In the last couple of days I have written posts on "Personal experience: learning from difficulties" and "Personal experience: caution over "goodwill" & "mindfulness" practice". 

What's much more over-whelming is the value of getting feedback. The post "Psychotherapists & counsellors who don't monitor their outcomes are at risk of being both incompetent & potentially dangerous" makes this point strongly and links to a whole series of other studies that have clearly demonstrated the value of regularly asking for feedback from clients both on progress and on the therapeutic alliance. I routinely do this. One of the four questions in the "Session rating scale" asks clients to rate how much they felt "heard, understood, and respected" in the session. It's sensible to be suspicious that their responses may be very slanted by knowing that I'm going to read & discuss their answers with them. However last year's conference poster presentation by Flora et al - "Social desirability and validity of clients' rating of the Session Rating Scale" - reported that "Monitoring treatment outcome and the therapeutic alliance has become a recommended practice. However, concern has been expressed that most client rate the alliance high. Clients (N = 173) at three sites were randomly assigned to three alliance feedback conditions to evaluate if social desirability and other demand characteristics influenced scores. Clients completed the Session Rating Scale (SRS; Miller, Duncan, & Johnson, 2000) the first three sessions of treatment in one of three feedback conditions: (1) Immediate Feedback (I) - SRS completed in presence of therapist and the results discussed immediately afterward; (2) Next Session Feedback (NS) - SRS completed alone and results discussed next session; or (3) No Feedback (NF) - SRS completed alone and results not available to therapist. No statistically significant differences in SRS scores across the feedback conditions were found, indicating that alliance scores are not inflated due to the presence of a therapist or knowing that the scores will be observed by the therapist. Additionally, the analysis showed that SRS scores were not correlated with a measure of social desirability but demonstrated evidence of concurrent validity with an established alliance measure." And I've been using a slightly adapted SRS measure in a recent process group that I've been running. All group members see everyone's SRS scores as they track week by week (including how I score the scale as well). Here's a copy of the chart for the first seven sessions of the group - missing values reflect the fact that not all group members manage to get to all meetings.

The 0 to 10 scale findings from peer group work. 

Talking about training in group work

"Is interpersonal group work better than sitting meditation for training mindfulness?" I guess there are tensions in our peer group produced by the fact that I do teach group work ... and I asked for regular feedback.

The group SRS chart.

More to follow ...

"No man was ever wise by chance."     Lucius Seneca

Yesterday I wrote a post about working with personally difficult information ... in this example, challenging group feedback.  There are so many research teams and streams of fascinating information emerging that look at how to cope well in stressful situations.  I have already mentioned Carol Dweck's work on "mindset", the value of mindful acceptance & perspective-giving reappraisal, and the potential helpfulness of self-affirmation.  It reminds me too of the very interesting body of work that I came across recently using Garnefski & Kraaij's "Cognitive emotion regulation questionnaire (CERQ)".  There are a scary number of research studies showing its relevance across many different life stresses.  Again and again the same findings emerge ... there are three cognitive emotional responses that are routinely associated with worse subsequent outcomes and one that is routinely associated with better subsequent outcomes.  The three associated with worse are the usual suspects.  They are responses involving rumination, catastrophizing and self-blame.  And the response that is so often associated with better outcomes?  It's "Positive reappraisal" with affirmative answers to the four questions "I think I can learn something from the situation", "I think that I can become a stronger person as a result of what has happened", "I think that the situation also has its positive sides" and "I look for the positive sides to the matter".

Good, so what can I learn from the feedback I got in the group last weekend?  Well one of the first things is for me to check that I've understood what was actually said and meant.  I'm in the process of doing this and, no surprise, the actual messages seem like they were somewhat softer & kinder than I had remembered.  I've talked also to two or three people who know me well to get their take on these issues.  Helpful in giving a gentler broader perspective.  However there is useful learning in this.  As pretty much always in the richness of group interactions, there are a whole series of potentially good avenues we could explore involving all group members to a greater or lesser extent.  What I'd like to stay with here though is the message that "Sometimes I can come across to others as not really being as caring & compassionate as my language appears to indicate ... that, at times, it can feel to them like I'm 'going through the motions' of being understanding & warm ... sometimes more maybe from the head than the heart".  Guilty as charged!  I'm sure that sometimes happens.  Maybe, in the group, I have been dissonant like this more than others, maybe less.  It's not important.  What is important to me is that I don't want this to happen and I'd love to learn more about making my sense of care for others more solid & genuine & helpful even more of the time.  Good territory to think about.

Einstein is reported to have said "It is theory which decides what we can observe".  I certainly feel that the particular "lens" that I use to look at experiences heavily effects what I notice & learn.  So the two "lenses" I'd like to bring out here are the Rogerian triad of genuineness, empathy & unconditional positive regard and Shaver & Mikulincer's five behavioural systems of care seeking, care giving, exploration, sex & power.  Despite my core trainings being in medicine and in cognitive-behavioural therapy, I find both of these "lenses" very helpful as ways of getting "a compass bearing" in the ebbing/flowing complexity of interpersonal interactions.  I quite often think of the genuineness/empathy/care triad as a three-legged stool. If any of the stool "legs" is too long or short, the stool gets wobbly and interactions are likely to get more problematic.  If my attempts at caring outrun my levels of empathy & genuineness, this can produce difficulties.  Similarly in the Shaver & Mikulincer model, if any of the behavioural systems isn't responding optimally to relevant environmental demands, then the "programme" tends to move into hyper- or hypo- activation.  For care seeking this would involve anxious or avoidant attachment styles.  For care giving, we may move into a colder, more distant hypo-activated state or a smothering, inappropriate hyper-activated state.  

I'm interested here in the effects of my internalised messages that "I should be a very warm, loving human being" or even just "I very much want to be a warm, loving human being".  What does this do to the genuineness/empathy/care balance?  What does it do to the care giving system?  It's a tricky issue.  I'm moved when I read words like William Penn's "I expect to pass through life but once. If therefore, there be any kindness I can show, or any good thing I can do to any fellow being, let me do it now, and not defer or neglect it, as I shall not pass this way again" or the Dalai Lama's "My religion is kindness" or even Freud's "Love and work are the cornerstones of our humanness."  And the research by and large backs this up.  See for example posts on Jennifer Crocker's fine work "Recent research: egosystem & ecosystem" or "Barbara Fredrickson's recent research on loving-kindness meditation" or "Cooperative behavior cascades in social networks".  There are excellent reasons to hold that being warm, open-hearted & compassionate is likely to be good both for others and for oneself.  My query is "How can I best allow/nourish/support myself in being open-hearted & kind?"  And a second query is "Can I try too hard?  Is there a danger of pushing out of shape ... of growing care out of proportion to genuineness & empathy ... of hyper-activating the care giving system so it slides into insensitivity?"  I'm confident the answer is "Yes, I can try too hard or in the wrong way to be more caring and slide into states that are less helpful." 

I'm not "religious" in the sense of believing in a divine power, however I do "pray" for others each day or at least I practise a form of "goodwill meditation".  See the handouts & recordings further down the "Compassion & criticism" page of this website.  And there are good reasons for thinking that this kind of practice can internally orientate me to respond to others with more kindness - see, for example, Hutcherson & colleagues' "Loving-kindness meditation increases social connectedness", Canevello & Crocker's "Creating good relationships: responsiveness, relationship quality, and interpersonal goals" and the blog post "4 studies on prayer and their implications for compassion, loving-kindness & goodwill meditation practices".  But it's so important that this orientation towards kindness is "real" and "authentic", not driven by "self-interest" or "obligation".  See "Motives for volunteering are associated with mortality risk in older adults" and "When helping helps: autonomous motivation for prosocial behavior and its influence on well-being for the helper and recipient" with the latter study highlighting that both giver & receiver benefit more when open-hearted behaviour is driven by genuine, self-chosen motivation rather than a sense that one "should" act this way.  Before the group last weekend, I spent a little time quietening and internally wishing all of us well, "praying" or "meditating" on the intention that each person would find the group helpful.  That doesn't mean that I wouldn't subsequently challenge people in the group.  Far from it, I think it makes it more likely that I would go out on a limb if it felt like it would be true and useful.  I'm sure though that this kind of goodwill orientation can, at times, become something of a habit, can at times look like the "polished bedside manner" that I was challenged on.

So how to respond to this possibility?  Partly I think by encouraging empathy & authenticity as I try to encourage caring.  The post "Meeting at relational depth" explores this territory well.  I do already pay a good deal of attention to empathy & authenticity, but maybe not as much attention as I pay to compassion.  Mindfulness - being aware of what is emerging in the present moment - is an obvious skill to explore here.  It's partly relevant, although the results reported by Escuriex & Labbé in their recent paper "Health care providers' mindfulness and treatment outcomes: A critical review of the research literature" are only tentatively supportive.  The abstract of their paper reads "A systematic and critical review of the research literature evaluated studies on whether ... health care providers who either practice mindfulness or possess greater levels of mindfulness experience better results with their patients than those possessing lower levels of mindfulness or those who do not engage in formal mindfulness practices ... Search keywords used were "therapist mindfulness," "outcome(s)," "client outcome(s)," "therapeutic alliance," "mindful therapist," "mindfulness," "therapist training," "health care professionals," "empathy," "therapist empathy," and combinations of these terms ... Twenty studies met the inclusion criteria ... The results are inconclusive as to whether those trained in formal mindfulness practices or who possess higher levels of mindfulness have better treatment outcomes than those who do not."  So the research on the value of mindfulness training for increasing empathy seems under-whelming, at the moment.

What's much more over-whelming is the value of getting feedback.  For more on this, see tomorrow's post.

"Honest criticism is hard to take, particularly from a relative, a friend, an acquaintance, or a stranger."   Franklin P. Jones

I'm a member of a "therapists' group".  We currently get together for a three hour meeting once a month.  I wrote about this initiative last year in the post "Setting up a therapists support group" where I said "The therapeutic relationships we establish with our clients are so central to our work. Being together, ‘encountering' a group of other experienced therapists in the here-and-now, gives us an opportunity to explore our ‘in-tuness', our flexibility, the issues that support, or get in the way of being present, empathic, caring, authentic with our clients ... we can be ... fellow travelers using our evolving interactions in the group to challenge & care for & inspire each other to help our clients more fully and deeply."

We had a meeting at the weekend and I and another group member "clashed" a bit.  I think we both, at times, found each other's interpersonal style somewhat difficult.  My memory is that he specifically mentioned an unease he had with how he perceived me sometimes when I was expressing caring or concern for others in the group.  I think that for him I, at times, came across as a bit forced or artificial or speaking in a way he was uncomfortable with.  These kinds of clashes in groups are a real opportunity for learning and I said something like "I guess it's pretty much inevitable that at times during this group some of us will have a bit of difficulty with others.  My sense is that potentially this can be very helpful ... a chance for everyone involved to get feedback, gain insight and maybe learn important & useful things about ourselves."  It didn't seem to me that the other person involved was very keen to step forward for feedback, but I was certainly open to it.  Several people spoke.  Someone talked about "a polished bedside manner" and someone else commented that he felt I came across at times as "in facilitator mode".  A third person said something like "I'm a bit hesitant about saying this but sometimes you come across to me as a bit seductive".   Very tricky to square that one with the "polished bedside manner"!

I joke about it, but it's painful to hear this kind of thing.  At least I find it painful.  Now a couple of days later, sitting before breakfast writing, it's a bit like feeling with my tongue for a sore place in my gum.  It's not that I have been thinking about it very much but, when I do, I ache.  There's so much that I could write about that's relevant to the experience of receiving challenging feedback.  For now I'd like to say something about feedback in interpersonal groupwork, something about responding to challenging information more generally in life, one or two thoughts about "goodwill practice" & mindfulness, and then come back full circle to the value of feedback.

So first feedback in interpersonal groupwork.  It's potentially very valuable.  In his classic book "The theory and practice of group psychotherapy", Irvin Yalom describes a dozen therapeutic mechanisms that research has identified as important in this kind of process group.  Usually interpersonal factors, catharsis and group cohesiveness are rated particularly highly.  There is considerable variation though - with the type of group studied, with how long the group has been meeting for, and with the participant's level of functioning and personality style.  Of twenty particularly endorsed statements about group value, several relate to receiving feedback including "Other members honestly telling me what they think of me", "Group members pointing out some of my habits or mannerisms that annoy others" and "The group's teaching me about the type of impression I make on others".  Interestingly the other side of the equation is also highlighted with particularly valued aspects including "Expressing negative and/or positive feelings towards another group member", "Learning how to express my feelings" and "Being able to say what was bothering me instead of holding it in".  Obviously this can be difficult territory.  I've been in groups as a participant where interpersonal "mud-slinging" was emphasised and encouraged.  Not helpful.  It's likely to be best to include this potentially "strong taste" in the group "cooking" with a good deal of care - see for example slides on process groups & constructive facilitator style.   

And how about the feedback I received a couple of days ago?  What can I do to make it more likely the "cooking" is nourishing for me rather than producing acute indigestion!?  This overlaps into the second point I wanted to touch on about responding to challenging information more generally in life.  It's easy to "defend" against it.  Sometimes it's important to defend against it, but quite often challenging information has great potential value.  Carol Dweck's work is relevant here and its emphasis on an "incremental", learning & mastery mindset rather than an "entity", success or failure mindset - see for example her paper "Defensiveness versus remediation: self-theories and modes of self-esteem maintenance" which is available in full text from her website.  Acceptance & reappraisal responses are likely to be helpful too.  I've been talking about acceptance and "turning towards difficulties" in a recent post on mindfulness and I'm a great fan of reappraisal and the space & perspective it often brings.  Fascinatingly, and to me surprisingly, these two coping responses - mindful acceptance & cognitive reappraisal - seem more entwined than I would have expected.  So rather than just bat away the challenging feedback I received in the group, I can let it in, be with it, literally feel its effects in my body ... and also step back to put it in perspective ... perspective about how the group is functioning and the ways others are participating, and perspective from gentle appreciative feedback I have received over the years from family, good friends, patients & others. 

This issue about maintaining one's sense of worth while still being open to new learning has been explored extensively as well in self-affirmation theory.  This is good territory.  The relevant Wikipedia article comments "People tend to interpret relatively uncomfortable information in a way consistent with their existing beliefs ... The need to protect a valued identity is a major source of biased processing.  Fortunately, people identify with multiple values. Researchers discovered that providing people with affirmation opportunities on alternative sources of self-integrity lead to a less biased evaluation to threatening information.  Self-affirmation increases the openness of people to ideas that are difficult to accept ... For example, when encountering threatening health information, people often try to resist the information and persist with their unhealthy habits.  In this case, self-affirmation can be used to help them be aware of potential risks and they may be more willing to consider the information, leading to higher motivation to engage in corrective reactions."  Knowing about self-affirmation theory makes good sense, particularly for health professionals & psychotherapists.  I've written about this in a past blog post and looked at its implications for creative forms of therapeutic writing as well.  So reminding myself of the appreciation of loving family & friends makes it much easier for me to look with clear eyes at what was said to me in the group feedback.  And there are many other ways that one could self-affirm to encourage this ability to stand firm and tall and open when faced with difficult information.  Being able to be loving is probably my central value, but courage rates highly for me as well and so does looking for what's true.  I can certainly self-affirm on these qualities when "threatened" over my sense of self as a loving, warm-hearted being.  I can walk around the experience and look at it from many different viewpoints ... how about, for example, if when I started to participate in this group I'd been told "You may well get feedback that could help you be more constructively loving and helpful for others".  "Wow" I would have said "Count me in. That sounds very worthwhile."  Well maybe that 's exactly the opportunity I now have! 

I'll look at this "opportunity" more in tomorrow's post.

I wrote about chapter eight in Mark & Danny's book last week.  This post is about chapter nine - the fifth week of meditation practice - "Turning towards difficulties" (pp. 159 to 182).  In their week-by-week programme summary (p.59), they write "Week five introduces a meditation - Exploring difficulty - that helps you to face (rather than avoid) the difficulties that arise in your life from time to time.  Many of life's problems can be left to resolve themselves, but some need to be faced with a spirit of openness, curiosity and compassion.  If you don't embrace such difficulties, then they can increasingly blight your life."  To powerfully illustrate this point, the chapter begins with a description of how "Elana Rosenbaum, a meditation teacher ... was in the middle of teaching an eight-week mindfulness course (about where we are in our programme now) when she found that she had a recurrence of her cancer."  Elana has written about her experience in the book "Here for now: Living well with cancer through mindfulness" and a further short book is due out by her this summer on "Being well (even when you're sick): Mindfulness practices for people with cancer and other serious illnesses".  Mark & Danny quote her quite extensively and go on to say "And what about the rest of us?  How are we relating to those things, large and small, day in, day out, that remind us of our vulnerabilities?" 

They write about "acceptance" highlighting that, when they use this word, they are not talking about resignation or giving up.  They link it to its roots, meaning "to receive or take hold of something ... to understand".  They say that, in this sense "Acceptance is a pause, a period of allowing, of letting be, of clear seeing."  Acceptance in this way " ... takes us off the hair trigger, so that we're less likely to make a knee-jerk reaction.  It allows us to become fully aware of difficulties, with all of their painful nuances, and to respond to them in the most skilful way possible."   This may take real courage, and as the self-determination theory experts Levesque & Brown have shown in their research, mindfulness tends to de-automatize our behaviour so that we're more likely to act in genuinely self-chosen, autonomous ways.  They write "Mindful attention may have particular adaptive value when individuals face challenging tasks or new behavioral choices" with benefits on "positive task performance and well-being outcomes associated with autonomous functioning."  I think there's a link here to C S Lewis's quote "Courage is not simply one of the virtues, but the form of every virtue at the testing point."  This quality of brave, open acceptance of "what is" can so often encourage skilful, value-driven responses as illustrated in the well-known "Bus driver metaphor".  And usually our choices on how to respond include both outer problem-solving actions and also inner problem-solving attitudes. 

For me there are two overlapping meanings or implications about acceptance & mindfulness here.  One is the way that the inner pause and openness of acceptance helps us make better choices, more in line with our true inner values.  And the second meaning, for me, is that sometimes that choice is simply to "accept" and be with what is happening without trying to change it outwardly ... although we know that this quality of mindful "acceptance" actually changes our situation & experience inwardly.  In fact, "acceptance" and "reappraisal" are two of of the most powerful inner-change strategies we have - see, for example "Cognitive reappraisal and acceptance: An experimental comparison of two emotion regulation strategies."  And, fascinatingly, these two skilful responses are more intertwined than one might initially think - as the authors of the recent paper "Positive reappraisal mediates the stress-reductive effects of mindfulness: An upward spiral process" found - "Positive reappraisal and mindfulness appear to serially and mutually enhance one another, creating the dynamics of an upward spiral. Through mindfulness practice, individuals may engender a broadened state of awareness that facilitates empowering interpretations of stressful life events, leading to substantially reduced distress."  And this week's extended meditation exercise is very much a training in turning towards difficulty, openness, courage and the deeper & potentially more creative "acceptance" that is involved in this.

As usual, I've put together a reflection sheet that you can use to jot down your reactions to this book chapter, and also a practice record to keep a note of your meditations.  Mark & Danny do a good job of explaining how to go about this "Turning towards difficulty".  It's typically health & wellbeing promoting to encourage ourselves to have an overall "approach" motivation to our inner & outer lives.  As the authors of the paper "Curiosity and well-being" reported, the tendency to "explore" helps to "broaden the thought-action repertoire by promoting interest in novel/challenging situations and to incrementally build knowledge and well-being".  Research shows that lower "emotional approach coping" is associated with "higher anxiety sensitivity and higher anxiety symptom severity".  While there is extensive research highlighting that engagement & "behavioural activation" are helpful both in the treatment of depression and in building wellbeing - see "Behavioral activation treatments of depression: A meta-analysis" and "Behavioral activation interventions for well-being: A meta-analysis".  Maybe somewhat counter-intuitively, the authors of the enjoyably named "Goals and responses to failure: Knowing when to hold them and when to fold them" even found, while researching how experimental subjects responded when faced with unsolvable anagrams, that "people with approach goals are better able to identify when they should disengage during failure, and disengage more completely, than people with avoidance goals."

So the practices this week include a daily extended meditation sequence starting with paying attention to breath, body, sounds & thoughts before moving on to "Exploring difficulty".  There are also developments in the brief "Breathing space" meditations, with encouragement to explore "naming" one's internal state, internally verbally noting the breaths, turning towards difficulty, and working more on continuing to be mindful during daily life.  Noting and naming one's inner state is an interesting request.  It might be helpful anyway to see how much your scores on the "Five facet mindfulness questionnaire - short form (FFMQ-SF)" have changed.  Quite often the facet "Describe" gets rather left behind in FFMQ-SF score improvements - see, for example, my earlier post "Mindfulness: the missing facet 'Describe'".  Possibly the relationship implications of increased skills in "Describe" may be the most important outcome here, but there are other benefits too - see the post "Naming emotions is another useful self-regulation & mindfulness strategy".  Finally Mark & Danny's "Habit releaser" request this week involves sowing seeds and/or looking after a plant (p. 181) and they describe the surprising benefits that this kind of "caring for" can bring.

I began thinking yesterday about what I actually do as a psychotherapist.  This lead to a light-hearted first post describing a "two-seven-two" model of integrative psychotherapy.  The initial "two" acknowledges the importance of an overview of what has been going on for the client and a good working alliance.  The "seven" describes a series of overlapping therapeutic areas that I pay attention to.  The first three of these are probably used by most psychotherapists - problem solving relevant outer issues, problem solving unhelpful internal response styles, and - where appropriate - looking at "ball & chain" contributions from the past that may be holding back progress in the present.

Four further therapeutic areas I consider, that are maybe less often considered by some psychotherapists, are biological interventions, focus on physical health, development of wellbeing, and using the here-and-now therapeutic relationship. By biological interventions I mean drug therapies, light, dietary supplements, herbs, and so on. As a medical doctor, I'm clearly in a good position to keep an eye on the possible value of these kinds of methods. The focus on physical health honours the truth of "mens sana in corpore sano". Psychotherapists are rightly interested in emotions & the mind. We can miss the importance of the body - "If a pickpocket meets a saint all he sees are his pockets". Posts like "New research shows diet's importance for preventing depression", "Recent research: three depression papers that get me thinking", "Dose-response relationship between physical activity and mental health" and "Common sense isn't common" all illustrate the value of looking at physical health if we're trying to improve psychological difficulties. I quite often say to clients something like "It's marvellous. Pretty much all the lifestyle, self-care choices that you could make to benefit your physical health are also likely to help your psychological health. What a bonus!".

As for the development of wellbeing, less than 20% of us qualify as really "flourishing" in our lives - see "The spectrum of mental health". This matters because "flourishing" psychologically is clearly a much pleasanter more rewarding state to be in. Additionally it is associated with more effective functioning - in thinking, creativity, energy, relating. And thirdly "flourishing" protects well against relapse into mental disorder. I talk more about these points in the post "Psychotherapy & positive psychology: why psychotherapists should pay attention". There is a flowering of good research on how to nourish happiness & wellbeing. As papers like "Behavioral activation interventions for well-being: A meta-analysis" have shown, approaches we already use in our work with mental distress are also likely to promote mental wellbeing. And there is much helpful we can learn additionally from positive psychology - for example, I am a big fan of "Self-determination theory" with its emphasis on the importance of responding to our needs for Autonomy, Competence & Relatedness. Relevant research papers are numerous, examples include "Persistent pursuit of need-satisfying goals leads to increased happiness", "Change your actions, not your circumstances: An experimental test of the Sustainable Happiness Model" and "It's not just the amount that counts: balanced need satisfaction also affects well-being". I very regularly speak with clients about their values, about what they feel is most important, about how they relate to others & themselves, and what they can do to grow their wellbeing.

And the fourth of these maybe less regularly considered therapeutic approaches is directly using the here-and-now of my relationship with the client. The series of blog posts starting with "Meeting at relational depth: outline of a 'research' workshop" speaks to this area. The ability to "shift gears" into very honest, caring, empathic here-and-now sharing is so valuable both in therapy and in our own personal close relationships - see "Friendship: science, art & gratitude". It's not an openess of interaction that many of us "swim in" very often. It can be a source of so much learning and growth. The psychotherapist Irvin Yalom used to use the question "How do we feel about the space between us?" When it feels appropriate, it's a question that I use too. There are many other instances like this. For example, if a client makes some comment - often self-disparaging - about what they feel I must think about them, an option I often follow is to ask "Would you like to know what I really think about you?". If they say "yes", I may set it up as a behavioural experiment, but I certainly do my best to answer very honestly & caringly. It's powerful. And I'm very ready to reciprocate and be on the receiving end of honest feedback about what they feel about me. Another example, for a client who says that they have trouble being really authentic, is to agree to use a quick "thermometer check" intermittently during the psychotherapy session. So if 100% represents being totally open, genuine & honest and 0% represents being completely closed & inauthentic, I may ask them every so often during the session roughly how they would rate themselves in their current interaction with me. If they estimate, for example, 60 to 70%, an obvious question is "If you feel prepared to, what would you share with me if you moved up to being say at least 80% open?"

That's the "two-seven" section of the model. There's the initial combination of an overall problem-solving approach combined with honouring the importance of the working alliance, then the seven overlapping kinds of treatment approach I may suggest using. The final "two" of the model involves a knowledge of the evidence base underpinning the different interventions and careful routine monitoring of both client progress and the state of the alliance. So with the evidence base I may well say to the client, I tend to recommend we use treatment approaches that have been shown through good research to be first choices for the kind of difficulty you have been experiencing. If these first choice approaches don't achieve the progress you want, then let's move on to or add in second choice approaches, and so on. Of course this evidence based selection is going to be affected by a whole series of other factors - client preferences, client's experience & response to different forms of treatment in the past, the severity of their disorder, the availability of different treatments, and so on. Then what holds it all together and helps to prevent slipping into a fruit salad of disorganized interventions,is consistent monitoring of outcome and alliance. See the post "Psychotherapists & counsellors who don't monitor their outcomes are at risk of being both incompetent & potentially dangerous".

A lot to think about. Hippocrates had it about right when he wrote "Life is short, art long, opportunity fleeting, experience deceptive, judgment difficult." Although sitting right in front of me on my desk is another thought. It's a picture given to me spontanously by my son a quarter of a century ago when he was maybe five or six years old. Above the picture of a smiling man is the simple statement "A doctor's life is a happy one" ... and it can be so often for psychotherapists too.

Here's my brand new "two-seven-two" model of integrative psychotherapy.  How do I know it's so fresh off the press?  Well I just came up with it lying warmly in bed an hour or so ago.  It's "serious" in the sense that I have been mulling over what I actually do as a therapist, and how I might categorise the different methods that I use.  I certainly qualify as "experienced".  My first work in "psychotherapy" (if you could call it that) was co-facilitating drop-in encounter groups while I was still a medical student in 1974.  That gives me about 38 years in the field, so I guess I've seen a fair amount.  The popularity of specific psychotherapy approaches sometimes seems to come and go a bit like a slowed version of changes in hemline fashion.  My core approach is cognitive-behavioural because that's currently where there's the most solid evidence base.  Times change though.  CBT evolves and other psychotherapy methods are increasingly getting their research hats on and showing that they too have good interventions to offer.  I am integrative, as CBT itself is becoming.  I think there are good reasons for encouraging this kind of diversification - see, for example, my post "Orlinsky & Ronnestad's 'How psychotherapists develop': three key recommendations for maintaining effectiveness".

So what's the "two-seven-two" model?  The initial two is the combination of an overall problem-solving approach and a deep valuing of the therapeutic alliance.  These two components intertwine.  I see the therapeutic/working alliance as involving Horvath's triad of agreement on the goals of therapy, agreement on what feel effective methods to use to reach these goals, and being good fellow-travellers - in tune and relating with warmth & respect.  John Norcross's recent overview of "The therapeutic relationship" in the multi-authored, 2010 edition of "The heart & soul of change: delivering what works in therapy" underlines the importance of the alliance.  The problem-solving diagram I put together from what the client tells me at our initial session(s) ensures that the therapeutic goals that they personally choose remain centre stage in our work.  To elicit these goals I often ask questions like "Let's imagine that we see each other over several sessions and that you're really pleased with how things have gone.  What would you want to have achieved?  What changes, what improvements would you most want to have made?" 

If you look at a PDF of the problem-solving diagram I most typically use, you'll see that there is space on the lower half of the page for a variety of therapeutic approaches to be jotted down.  Here's where the "seven" section of of the "two-seven-two" model comes in.  Three of these therapeutic approaches are probably common to many therapists; four of them are maybe less routinely used.  The three more usual components could be described as outer (current) problem solving, inner (current) problem solving, and tackling the "ball & chain".  So, often a client presents with a particular life difficulty - maybe a relationship that is going wrong, or a conflict at work, or a feeling of being depressed, or some other experience that they want to change.  I will typically explore with them what they could do to tackle the outer situation better and whether they also would benefit from working on their possibly somewhat dysfunctional internal responses.  The outer work might - for example - involve couple therapy, or job hunting, or behavioural activation, while the inner work might - for example - involve reappraisal methods, or mindfulness training, or a focus on developing self-compassion.  The "ball & chain" focus would be used if it seemed that the effects of past experiences - possibly childhood or other trauma - needed to be addressed to allow the client to move forward adequately in their current life situation.

I'll write the second half of this "two-seven-two" integrative model post tomorrow.

Last week I wrote about chapter seven of Mark & Danny's book.  This post is about chapter eight - the fourth week of actual meditation practice - entitled "Moving beyond the rumour mill" (pp. 134 to 158).  In their week-by-week overall summary of the whole programme (pp. 58 to 60), they write "Week four introduces a Sounds and Thoughts meditation that progressively reveals how you can be sucked unwittingly into 'over-thinking'.  You'll learn to see your thoughts as mental events that come and go just like sounds.  By meditating on the sounds around you, you'll come to learn that 'the mind is to thought what the ear is to sound'."  I really like this aphorism - "The mind is to thought what the ear is to sound."  And, again & again, chapter eight revisits this key issue of how we relate to our inner experiences.  Can we learn to make some space, to not be swept away so easily and for so long by the stream of thoughts, feelings & sensations we all live with.  And we will get swept away.  I've been meditating for forty years.  In an hour or so I intend to meditate again.  I am very confident that I will repeatedly get "swept away".  And another aphorism from this wise & helpful chapter - "The experienced meditator is not someone whose mind does not wander, but one who gets used to beginning again".  Great.

So the actual practices for this week are to go through the 8 minute "Breath and body" meditation, that we're already familiar with, followed straight away by the new 8 minute "Sounds and thoughts" meditation.  The aim is to practise this 16 minute sequence twice a day for six days of the next week.  We're also requested to continue to use the short 3 minute "Breathing space" meditation "formally" twice a day, as we have been doing, and additionally to begin exploring the "Breathing space" practice "informally", for varying lengths of time, at many other points in our day.  Finally the "Habit releaser" for this week involves a trip to the cinema.  If you're finding it helpful to use, here is a practice record for this work.   

This chapter "Moving beyond the rumour mill" looks especially at how we can get caught & torn by thoughts like some poor first world war soldier trapped & ripped on miles of barbed wire entanglements.  Like my first world war soldier example, there are so many images & metaphors for this human struggle with unhelpful thoughts & feelings.  One of my favourites is "The bus driver metaphor" that I often talk about with clients.  Others I use are the wise fish, dealing with a loved but naughty child, and coping with a neighbour's overloud radio or very noisy traffic.  Mark & Danny come up with a further sequence of metaphors - the rumour mill, the soundscape, the king/queen & their retinue, sitting by a stream, watching a film and getting caught in the rain to name just some of them.  Pretty much every teacher of meditation is going to have their list of favourite metaphors & analogies for the challenge of relating to unhelpful mental activity.  Learning mindfulness skills is likely to be helped if you choose & remind yourself of just a few of these many metaphors that you personally find particularly memorable and useful.    

It's very clear that habitual responses like rumination/worry, catastrophising & self-blame are patterns that are routinely associated with worse outcomes - see for example a handout I use "Rumination, from TRAP to TRAC" or Garnefski & Kraaij's "Cognitive emotion regulation questionnaire".  Interestingly it's the analytical, evaluative self-focused ruminative style that seems particularly toxic with a more sensory-based, experiential style (as in mindfulness) being helpful rather than damaging - see, for example, "The effects of self-focused rumination on global negative self-judgements in depression".  A particulary troublesome pattern is the tendency to respond to temporary episodes of low mood with self-focused ruminative activity.  This is a classic pathway into depression.  As the researchers Barnhofer & Chittka reported in their recent paper "Cognitive reactivity mediates the relationship between neuroticism and depression" - "Tendencies to respond to mild low mood with ruminative thinking mediated the relation between neuroticism and current symptoms of depression ... The results suggest that neuroticism predisposes individuals to depression by generally increasing the likelihood of ruminative responses to low mood ... These findings suggest potential targets for interventions to help preventing the occurrence, or recurrence of depression in those who due to their temperamental predisposition are at an increased risk."

And this is what mindfulness training does.  By teaching us to be more understanding, more mindful, more self-compassionate, we begin to step away from these ruminative vicious spirals that can so easily lead us down into depression.  See, for example, "How does mindfulness-based cognitive therapy work?" and "Rumination and worry as mediators of the relationship between self-compassion and depression and anxiety".  And mindfulness training seems particularly well-suited to this challenge - see "A randomized controlled trial of mindfulness meditation versus relaxation training: effects on distress, positive states of mind, rumination, and distraction" with its conclusion "The data suggest that compared with a no-treatment control, brief training in mindfulness meditation or somatic relaxation reduces distress and improves positive mood states. However, mindfulness meditation may be specific in its ability to reduce distractive and ruminative thoughts and behaviors, and this ability may provide a unique mechanism by which mindfulness meditation reduces distress."  In fact, if you don't learn to use mindfulness to reduce tendencies to rumination, you're liable to run into trouble as the authors of "Rumination as a predictor of relapse in mindfulness-based cognitive therapy for depression" reported "Rumination significantly decreased during the MBCT (mindfulness-based cognitive therapy) course.  Post-treatment levels of rumination predicted the risk of relapse of major depressive disorder in the 12-month follow-up period even after controlling for numbers of previous episodes and residual depressive symptoms".  You can get an idea how you're doing with reducing a tendency to this self-focused, analytical, 'brooding' kind of response style by tracking progress using a simple measure like the four-item "Rumination scale". 

As usual, you're more likely to digest and benefit from what you've read in the "Moving beyond the rumour mill" chapter and this blog if you use a simple reflection sheet to record your reactions & thoughts.  And next week I'll write on chapter nine of the book - "Turning towards difficulties".

I wrote yesterday about the importance of processing "hot cognitions" and feelings.  In today's post I aim to to drill down more into the emotional evocation and processing of chair work. "Two chair work for conflict splits" is often relevant, Robert Elliott suggested in this Emotion-focused therapy workshop, when clients display a.) Two wishes or action tendencies. b.) There is description of a contradiction or conflict. c.) A sense of struggle or coercion is expressed. This pattern is obviously observed when there is conflict over a decision that needs to be made. Typically there's a sense of uncomfortable "tornness". These conflicts may also emerge, Robert pointed out, as self-evaluative splits (self-criticism) in depression, as coaching splits for example with studying & lifestyle (self-coercion), and as attribution splits - often seen in social anxiety (externalized, over-reaction to others). There are many potential clinical applications, including for depression, borderline processes, substance abuse, PTSD, and anxiety disorders. Interestingly a very recent paper also suggests this approach's potential relevance for eating disorders too - "'It's like there are two people in my head': A phenomenonological exploration of anorexia nervosa and its relationship to the self". For me, with my primary training being cognitive-behavioural, it's fascinating to consider the great breadth of possible application of this two chair method. It can certainly respond to John Teasdale's plea to work more with "hot cognitions" and CBT is so frequently concerned with competing beliefs about distressing situations. There seems so much work out there already on the use of this kind of two chair work specifically for self-attacking, self-critical splits - for example Paul Gilbert's Compassionate Mind Training approach or EFT developments as described in the book "Emotion-focused therapy for depression". I'm really interested, as well though, in exploring this two chair approach when working with the internal "self-scarer" voice one finds so often with anxiety disorders. I haven't seen much published on this. It feels interesting. I like too the approach's potential application for "coaching splits". Robert demonstrated this method with a course member volunteer. Then when we came to move into small groups for practice, I too worked "as client" on a personal "coaching split". It has been helpful. Great.

Robert pointed us in the direction of his co-authored book "Learning emotion-focused therapy" for extending the material covered in this afternoon seminar. There are also many relevant research studies. One that I find particularly interesting and helpful is Missirlian & colleagues' paper "Emotional arousal, client perceptual processing, and the working alliance in experiential psychotherapy for depression" where the authors found that it was a combination of emotional arousal in conjunction with perceptual processing that was particularly predictive of better therapeutic outcome. Emotional arousal and perceptual processing were measured separately. The arousal measure I haven't come across before and it chimes well with my strong sense of how voice quality tells us so much about depth of emotional connection. The researchers used the Client Emotional Arousal Scale-III (CEAS-III) which "assesses the quality and intensity of client emotions based on evaluation of the client's degree of arousal from voice and body and the degree of restriction of expression. In this rating, an "emotional voice" ... is characterized by "an overflow of emotion into a speech pattern" and can be detected by attending to the following aspects: accentuation pattern, regularity of pace, terminal contours, and whether there has been a disruption of speech patterns. CEAS-III assessment is divided into two parts: First, the client's primary emotion is identified; second, the overall level of intensity of the client's primary emotion (modal intensity) as well as the peak intensity, or intensity of the maximally aroused moment, are rated ... ratings are based on a 7-point scale, where upper levels indicate higher arousal intensities (e.g., 1.
Client does not express emotions. Voice or gestures do not disclose any emotional arousal; 4.
Arousal is moderate in voice and body. Emotional voice is present; ordinary speech patterns are moderately disrupted by emotional overflow as represented by changes in accentuation patterns, unevenness of pace, changes in pitch. Although there is some freedom from control and restraints, arousal may still be somewhat restricted; 7.
Arousal is extremely intense and full in voice and body. Usual speech patterns are completely disrupted by emotional overflow. Arousal appears uncontrollable and enduring. There is a falling apart quality)."  Mm ... you can get the picture. This is certainly John Teasdale's "hot cognition" territory.

Meanwhile processing was measured using the "Levels of Client Perceptual Processing (LCPP)" method which "assesses the way in which clients process their experiences in therapy. The LCPP consists of seven mutually exclusive categories, each category representing a particular kind of mental operation: (I) recognition, (II) elaboration, (III) externally focused differentiation, (IV) analytic differentiation, (V) internally focused differentiation, (VI) reevaluation, and (VII) integration. Levels I-III of the LCPP are representative of automated, or a nonreflective mode of processing, whereas Levels IV-VII represent a deliberate or controlled and reflective manner of processing". The expectation is that a deep internally focused, differentiation & reevaluative integration of one's strongly felt emotional experience can be particularly helpful. Pascual-Leone & Greenberg revisited this territory in their paper "Emotional processing in experiential therapy: Why "the only way out is through"." They reported "The purpose of this study was to examine observable moment-by-moment steps in emotional processing as they occurred within productive sessions of experiential therapy. Global distress was identified as an unprocessed emotion with high arousal and low meaningfulness ... The qualitative findings produced a model showing: global distress, fear, shame, and aggressive anger as undifferentiated and insufficiently processed emotions; the articulation of needs and negative self-evaluations as a pivotal step in change; and assertive anger, self-soothing, hurt, and grief as states of advanced processing ... A multivariate analysis of variance showed that the model of emotional processing predicted positive in-session effects and ... that distinct emotions emerged moment by moment in predicted sequential patterns." I think I've been guilty sometimes of using chair work a bit like "a sausage processing machine" - set up the conflict dialogue, follow the therapist do-it-yourself instructions, and bingo out comes the positive therapeutic response. This point of view isn't totally bad. The following diagram illustrates a simplified "cookery" model of two chair work:
  
                                                   (This diagram is downloadable both as a PDF file and as a Powerpoint slide). 

This flow chart is helpful, but it's useful too to keep a broader sense of what this work is probably about.  Emotional arousal signals what's important to us.  Often in group work one sees this - it's as though the group is an electrical circuit and when someone is personally touched by what's happening, one can see them light up like an electric bulb.  Same in one-to-one work or in life more generally.  Noticing when emotion bubbles up is a royal road to material that's likely to be significant.  And being able to notice, stay with, articulate and "unpack" the emotions gives us access to meaning.  It's a bit like say the London underground map.  Emotional arousal lights up parts of the map.  Seeing what lights up, the intensity, the extent, the mix of colours, the interconnections - this perceptual processing allows clearer meanings to emerge, reappraisals to occur, integration to develop.  Arousal and processing: lighting up and observing/expressing/learning: key ingredients, held in the safe bowl of a caring (therapeutic) relationship.  And as shown in the Pascal-Leone study (above) this work encourages " ... global distress, fear, shame, and aggressive anger as undifferentiated and insufficiently processed emotions" via "the articulation of needs and negative self-evaluations as a pivotal step in change" to shift to "assertive anger, self-soothing, hurt, and grief as states of advanced processing."

So partly, in two chair work, it's as if we very deliberately stand in front of the "London underground map" and have the courage to allow emotion to light up key areas that really matter to us.  This involves emotional awareness & regulation - mentioned as two of the four key emotional processes in Greenberg & Pascual-Leone's paper, or the identification & regulation described as two of four core emotional competencies by Nelis & colleagues.  This isn't easy.  Those who suffer from depression often have difficulty really looking at the emotionally coloured detail of what may have contributed to their vulnerability - see for example the recent papers "Overgeneral autobiographical memory as a predictor of the course of depression: A meta-analysis" and "Negative intrusive memories in depression: The role of maladaptive appraisals and safety behaviours."  One sees related processes too with trauma so, in their article "Characteristics and organization of the worst moment of trauma memories in posttraumatic stress disorder", Jelinek et al commented "It has been proposed that the organization of the worst moment in traumatic memories ("hotspots") is of particular importance for the development of PTSD. However, current knowledge regarding the organization and content of worst moments is incomplete. In the present study, trauma survivors with (n=25) and without PTSD (n=54) were asked to indicate the worst moment of their trauma and to give a detailed narrative of the traumatic event. The worst moment and the remaining narrative were analyzed separately with regard to organization and emotional content. Results indicated that worst moments of trauma survivors with PTSD differed from the remaining narrative and from worst moments described by trauma survivors without PTSD in that they were characterized by more unfinished thoughts, more use of the present tense and lower levels of cognitive processing."  And this brings us to the need for "perceptual processing" to digest the raw materials thrown up through emotional awareness.  It's not typically enough for emotional arousal to light up the map, and emotional regulation to allow us to keep looking at the picture that emerges.  We also need Greenberg & Pascal-Leone's third & fourth key emotional processes - "active reflection on emotion (meaning making), and emotional transformation" - and the last two of Nelis et al's core emotional competencies - "understanding ... and utilization."  Maybe this is partly why Greenberg & colleagues found, in their study, that "An optimal frequency (25%) of highly aroused emotional expression was found to relate to outcome, with deviation from this optimal frequency predicting poorer outcome. Conclusions: Too much or too little emotion was found to be not as helpful as a moderate amount."  We need time to heat up the therapeutic meal, but also we need time to chew it over and digest it.  Thoughtful use of two chairs methods can be very helpful with this - both the dialogue sequence itself and, very importantly, then discussing, maybe writing about, and acting on the understandings that emerge. 

We're looping back to the first of this three post series - on narrative therapy and trauma processing - where we emphasised that "successful psychotherapy entails the articulation, revision, and deconstruction of clients' maladaptive life stories in favor of more life-enhancing alternatives".  Precious work.  As the great poet Rilke wrote "Perhaps all the dragons in our lives are princesses who are only waiting to see us act, just once, with beauty and courage.  Perhaps everything that frightens us is, in its deepest essence, something helpless that wants our love."

I wrote yesterday about the morning session on "Narrative therapy and trauma processing" in the third day of an "Emotion-focused psychotherapy: Level 2 workshop series" that I'm attending at the University of Strathclyde.  A couple of months ago, in my first post about this whole workshop series, I wrote "As a psychotherapist who is primarily cognitive-behavioural in orientation, why am I putting in all this time & effort to deepen my understanding & skills in Emotion-focused therapy (EFT)? Well, EFT/Gestalt techniques have widely infiltrated a whole series of areas in CBT. So Arntz & colleagues' very successful schema therapy draws heavily on EFT - see, for example, their book "Schema therapy for borderline personality disorder" and extending the approach out to Axis I disorders too, their forthcoming publication "Schema therapy in practice". Paul Gilbert's CBT-related Compassionate Mind work also incorporates EFT/Gestalt derived methods - see "Compassion: Conceptualisations, research and use in psychotherapy" - and Kristin Neff's paper "Self-compassion and adaptive psychological functioning" (available in free full text from Neff's website) demonstrates significant increases in self-compassion and decreases in self-criticism three weeks after a 20 to 30 minute Gestalt two chair dialogue exercise. Work on PTSD can also draw on these experiential methods, and the current surge of interest in imagery overlaps into this territory as well - see the recent "Oxford guide to imagery in cognitive therapy".

And of all the EFT approaches that other therapies have incorporated, probably the stand-out import has been chair work ... and that's the topic of this afternoon's workshop.  In fact we're going to look at "two chair work for conflict splits".  In later seminars we'll be exploring other aspects of this approach like "empty chair work for unfinished business".  When, as a non-EFT psychotherapist, one initially comes across the idea of asking clients to dialogue between different aspects of themselves or between themselves and someone else who isn't actually in the room ... well it can seem a bit artificial, forced and even embarrassing.  I did a first workshop with Les Greenberg seven years ago, followed fairly rapidly by a more formal level 1 training with Les, Jeanne Watson, Antonio Pascual-Leone, and Robert Elliott (who is running today's training).  Subsequently I've been to workshops with both Arnoud Arntz and Paul Gilbert.  I use "chair work" pretty regularly and clients frequently report it as one of the most emotionally moving & memorable aspects of their therapy.  This matters.  In his paper "Emotional processes in psychotherapy: evidence across therapeutic modalities", Whelton wrote "At the present time there is an interest in emotion research in therapy that cuts across all therapeutic modalities. Emotional processing and depth of experiencing, two heavily-researched emotion process categories of the behaviourists and humanists respectively, have been shown to have a robust association with outcome. There is accumulating evidence that both the in-session activation of specific, relevant emotions and the cognitive exploration and elaboration of the significance and meaning of these emotions are important for therapeutic change". 

Nearly twenty years ago, in his seminal paper "Emotion and two kinds of meaning: cognitive therapy and applied cognitive science", the great CBT researcher John Teasdale wrote "The clinical cognitive approach assumes that emotional reactions are mediated through the meanings given to events. Cognitive therapy aims to change emotion by changing meanings. It focuses on specific level meanings, evaluating the truth value of particular beliefs ... This focus on meaning at a specific level causes problems, e.g. the contrasts between 'intellectual' and 'emotional' belief, between 'cold' and 'hot' cognition, and between explicit and intuitive knowledge ... the Interacting Cognitive Subsystems (ICS) approach ... suggests a therapeutic focus on holistic rather than specific meanings, a role for 'non-evidential' interventions, such as guided imagery, and a rational basis for certain experiential therapies."  There is a danger that cognitive therapists can find themselves all too easily working at the level of "cold" rather than "hot" cognitions.  In their fascinating paper "Clients' emotional processing in psychotherapy: a comparison between cognitive-behavioral and process-experiential therapies", Jeanne Watson & Danielle Bedard wrote "The authors compared clients' emotional processing in good and bad outcome cases in cognitive behavioral therapy (CBT) and process-experiential therapy (PET) ... Twenty minutes from each of 3 sessions from 40 clients were rated on the Experiencing Scale. A 2 x 2 x 3 analysis of variance showed a significant difference between outcome and therapy groups, with clients in the good outcome and PET groups showing significantly higher levels of emotional processing than those in the poor outcome and CBT groups, respectively ... The results indicate that CBT clients are more distant and disengaged from their emotional experience than clients in PET."  And I would emphasise, even just comparing clients in the CBT group, a deeper level of emotional processing - working more with "hot" cognitions - was associated with better clinical outcome.  I find it valuable to keep a rough notion of what level we are on the "Experiencing scale" (PDF here) when I'm working with clients.

It's not a question however of the more the better.  In the abstract of their paper "Optimal levels of emotional arousal in experiential therapy of depression", Carryer & Greenberg reported "Objective: To determine the relationship between length of time spent expressing highly aroused emotion and therapeutic outcome. Method: Thirty-eight clients ... treated for depression with experiential therapy, were rated on working alliance and expressed emotional arousal ... in their three highest arousal sessions ... Results: Hierarchical regressions showed that a nonlinear pattern of expressed emotional arousal predicted outcome significantly above the alliance. This combination predicted 30% of outcome variance on the BDI ... An optimal frequency (25%) of highly aroused emotional expression was found to relate to outcome, with deviation from this optimal frequency predicting poorer outcome. Conclusions: Too much or too little emotion was found to be not as helpful as a moderate amount. It was concluded that expressed emotional arousal in experiential therapies has a more intricate relationship with therapeutic outcome than has previously been shown and that it is moderate amounts of heightened emotional arousal that improve predictions of therapeutic outcome."  And for some clients, even "moderate amounts of heightened emotional arousal" will be unhelpful initially - see the series of blog posts on Marylene Cloitre's fine work starting with "Improving treatments for complex PTSD and for survivors of child abuse" for hard data on the value of getting these issues right therapeutically. 

As Greenberg & Pascual-Leone point out in their paper "Emotion in psychotherapy: A practice-friendly research review" "Four distinct types of emotion processes are identified in the literature as useful in therapy, depending on a client's presenting concerns: emotional awareness and arousal; emotional regulation, active reflection on emotion (meaning making), and emotional transformation."  And in a startling article last year - "Increasing emotional competence improves psychological and physical well-being, social relationships, and employability" - Nelis & colleagues reported on an broad based group training focusing on "teaching theoretical knowledge about emotions and on training participants to apply specific emotional skills in their everyday lives. Sessions were centered on the four core emotional competencies: identification, understanding, regulation, and utilization."  Outcomes were exciting - "This study builds on earlier work showing that adult emotional competencies (EC) could be improved through a relatively brief training ... Results of Study 1 showed that 18 hr of training with e-mail follow-up was sufficient to significantly improve emotion regulation, emotion understanding, and overall EC. These changes led in turn to long-term significant increases in extraversion and agreeableness as well as a decrease in neuroticism. Results of Study 2 showed that the development of EC brought about positive changes in psychological well-being, subjective health, quality of social relationships, and employability. The effect sizes were sufficiently large for the changes to be considered as meaningful in people's lives."

OK, my focus is becoming over-broad.  See tomorrow's post to drill down more into the emotional evocation and processing of chair work. 

Yesterday was the third day of the seven seminar "Emotion-focused psychotherapy: Level 2 workshop series" that I'm attending at the University of Strathclyde.  I wrote about the second workshop last autumn in the posts "Emotion-focused therapy workshop series (first post): excitement and why am I doing this?" and "EFT workshop series (second post): client processes and therapist-client conflict".  So how was yesterday's workshop for me?  Irreverently that question reminds me of the joke "The love making was so good that even the neighbours stopped for a cigarette". 

It was a good day.  Pretty jam-packed.  In the morning we covered narrative therapy, trauma and their confluence in EFT.  It's topical territory.  Les Greenberg & Lynne Angus's book "Working with narrative in emotion-focused therapy: changing stories, healing lives" came out just last year.  The book description comments "In psychotherapy, as in life, all significant emotions are embedded in important stories, and all significant stories revolve around important emotional themes. Yet, despite the interaction between emotion and narrative processes, emotion-focused therapy (EFT) and narrative-informed therapies have evolved as separate clinical approaches. In this book, Lynne Angus and Leslie Greenberg address this gap and present a groundbreaking, empirically based model that integrates working with narrative and emotion processes in EFT. According to Angus and Greenberg's narrative-informed approach to EFT, all successful psychotherapy entails the articulation, revision, and deconstruction of clients' maladaptive life stories in favor of more life-enhancing alternatives ... Engaging, in-depth case studies ... illustrate how the model can be applied to treatment of depression and emotional trauma."  Mm ... I like the comment "successful psychotherapy entails the articulation, revision, and deconstruction of clients' maladaptive life stories in favor of more life-enhancing alternatives".  I'm less convinced by their use of the description "empirically based model".  I would have thought that implied a bedrock of outcome research, that hasn't happened so far and may never do so.  Having said that, there is encouraging emerging work that is relevant - for example last year's paper by Vromans & Schweitzer "Narrative therapy for adults with major depressive disorder: improved symptom and interpersonal outcomes".

And the more I think about it, the more seriously I am attracted to this territory.  I'm a huge fan of our attempts to use evidence-based approaches when we try to help our clients.  Compassion calls out for us to be as effective as we can be in relieving suffering and good science helps us distinguish what's genuinely useful from what's hogwash.  There can easily be problems though with this evidence-based medicine (EBM) approach.  Like Mulla Nasruddin and his lost keys, we can look very thoroughly but in the wrong place - see for example November's post "Psychotherapists & counsellors who don't monitor their outcomes are at risk of being both incompetent & potentially dangerous".  There's a real surge in energy for narrative-based approaches as a way to humanise, balance and increase the helpfulness of EBM.  There are many recent papers highlighting this hope - examples include "The marriage of evidence and narrative: scientific nurturance within clinical practice", "Narrative and psychiatry" and "Narrative vs evidence-based medicine--and, not or".  A whole issue of the journal "Psychotherapy Research" last year explored a variety of relevant narrative-based approaches, and last month's British Journal of Psychiatry featured a major review article "Conceptual framework for personal recovery in mental health: systematic review and narrative synthesis".  Its abstract reads "Background: No systematic review and narrative synthesis on personal recovery in mental illness has been undertaken. Aims: To synthesise published descriptions and models of personal recovery into an empirically based conceptual framework.  Method: Systematic review and modified narrative synthesis.  Results: Out of 5208 papers that were identified and 366 that were reviewed, a total of 97 papers were included in this review. The emergent conceptual framework consists of: (a) 13 characteristics of the recovery journey; (b) five recovery processes comprising: connectedness; hope and optimism about the future; identity; meaning in life; and empowerment (giving the acronym CHIME); and (c) recovery stage descriptions which mapped onto the transtheoretical model of change ... Conclusions: The conceptual framework is a theoretically defensible and robust synthesis of people's experiences of recovery in mental illness. This provides an empirical basis for future recovery-oriented research and practice."  Narrative approaches are very much flourishing!

What about trauma?  One might think that the NICE guidelines' advocacy of trauma-focused cognitive therapy and eye movement desensitisation as the recommended evidence-based approaches for posttraumatic stress disorder has somewhat closed this debate.  NICE are certainly clear in their statement "where symptoms have been present for more than 3 months after a trauma, offer trauma-focused psychological treatment (trauma-focused CBT or EMDR) to all patients".  I do think though that Wampold et al's major paper "Determining what works in the treatment of PTSD" has opened up the debate over what types of treatment we should be using for trauma-related problems.  And as Arntz & colleagues have shown, clinically relevant trauma extends way beyond the relatively narrow confines of classical PTSD - see "Symptoms of post-traumatic stress disorder after non-traumatic events: evidence from an open population study".  It's no longer controversial to argue as I have done in the presentation "Traumatic memories" that "1.) Trauma memories are very common in depression and anxiety as well as in PTSD.  2.) Disorder onset, severity and persistence seem contributed to by memories and ‘images'.  3.) Lessons from PTSD treatment may well improve treatment of depression and anxiety".  Last year's excellent book "Oxford guide to imagery in cognitive therapy" co-authored by my friend & colleague James Bennett-Levy, provides a fine state-of-the-art clinical overview of this territory. 

Riches indeed!  Narrative approaches, trauma and emotion-focused therapy all covered in a morning.  Gosh our course facilitator, Robert Elliott, likes crunching on big mouthfuls of material.  And he delineated a useful structure for working with a narrative-based EFT approach to trauma symptoms and off we went in small groups to try it out.  Good, and in the afternoon we went on to begin looking at therapeutic "chair work" and it struck me that - with conflicting & updating "meanings" being so central to trauma work - maybe chair dialogues between different meaning standpoints might also sometimes be useful when working with trauma, a potential bridge between our morning and afternoon sessions.  Tomorrow I'll write about the "two chair work" second half of this day seminar in the post "The importance of working on 'hot cognitions' and feelings".