or items, in your writing.

• And, while we’re at it, a comma before the last item in a list (after ‘and’). This is known as an ‘Oxford comma’, and is recommended by the American Psychological Association (APA) to improve clarity. So, for instance, you’d write that ‘Across the counselling, psychotherapy, and psychiatric literature…’ rather than ‘Across the counselling, psychotherapy and psychiatric literature…’

• Watch out for over-capitalising words. In most cases, you don’t need to capitalise—you’re not writing German (unless, of course, you are). Most words don’t need capitalisation (e.g., ‘person-centred therapy’, not ‘Person-Centred Therapy’), unless they are ‘proper nouns’ (that is, names of specific one-of-a-kind items, like Fritz Perls or the University of Sussex).

• Key terms should be italicised on first use. Say you’re writing an essay about phenomenology, or it’s a key term that you’re going to define subsequently. The first time you use the term, italicise it. For instance, ‘Person-centred therapy is based upon a phenomenological understanding of human being. Phenomenology was a philosophy developed by Husserl, and refers to…’. An exception to this is that, if you want to introduce a term but without any subsequent definition (perhaps it’s not that central to your essay), put it in quotation marks. For instance, ‘Transactional analysis is based on such concepts as “ego states” and “scripts”, while Gestalt therapy…’

Quotations AND CITATIONS

• Reference your claims. Whenever you state how things are, or how things might be seen, reference where this is from. Typically, a paragraph might have four or more references in it. If you find that you have several paragraphs without any at all, check you’re not making claims without saying their source. If it’s your own opinion, that’s fine (particularly later on in essays, for instance in the discussion), but be clear that that’s the case.

• If you give a direct quotation, give the page number of the text it’s from (as well as the author(s) and date).

• If a quotation is more than 40 words (a ‘block quotation’), indent it.

• Otherwise, treat direct quotations as you would other text. So you don’t need to italicise it, put it in font size 8 or 18, use a different font colour etc. The same for quotations from research participants: use quotation marks and treat as block quotations if over 40 words, but otherwise leave well enough alone.

• The page number comes between the close quotation mark and the full stop (if the direct quote is in the text). For instance: Rogers (1957) said, ‘The greatest regret in my career is that I didn’t develop pluralistic thinking and practice’ (p. 23). The only exception to this is with block quotations, in which case the page number comes after the full stop. Stupid, I know, but there you go.

• In text citations for papers with 3 or more authors only need the first author now from first citation onwards, with ‘et al.’: e.g., ‘Cooper et al. (2021) say…’

Paragraphs, Sentences, and Sections

• One paragraph, one point. Don’t try and squeeze lots of different points and issues into one paragraph. Often, a good way to write paragraphs is with a first sentences that summarises what you are saying in it, then subsequent sentences that unpack it in more detail.

• Keep sentences short. In most cases, it doesn’t need to be more than three lines or so. If it’s longer, check whether you can break the sentence down into simpler parts.

• Keep sentences simple. You don’t normally need more than two or three ‘clauses’; and if you’ve got more, for instance, like this sentence has—with lots of commas, semi-colons, and dashes in it—you can see how it starts to get more difficult to follow, so try and simplify.

• Make sure you give clear breaks between paragraphs. So that the reader can see where one ends and the other begins. For instance, have a line break, or else indent the first line of each paragraph.

• Headings should stand out. That’s what they are there for, so make sure they are different from the rest of the text. For instance, do as bold and centred. Also, if you are using different levels of headings (for instance, headings, subheadings, and sub-subheadings), make it really clear which are which, with higher levels more prominent in the text.

• Don’t forget page numbers. If you want your assessors to be able to give feedback, they need to be able to point to where things are.

General writing

• Use acronyms sparingly. ‘The AG group felt that ACT was superior to CBB on the TF outcomes…’ Unless you’ve got the memory of a child genius they’re a nightmare. If you do use them, make sure you explain what they are on first use.

• Avoid jargon/overly-casual terms. ‘The therapists in the study seemed quite chilled; but, for future research more groundedness and heart-centredness could possibly help.’ Enough said!

• Avoid repetition. Saying something once is nearly always enough. You don’t need to repeat it again and again. It gets tedious. Especially when you say things over and over again.

• Be consistent in the terminology that you use. For instance, if you are doing an interview study with young people, don’t switch randomly between calling your participants ‘young people’, ‘adolescents’, ‘teenagers’, ‘clients’, and ‘participants’. Choose one term and stick to it and; if you do use more than one term, be consistent in which one you use when.

• Use footnotes/endnotes sparingly. It can be frustrating for a reader to jump between your main text and then subtexts written elsewhere. So try and include everything in your main text if you can (for instance in parenthesis).

• Don’t assume your readers know what things mean. ‘When it comes to measures based on normative, formative indicators…’ What? You don’t know what ‘normative’ and ‘formative’ mean (and it’s not a music group, though the name ‘The Normative Formatives’ is pretty cool!). The point here, as above, is to spell things out so that the reader knows what you are talking about. If it’s brief you could do that in parenthesis in the sentence. If not, give it dedicated sentences.

• Check the spell and grammar checkers. Those wiggly blue and red lines underneath your writing (on Microsoft Word) do mean something. Sometimes it’s just the software being over-sensitive, but it’s always worth checking and seeing what it’s picking up. If you’re software doesn’t do spell and grammar checks, it might be time to upgrade. You need something or someone else to give this a thorough check through before submitting any piece of work.

• Make your file names meaningful. And finally, if you are sending out documents for assessments as digital files, give it a name that is going to mean something in someone else’s system. ‘Essay.doc’ or ‘Berne version 3 final’ is really not going to help your assessor know which is your submission—particularly in the midst of tens or hundreds of others. So make sure your surname is in the file title (unless the submission needs to be anonymised), and add a reference to the specific assignment: for instance, ‘Patel case study 1’. Adding a date of submission, or completion, is also very useful, though I would suggest always doing this in the format ‘year-month-day’ (rather than ‘day month year’), so that computers store more than one version of the file in the correct order (assuming the files are sorted alphabetically). So that gives you a file title like ‘Patel case study 1 2020-03-10’ and, with a name like that, it’s unlikely to get mixed up with anything else.

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With many of these ‘rules’, the main thing is to be consistent. For instance, most markers won’t mind if you use double quotation marks rather than single, or italicising all your quotes, but the key thing is to do it all the way through. It’s when it’s changing that it gets confusing, because the reader thinks you might mean something by it, when in fact it just means you weren’t thinking about it. But how do we know?! Bear in mind, in particular, that your marker may have several assignments to work through, so anything that can help make their life easier is likely to be worth it. And the great thing is, once you get into these habits, they’ll stick with you for next time. As your academic level progresses, there will be more and more expectation that you’ll get these things ‘right’. So use the checklist to go through your first few assignments, and also ask a peer to scrutinise it using the checklist, and once you’re finding that you’re addressing the issues from the start you can stop using it.

Last thing, and I’ve already said this (so much for avoiding repetition!), but for a brilliantly concise and comprehensive guide to academic writing, go to the Publication Manual of the American Psychological Association (now in its seventh edition). Keep it by your writing desk, your bedside, your toilet…. it’s an invaluable investment in terms of getting through your assignments, because it gives you a consistent and clear set of guidelines on everything from referencing to headings to writing style.

Actually, sorry, really really last thing, and I couldn’t end this blog without saying it because my students won’t recognise me. Times New Roman 12 point. That’s all you need. No Comic Sans, no Bahnschrift Light SemiCondensed. Just one, nice, clear font all the way through.

Keep it simple and let the glorious light of your creative genius through. Good luck!

Acknowledgements

Photo by Lovefreund

How Different are the Different Therapies? A Directional Perspective

Person-centred therapy, CBT, psychoanalysis… there’s over 450 different therapies out there, and often we focus on the differences between them. But how different are they really?

Of course, the specific methods that different therapies use can be very different (interpretation, for instance, vs two chair work vs behavioural experiments). But, in this blog, I want to suggest that where they are trying to help clients get to, and the underlying principles by which they are trying to do that, are actually pretty similar.

What I think all the therapies are trying to do, in a nutshell, is to help clients find better ways of getting from where they are towards where they want to be.

Yup, ‘better’. That’s something of a taboo word in the therapy field. But, of course, I don’t mean ‘better’ as defined by the therapist, or by society more widely; but in terms of what is most helpful for the client on their journey. So that might include more positive self-talk, or trying to see friends more, or mindfulness exercises. In every therapy, however implicit, there’s always some hope for change—even if the change is a move towards greater acceptance of where they are at.

Some therapies, like CBT, do that by providing a lot of structure and guidance. Others, like non-directive approaches, do it by providing clients with space to work out for themselves where they’re at and where they want to go. How different is that? Well, some teachers do a lot of standing up and delivering content. Others prefer to provide pupils with time and space for self-learning. There’s certainly variations in these methods, but that doesn’t mean that they’re trying to do different thing. All teachers want to help pupils learn (I’d hope) , and all therapists want to help clients find positive ways forward in their lives. At least, I’d hope that was the case.

But what about real theoretical differences in how well-being, distress, and change are conceptualised? In my latest book, Integrating counselling and psychotherapy (Sage, 2019), what I suggest is that, in fact, there’s a set of common principles that underlie all the different models, methods, and understandings. These can be summarised as follows:

• Human beings are directional: that is, we act towards our worlds in meaningful, intelligible ways. We do things for reasons, not just randomly—striving towards the things that we most deeply want in our lives, like safety, love, or closeness with others.

• A ‘good life’ is one in which we can get towards those things. This is not just about achieving them, but feeling like we are oriented towards them and progressing at sufficient pace.

• Sometimes we experience problems because the way we try and get one of these thing can make it more difficult for us to get another. For instance, a client really wants intimacy in their life, but they’re also afraid of being un-safe by opening out to others. These conflicts (or what I call ‘dysergies’) might be a consequence of what we’ve learnt from our pasts about how to get the things we want, our environments, or because of ‘biases’ in the ways that we think.

• And, sometimes, we can experience problems because we just haven’t learnt the best ways of getting the things that we really want. For instance, we haven’t learnt the communication skills that we need to get closer to others.

• So what all therapies do is one of two things, and generally both:

  1. They help clients find more synergetic ways of getting what they want: e.g., getting both safety and love. So, for instance, a therapist works with a client to help them realise that they’re avoiding intimacy because they’re scared of getting hurt, and then helps them think about ways of maybe bearing some of that hurt so that they can, ultimately, experience love in relationships and feel safer at the same time.

  2. They help clients find more effective ways of getting what they want: for instance, learning that they can experience more intimacy by being more honest about themselves, or that the best way of overcoming a fear is to face it.

So what does this mean? One implication of seeing a common set of principles underlying all the different therapies is that it can then make us more open to the many different methods and understandings that are out there: less ‘schoolist’ and ‘tribalist’ in our approach. Supposing, for instance, that I am trying to help my client find answers to their relational problems by providing an empathic and accepting non-directional environment. Great. And maybe that’s what I’ll keep on doing. But perhaps I’ll also help them through some psychoeducation in effective communication, or perhaps also by interpreting some deep-seated fears they have of intimacy. Of course, I need appropriate training in any method or set of ideas that I am going to use, but a common framework helps me see other approaches as resources and possibilities, not as competition. There’s been far too much sabre-rattling for years between the different therapeutic schools. Articulating a common set of principles can help us break down some of the walls and meet each other as friends rather than enemies.

Yes, integrative and eclectic approaches have been doing that for years. But, even for these approaches, it can be difficult to articulate the principles on which an integration is based: why it’s a coherent—rather than mish-mashy—approach to therapy. So what’s described here can still be of value in working out the common underlying threads behind an integrative or eclectic form of practice. But, importantly, the inference here is not that we should all be practising in multi-method ways (and that’s something we also emphasised strongly in our pluralistic approach). The fact that there is a common thread underlying the different therapeutic approaches doesn’t make a purely psychoanalytic practice, or a purely person-centred one, any less valuable.

If you’re interested in these ideas, do have a look at my latest book. It starts by introducing this idea of directionality and how it relates to wellbeing and distress, and then goes on to talk about the way in which the main therapeutic approaches (psychodynamic, humanistic, existential, and CBT) can be aligned with it. The final part then talks about some common practices that come out of it, like helping clients to identify the things that they want most in life. The book covers a lot of ground (maybe too much), but it’s part of a pluralistic striving to bring lots of different therapies together and to find what is common amongst us. That’s not, in any way, to minimise the unique contribution that each of our different therapeutic approaches can make. But to help establish some common touchstones that can bring us further into dialogue with each other.

Person-Centred Therapy is Not One Thing: An Introduction to the Tribes

Has anyone ever said to you, ‘That’s not person-centred’, or ‘Person-centred therapists would do…’? If so, you might want to point out to them that there’s no such thing as ‘person-centred’—it’s not one, homogeneous ‘thing’. Rather, it’s a wonderfully diverse family of approaches, each with something very special to offer to the wider therapeutic field.

It starts with the classical client-centred approach of Carl Rogers from the 1930s onwards. Rogers reacted against the behaviourism and expert-directed approaches of his time, and instead emphasised the client’s own ability to find their answers to their problems. So the hallmark of the classical approach is a non-directive stance: letting the client lead the way in an accepting and empathic environment. The classical approach is still very popular and you can read about it in Tony Merry’s chapter in the brilliant Tribes of the Person-Centred Nation. There’s some argument that Rogers, himself, moved away from a classical stance in the 1960s towards a more relational standpoint (see below), but others argue that Rogers style of practice never really varied throughout his career.

Out of Rogers’s work you get the emergence of non-directive therapies with children, particularly the work of Virginia Axline. Person-centred play therapies are still very popular today and have a very good evidence base, developed by world-class researchers like Dee Ray at the University of North Texas. Natalie Rogers, Carl Rogers’s daughter, also developed an approach called Creative Connections which offers clients a non-directive space to engage with a wide variety of creative media, such as dance, music, and drama.

Focusing, which emerged in the 1960s, was probably the most important development from Rogers’s work, and took it in new and creative directions. Gendlin, its founder, believed that some clients needed to get more in touch with their inner ‘felt senses’ before they could really use therapy to its fullest. So focusing encourages clients to ‘listen inwards’ to their bodies and allow their feelings and bodily experiences to emerge. It’s really popular today in ‘peer focusing partnerships’, as well as in focusing-oriented psychotherapy; and psychotherapists of all orientations may use focusing methods in their work.

One reason why Gendlin’s break from Rogers was so critical is because it introduced the idea that some clients, some times, do need therapist direction to make the most of the work. This stance was developed further by Laura Rice and subsequent founders of emotion-focused therapy (EFT; like Les Greenberg, Robert Elliott, and Jeanne Watson) who articulated a series of methods that could be used to help clients get deeper into their emotions: the key, as they saw it, to therapeutic progress. EFT, for instance, uses ‘empty chair work’ to help clients express, and process, their feelings towards others; and ‘clearing a space’ to help them deal with overwhelming feelings. EFT is very well supported by the empirical evidence and in the US is ranked as an evidence-based therapy for depression. There’s lots of CPD trainings available on it and an international society. Sue Johnson, who worked with Les Greenberg, developed an approach called emotionally focused therapy, which has many similarities to Greenberg et al.’s EFT but is particularly oriented to work with couples. However, there’s another EFT, ‘emotional freedom technique’ (the one with lots of tapping), which is something entirely differ.

Counselling for Depression (CfD, now termed person-centred experiential counselling for depression) combines a classical person-centred approach with some ideas and practices from EFT. It was specifically developed to fit within the NHS’s NICE guidelines for treatments for depression, and was based on core competences for humanistic therapies. This therapy is now delivered across the country, mainly within health settings, as an evidence-based interventions. Several CPD trainings in this approach are available, for instance at the Metanoia Institute in London.

Around the 1980s, motivational interviewing (MI) began to develop in the field of treatments for drug dependency, and is now one of the best evidence interventions across the psychotherapy field. Bill Miller, one of the founders of the approach, was strongly influenced by the writings of Carl Rogers, and there is an emphasis in the approach on being empathic and engaging with the client’s perspective. However, it is more directive than classical person-centred therapy. For instance, if a client is struggling between the part of them that wants to give up drugs and the part of them that doesn’t, an MI therapist would tend focus on their ‘change talk’ (that is, the part that does want to give up drugs), whereas a classical person-centred therapist might be more likely to reflect both positions.

Another important development around this time was pre-therapy. Developed by Garry Prouty in the US, this approach was specifically developed for clients who are ‘contact impaired.’ That is, who are less in touch with ‘reality’: for instance, people experiencing psychosis or depersonalisation. Pre-therapy uses very concrete reflections—for instance, ‘You are looking at the wall,’ ‘You are smiling’—to try and help the client back into contact with their world and with others.

Relational, or dialogical, approaches to person-centred therapy differ from EFT or MI in that they are not a specific set of therapeutic methods, but more of a description of a therapeutic style or stance. As with EFT or MI, though, they are something of a break from the more classical style, and emphasise a more interactive therapeutic approach in which the emphasis is on the therapist being particularly present and real to the client. So that might involve some more challenging, or more introduction of the therapist’s own perspective into the work. You can read about the philosophy underlying this approach in the work of Peter Schmid, or see my own work with Dave Mearns on relational depth.

Similarly, an existentially-informed approach to person-centred therapy, which you can also read about in the Tribes book, is not a specific therapeutic model but a form of classical/relational person-centred therapy informed by ideas from existentialism. So the therapist might be particularly attuned to a client’s sense of meaning in life, or their anxieties around freedom and choice.

Of course, in reality, a wide variety of therapeutic methods and theories can be (and have been) incorporated into a person-centred approach, and that leads us to integrative approaches to person-centred therapy. Sometimes these are just personal forms of integration: for instance, when a person-centred practitioner begins to bring in ideas and methods from narrative therapy, or from transactional analysis. But there are also more systematic forms of therapeutic integration, and David Cain writes about these in his chapter in the Handbook of Person-Centred Psychotherapy and Counselling (2nd ed). Pluralistic therapy, for instance, developed by John McLeod and myself, argues that being ‘person-centred’ means responding to the unique individual wants and needs of each client, and that means recognising that a strictly non-directive approach will not be the most appropriate way of working at all times. Rather, pluralistic therapy suggests that we should talk to clients about what they want from therapy, and be transparent about what we can offer; that we can either offer our clients the kind of therapy that may most help them, or else refer on as appropriate. You can read more about a pluralistic approach to person-centred therapy on my blog here.

For me, what makes person-centred therapy wonderful is this diversity of riches: so many different ways to think and practice. And, perhaps, we shouldn’t expect anything less from a therapy that focuses on the person and how they, uniquely, see and experience the world. Of course, when we first train, we often need to start with the basics—like the ‘core conditions’, or unlearning a natural tendency to give advice—but growing as a person-centred therapist means recognising that there are so many different ways we can flesh out this identity: spreading our wings, and finding our own unique person-centred stance.

To find out more about the different forms of person-centred therapy, Pete Sanders’s (ed.) Tribes of the Person-Centred Nation (2nd ed) provides a great account of the major developments. Pete’s chapter in the Handbook of Person-Centred Psychotherapy and Counselling (2nd ed) gives a very useful summary. The national organisation for person-centred therapists in the UK is The Person-Centred Approach (TPCA), and their website has lots of useful information and links to current developments.

Assessing Client Preferences in Counselling and Psychotherapy? Some Pointers

Research shows that accommodating clients’ preferences in therapy can lead to better therapeutic alliances, lower dropout, and improved outcomes. But how can you go about finding out what clients actually want?

‘Just ask’? It seems the obvious answer and often it is. Asking clients what they want from therapy can be the most relational, respectful, and nuanced way of finding out about their preferences. Therapists can ask clients about their preferences in lots of different areas:

• The methods that they would like to use: for instance, would they find it helpful to do a short relaxation exercise at the start of each session?

• The topics that they would like to talk about: for instance, do they want to focus on their past experiences, their current circumstances, or both?

• The aims for the therapeutic work: for instance, do they want to change their behaviours, or come to a greater acceptance of their life?

• The therapist’s style of engagement: for instance, do they want more or less challenge from the therapist?

• Contracting and format issues: for instance, would they like sessions weekly or fortnightly?

Often, first sessions are the best time to start talking about these issues, and generally research show that clients do like to be involved in these kinds of decisions. However, for some clients—particularly those who have not had therapy before—it can feel overwhelming to be asked too many questions about what they want, so sensitivity and timing are essential in helping clients articulate how they would like therapy to be.

There are, however, also downsides to relying on verbal dialogue, alone, to assess clients’ preferences. First, face-to-face, clients may find it hard to be fully open about what they want from therapy, particularly if they think that the therapist may disapprove of their preferences. Second, therapists may neglect to ask questions about the preferences that are of most importance to clients.

One way of addressing this second problem is by using a relatively structured, and comprehensive, schedule for asking clients about their preferences. Barbara Vollmer and colleagues, for instance, have developed the ‘Treatment Preference Interview’, which is a semi-structure, discussion based tool that assesses clients’ preferences about the therapist, their activities, and the type of therapy to be offered (Vollmer, B. et al. [2009]. A therapy preferences interview: Empowering clients by offering choices. Psychotherapy Bulletin, 44[2], 33-37).

This kind of schedule is a great idea; but it can be pretty time consuming, and it still does not get around the problem that clients may find it difficult to say, on a face-to-face basis, what they want from therapy.

It’s for this reason that we developed a freely-available questionnaire to help stimulate discussion about what clients want from therapy: the Cooper-Norcross Inventory of Preferences (with validated translations available in German, Italian, and Serbian). The form consists of 18 items, which ask clients about the particular style of therapy that they want (see below). There are then a series of open questions asking clients about strong preferences in other areas of therapy, such as format and use of self-help materials. The 18 items are grouped into four over-arching dimensions:

• Whether the client wants the therapy to be more therapist-led, or more client-led

• Whether the client wants encouragement to go into strong emotions or not

• Whether the client wants to focus on their past, or their present and future

• Whether the client wants warm support or more focused challenge.

Clients’ responses for each dimension can be added together, so that it’s possible to see where they might have strong preferences. For instance, it may emerge that a client wants a more client-led therapy and to focus on their past, but does not have strong preferences on the other dimensions.

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If you’re interested in how we developed the C-NIP, and evidence of its reliability, our original paper is here. We also conducted a very interesting comparison of therapy preferences for therapists (as clients), and laypeople, which can be found here.

Of course, it’s not a case of just giving the form to the client and then doing whatever they want. The aim of the C-NIP is to act as the basis for a dialogue, so that therapist and client can discuss in more detail the ways of working that are most suited to that individual. And, of course, the client may have preferences that the therapist cannot accommodate. For instance, a person-centred therapist may not be trained, or willing, to practice in a highly goal-oriented, directive way. But, probably, it’s better that such strong preferences are brought to the fore at the start of therapy, rather than emerging several months down the line. That way, any incompatibilities between therapist and client can be talked about and, if necessary, onward referrals can be made.

Our research shows that clients, in general, like to complete the C-NIP. They find it refreshing to be asked what they want from therapy, and appreciate the offer of different ways of engaging. A few clients, though, do find it less helpful: particularly those that are new to therapy and have no idea what it is or what they want. So, again, sensitivity and timing are needed in the use of the questionnaire. For instance, it might make more sense to introduce the C-NIP a few sessions in to therapy and, in fact, we recommend that therapists use it at review points (for instance, Session 4 and Session 10) to check how the client is experiencing therapy and whether there is anything they would like to change.

A paper version of the C-NIP measure can be accessed here, and guidelines for its use are here. We also have a website where the questionnaire can be completed online, with automatic calculations of scores on the four different dimensions. We’re currently doing further research into the C-NIP, and our online site asks if we can, anonymously, hold on to data; so if you and your client were willing to complete the questionnaire online that would be really helpful for us.

In conclusion, research into assessing, and accommodating, client preferences shows that it is a complex and nuanced area. One thing that is clear is that it’s not as simple as just asking clients what they want and doing it. Often clients don’t know, and sometimes what they want at the start of therapy is not what’s ultimately most helpful to them. Nevertheless, that doesn’t mean that asking clients about their preferences is a waste of time: clients do sometimes have strong preferences, and not talking about—or adjusting to—these can sometimes lead to poor therapeutic outcomes and dropout. So developing skills in assessing client preferences is an important area for ongoing training and development: helping us to provide each client with the particular therapy that is best suited to them.

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.