Person‐centred counsellors' experiences of working with clients in crisis: A qualitative interview study

Aims: This study aims to explore and understand person‐centred therapists’ experiences and work with clients at the pivotal point of crisis. Specifically: how do person‐centred therapists experience working with clients in crisis? Do they identify differences in crisis intervention compared to non‐crisis work? What do they perceive as helpful to crisis clients? How relevant are therapists' own experiences of crisis? Method: Participants were all experienced person‐centred therapists. Qualitative, semi‐structured interviews were conducted and the data were analysed qualitatively using person‐centred/phenomenological methodology. Results: Respondents identified differences in their experiences. Typically, therapists described polarity in their experience of danger and opportunity, also heightened energy levels within themselves, perceived higher levels of engagement, faster pace of work, experiences of reaching ‘relational depth’ earlier, and the importance of assisting symbolisation of clients' experience in awareness. Clients were experienced as vulnerable, unable to access previous coping mechanisms, in a state of breakdown and disintegration, but also as wide open, having dropped their usual defences, and more available to engage in therapy and enter the process of change and potential post‐crisis growth. Discussion: The findings are discussed in relation to prevailing models of crisis intervention, person‐centred theory and theoretical developments in post‐traumatic growth in the aftermath of crisis.     

Person‐Centred and Experiential Psychotherapy Scale: Development and reliability of an adherence/competence measure for person‐centred and experiential psychotherapies

Aims: This study aimed to assess the reliability of the Person‐Centred and Experiential Psychotherapy Scale (PCEPS), a new adherence/competence measure of person‐centred and experiential psychotherapies. The PCEPS consists of 15 items with two subscales: Person-Centred Process and Experiential Process. Method: One‐hundred twenty audio‐recorded segments of therapy sessions were rated independently by two teams of three raters using the PCEPS. Half of the segments were 10 minutes long and the other half were 15 minutes long. Six therapists were experienced therapists and four were counsellors in training. Seven of the therapists identified their work as ‘person‐centred’, and three identified their work as ‘process‐experiential’. Three raters were qualified and experienced person‐centred therapists and three raters were person‐centred counselling trainees in their first year of training. Results: Interrater reliabilities were good (alpha: .68–.86), especially when ratings were averaged across items (alpha: .87); interitem reliabilities were quite high (alpha: .98). Exploratory factor analyses revealed a 12‐item facilitative relationship factor that cuts across Person‐Centred and Experiential subscales (alpha: .98), and a nonfacilitative directiveness factor (3 items, alpha: .89). Conclusions/Implications: The PCEPS has potential for use in RCT research as well as in counselling training and supervision, but will require further testing and validation.     

Therapists facing masks: A qualitative study of the nature of relationships between masks and relational depth

Background

Central to this research was exploring characteristics facilitating and disinhibiting meetings at relational depth to explore underlying driving factors of change. The overall aim was to explore relationships between masks and relational depth. Viewing masks as a characteristic sought to understand further the socio-cultural impacts of masks on client/patient care and decision-making to meet at depth. This research demonstrates immediate social and international context due to COVID-19.

Methods

A phenomenological methodology was utilised. The primary research vehicle was an examination of primary data from semi-structured interviews. Four therapists who had used masks within sessions (where both therapist and clients wore masks) provided data on meetings at relational depth.

Findings

Interpretative phenomenological analysis revealed four themes: ‘epicentre of aetiology’, ‘loss’, ‘masked-disinhibition’ and ‘disconnection paradox: depth through disconnection’. Findings suggest masks are a characteristic that can facilitate and inhibit meetings at depth—acknowledging common factors, including how therapists related to masks as an extended part of the client, and mutuality within disconnection to masks, not one another, was significant.

Conclusions

Findings suggest the exigent presence of masks could facilitate or inhibit meetings at depth, regulated by what masks represented to therapists/clients at moments of contact. Yet, when both therapist and client appeared mutually disconnected (to masks, not each other), they found moments of relational depth within the disconnection. Masks are suggested as a characteristic that can influence meetings at depth. Opportunities for depth seemed reliant on individual capabilities to offer depth, emphasising therapists' experiential awareness of their interoceptive process.     

Countertransference issues in psychotherapy with lesbian and gay clients

This article briefly reviews literature on responses towards same-sex (lesbian and gay) sexualities from psychoanalytic and ‘lesbian and gay affirmative’ psychotherapeutic perspectives. An analysis is presented of reports of countertransferential reactions to lesbian and gay clients, obtained from interviews with fourteen psychotherapists who work in a lesbian and gay affirmative manner and eighteen clients who had received affirmative psychotherapy. Data were subjected to grounded analysis. Participants consistently attended to the thoughts, feelings and values that therapists held in relation to lesbian and gay clients and how these affected the meanings and practices available to them. These were linked with the therapist's sexual identity among other factors. Negative countertransferential reactions were regarded as potentially occurring among heterosexual and lesbian and gay therapists and were seen as arising from therapists’ conscious and unconscious fears about same-sex sexualities. These findings indicate a need to continue debating these issues more widely in the professional arena.     

Love in therapy: A qualitative study of how clients perceive their therapists’ emotions

Relevant literature on attachment theory has explored the importance of emotional experience inside the therapeutic setting, highlighting that the active engagement of the therapist with the client is necessary in the process of change. However, less is known about the clients’ perception of the therapists’ emotional expression during a session. In this qualitative study, we used narrative thematic analysis to examine 10 semi-structured interviews with clients in an enriched systemic therapy approach. Focusing on the similarities of clients’ experiences, what emerged from the interviews were specific ‘perceived emotions’ and the related facial expressions of the therapists that were given attention by the clients. Based on our findings, six emotional themes were identified and are considered prominent: (i) ‘excitement’, (ii) ‘calmness’, (iii) ‘affection’, (iv) ‘empathy’, (v) ‘anger’ and (vi) ‘sadness’. Also, the analysis revealed two distinct functions of the expression of the therapist’s emotions: (i) they are an essential part of the therapeutic relationship and, (ii) they provide clients with alternative ways of experiencing emotions and motivate them to change. Therapists are invited to recognize the importance of their own emotional and facial expression in therapy considering it a form of self-disclosure. Suggestions for further research are also provided.     

The analysis of young people’s experiences of domestic violence: spiritual and emotional journeys through suffering

The hermeneutical analysis of the stories of young people who have experienced domestic violence is described as multi‐layered having been developed from a voice centred relational methodology. The purpose was to uncover the complexity of lived experience. As the analysis proceeded, the young people’s voices emerged as ‘feeling’ voices, encompassing emotionality. Each young person’s journey through suffering was characterised by individuality, but the analysis has offered a glimpse of commonality which is present within each of the young people’s stories. Their resilience, their journey from disempowering to humanising emotions and their indomitable spiritual powers have been revealed through the analytical process.     

The experiences of therapists using a new client‐centred psychometric instrument,PSYCHLOPS (Psychological Outcome Profiles)

PSYCHLOPS (‘Psychological Outcome Profiles’) is a newly developed client‐generated psychometric instrument which can be used as an outcome measure. Uniquely, it asks clients to state their own problems, in their own words. As part of its validation, we used it alongside an existing measure, CORE‐OM (‘Clinical Outcomes Routine Evaluation – Outcome Measure’). Based on a qualitative methodology, we report here on the first‐hand experiences of four therapists using both instruments. The key themes that emerged from therapists’ responses were feasibility, validity and usefulness. Both questionnaires were perceived as complementing each other, the qualitative information from PSYCHLOPS balancing the quantitative information from CORE‐OM and that both could contribute to the therapist‐client interaction. The key features of PSYCHLOPS are likely to prove attractive to therapists and should increase acceptance and uptake of outcome measures.     

We have travelled a long distance and sorted out the mess in the drawers: Metaphors for moving towards the end in psychotherapy

Aim: To explore the process of ending in psychotherapy, in particular how clients and therapists draw on their notions of client improvements and prepare for the upcoming end. Data: The data comes from an intensive process‐outcome study at the University of Oslo, Norway. The study includes audio‐recording from all sessions and separate post‐therapy interviews with clients and therapists. Twelve psychotherapy dyads were selected because they had reached a ‘good enough’ ending. Therapy duration ranged from 7–43 months. The number of sessions ranged from 10–67. Method and analysis: A hermeneutical‐phenomenological approach analysed and combined the observational and reflexive data. The analysis was carried out using a method for systematic text condensation and through reflexive dialogues with the material and between the researchers. Findings and discussion: The language of improvement towards the end of treatment seemed packed with metaphors conveying growth in both affective and relational management. Metaphors based on travel (how they have moved); cleaning (how they have cleaned up and sorted out things); sensing (how the clients have grown stronger, got their heads above water and see things differently); and the clients’ feeling of having received something (gifts or tools) are widely used. Such metaphors are created in the interaction with a mutual sensitivity to their capacity to confirm and regulate affect towards the end. In this sense, the metaphors celebrate accomplishments in a way that exceeds therapy, and the client can keep them to use afterwards.     

Inviting passage to new discourse: ‘Alive moments’ and their spiritual significance

Some social constructionists assert that therapeutic change occurs when clients' meanings for problems and solutions shift from those found in resource‐impoverished discourses to those affording resourceful and preferred possibilities. Referred to as ‘positioning theory’, our research examined this assertion by inviting clients and therapists to speak of a significant, but ambiguous, experience in unfamiliar discourse: spiritual discourse. Clients were asked to review videotapes of their sessions, selecting moments that felt most ‘alive’ to them for discussions with the researcher, including inquiries as to whether ‘alive’ moments held any spiritual significance. The outcomes are portrayed as a ‘poetic collaboration’ between the researcher, clients and therapists — while clients' and therapists' reported experiences for changes in discourse and meaning are highlighted. Implications regarding sensitivities required when co‐constructing meanings for ambiguous but significant experiences in therapy are discussed. Possibilities for more research examining poetic practices and processes in therapy are also considered in terms of positioning theory.     

No Empathy for Empathy: An Existential Reading of Husserl’s Forgotten Question

ABSTRACT

Empathy is a term used to denote our experience of connecting or feeling with an Other. The term has been used both by psychologists and phenomenologists as a supplement for our biological capacity to understand an Other. In this paper I would like to challenge the possibility of such empathy. If empathy is employed to mean that we know another person’s feelings, then I argue that this is impossible. I argue that there is an equivocation in the use of the term ‘empathy’ which conditions the appropriation of the Other as we think that we know how the Other feels. To claim that we do know an Other’s feelings – or any kind of their intentional experience – means to appropriate their experience through our own. I will first reveal the equivocal use of the term ‘empathy’ and, then, I will explore Husserl’s use of the term. In Husserl, the understanding of an Other as empathy is only partial. I shall conclude by reiterating a thesis from philosophy of existence and feminist theory according to which to know another person comes from creating a community with them and not because we have a biological structure that can mirror each other’s feelings.     

“‘Ninja’ levels of focus”: Therapeutic holding environments and the affective atmospheres of telepsychology during the COVID-19 pandemic

The COVID-19 crisis in Australia led to a rapid increase in the use of telehealth services to offer psychological therapy (often referred to as ‘telepsychology’). In this article, we discuss the intersection of the social psychology concepts of therapeutic holding spaces and containment with more-than-human theory as it relates to Australia's mental health sector during the COVID-19 crisis. Drawing on our recent qualitative survey research into Australian psychologists' use of telepsychology during the crisis, we consider the ways that they worked to build and maintain therapeutic holding spaces and alliances over teleconferencing platforms during this extraordinary time of social crisis and isolation. We explore and contextualise three important findings from our study: 1) the limited viewing area of a flat screen makes it difficult for therapists to read and respond to their client's body language and requires different forms of returned bodily gestures in order to show empathy; 2) most respondents implemented different affective and relational strategies online to ensure they were not missing important non-verbal cues from their clients; and 3) the traditionally ‘safe’ therapeutic holding space created in face-to-face therapy can be easily subverted by client-end interruptions, and concerns around safety or personal privacy in the client's home environment. In bringing these issues to the fore, we highlight the online therapeutic holding space as a temporally and socially situated human-technological assemblage in which a series of affective, spatial, relational and sense-making agencies coverage, opening or closing off capacities for therapists and their clients.     

‘Feeling for’ and ‘feeling with’: developmental and neuroscientific perspectives on intersubjectivity and empathy

This paper discusses research by Beatrice Beebe, Bessel van der Kolk and others, exploring the interpersonal processes that underpin early relational trauma and how this contributes to adult psychopathology. An essential feature of early relational trauma, the infant's experience of being unable to evoke an empathic response from the caregiver and the feelings of shame this gives rise to, is discussed and its implications for psychotherapy are considered. The neuroscience that underpins two forms of empathy in the therapeutic relationship, of ‘feeling for’ and ‘feeling with’ the patient is discussed and explored in relation to the concordant and complementary countertransference. I argue that when therapists respond to the projection on to them of the abuser by an increasingly determined adherence to analytic technique, this may become a complementary countertransference identification with the abuser and an enactment of the abusive relationship.     

Moments of empowerment: A qualitative analysis of positively experienced episodes in brief person‐centred counselling

38 positively experienced episodes in brief person‐centred counselling with six clients were analysed. The Interpersonal Process Recall (IPR) method was used as the prime research tool. Clients were asked to identify positively experienced moments in the counselling session during a post‐session review interview. Clients and counsellors were invited to report on the feelings, perceptions and intentions they recalled experiencing during these moments. Three analyses were used to categorise the meaning and feeling quality of these moments, and a taxonomy of types of positively experienced episodes was also created. The most frequently reported positive client experiences were associated with empowerment, safety and insight. Other significant themes emerging from the analysis included: freedom in the relationship, shortcomings of the relationship, assurance of the relationship, unfolding of the client's personal meaning, and the importance of the counsellor's presence. Taxonomy of episodes revealed nine categories: four of them focused on the strengthening of the therapeutic relationship, and five focused on the empowerment of the client's self. These findings are discussed, and implications for theory and practice explored.     

Therapist perspectives on using silence in therapy: A qualitative study

Twelve experienced therapists were interviewed about their perceptions of why they used silence in therapy. Qualitative analyses revealed that these therapists typically perceived themselves as using silence to convey empathy, facilitate reflection, challenge the client to take responsibility, facilitate expression of feelings, or take time for themselves to think of what to say. Therapists generally indicated that a sound therapeutic alliance was a prerequisite for using silence, and they typically educated their clients about how they used silence in therapy. Therapists typically believed they did not use silence with clients who were psychotic, highly anxious, or angry. They typically thought they now used silence more flexibly, comfortably, and confidently than when they began doing therapy. Therapists typically believed they learned how to use silence from their own experience as a client and from supervision.     

The facilitative interpersonal skills method: Difficult psychotherapy moments and appropriate therapist responsiveness

The Facilitative Interpersonal Skills (FIS) task is a performance test of therapists’ use of common relational skills (e.g. empathy, building expectations). The FIS method includes (a) materials that simulate difficult client moments on video, which are used to collect therapists’ responses to these situations; and (b) independent ratings of these responses. Many of the FIS items are informed by psychotherapy processes that have been linked to outcome and facilitative conditions that have been reframed as individual therapist skills (e.g. alliance bond capacity). Overall, the FIS has predicted psychotherapy outcome. A single study is described in which FIS predicted the therapist effect using multilevel modelling of a large sample of clients who were nested within therapists. We also summarise two additional outcome studies that used experimental designs. One future direction is to better understand how therapists form responses to these difficult moments. We conclude that forming an optimal therapeutic response during challenging, emergent in‐session situations involves responsiveness (Stiles et al., 1998), or finding a response that fits the clients’ needs within any moment.     

The experience of counselling for female clients with anorexia nervosa: A person‐centred perspective

Anorexia nervosa is a serious and potentially life‐threatening condition, which has been studied from a range of theoretical perspectives. However, the relevance of person‐centred theory and practice in relation to anorexia nervosa has not previously been explored in the literature. The purpose of this study was to understand the experiences of clients who had received counselling for anorexia nervosa, and to set these experiences against the backdrop of person‐centred theory. The study is based on intensive heuristic analysis of interviews with five clients who had completed counselling for anorexia nervosa within the previous three months. Collaboration between the researcher and the participants led to an identification of two of the six ‘core’ conditions identified by Rogers as being of real importance to clients with anorexia: unconditional positive regard and congruence. The context in which counselling is offered was also of crucial significance to these clients. Implications for practice are discussed.     

Care Versus Control: The Identity Dilemmas of UK Homelessness Professionals Working in a Contract Culture

UK voluntary and community sector organizations (VCOs) play a key role in caring for homeless people. However, there are widespread concerns about the impact of increasing government contracting on the quality of their services. This paper examines understandings of homelessness and identities as homelessness professionals, as expressed by VCO professionals. By so doing, it considers how ‘partnership working’ enables or undermines their capacities to care. The paper uses 24 in‐depth interviews and four focus groups with London‐based homelessness professionals. Professionals expressed deep tensions in their experience of their role. On one hand, they reported a deep ethical commitment to care and to develop quality supporting relationships to respond to their clients' complex needs. On the other, their capacity to care was undermined by their dependence on statutory resources and the controls this involved over the way VCOs delivered care. Professionals had to adjust to statutory monitoring frameworks and hard performance targets, which detached them from the human and intimate encounter with their clients and constrained their person‐centred caring interventions. The findings highlight the contradictory nature of contemporary systems of ‘joined up’ welfare that neglect the very human and complex nature of the issues that they were originally created to address. Copyright © 2013 John Wiley & Sons, Ltd.