Evaluating the effectiveness of counselling in primary care: Taking a fresh look

One criticism voiced by counsellors and psychotherapists is that research does not reflect either the culture or values of therapy. Researchers, on the other hand, accuse practitioners of not attending to their findings, and the implication is made that the latter engage in treatment processes that are ill‐informed. These polarised understandings give rise to the situation where the client — and his or her development — fall into the practice‐research gap. In more recent studies of counselling in primary care, an attempt has been made to offer new perspectives for interpreting and understanding findings, and the relative value — and limitations — of different research questions and methods. They provide just a few examples of how practitioner‐researchers in the future may ask more precise questions, yet reflect on their findings from a broader set of viewpoints.     

Spontaneous Self‐Practice of Cognitive Behavioural Therapy (CBT) by Aboriginal Counsellors During and Following CBT Training: A Retrospective Analysis of Facilitating Conditions and Impact

Previous cognitive behavioural therapy (CBT) training studies have suggested that therapists who practice CBT strategies on themselves during training may experience professional and personal benefits. However, it has also been reported that some CBT trainees are reluctant to engage in self‐practice. The present study reports an incidental finding from a CBT training study with Aboriginal counsellors: all five counsellors reported that they practiced CBT techniques on themselves without specific encouragement by the trainers to do so. This paper therefore posed three questions: (a) Why—in contrast to some other trainees—did this group choose to apply CBT to themselves? (b) How did they apply it—with what purpose, in what contexts, and which skills? (c) What was the impact of CBT self‐practice? Data from the group's reflections were qualitatively analysed by two of the researchers, and “member checked” by the remainder. Results indicated that the counsellors were motivated to practice CBT on themselves for two principal reasons: the value they placed on CBT, and their personal need resulting from the high number of crises experienced while living and working in their communities. The counsellors reported practicing CBT in a wide variety of contexts as part of their learning. As in previous studies, the impact of CBT self‐practice was that it increased their confidence and competence as therapists. It also appeared to be a valuable burnout prevention strategy. If the results are generalisable, they suggest that self‐experiential training in CBT may be a culturally responsive and adaptive way for Aboriginal counsellors to enhance their learning of CBT skills.     

Researching a client's experience of preconceptions of therapy - A discourse analysis

This paper uses discourse analysis to look at clients' preconceptions of therapy, through the presentation of a case study. Further findings suggest that discourse analysis may be a useful approach to helping psychotherapists and counsellors as part of their practice.     

Learning from experience: Examining the impact of client work upon two trainee therapists

This qualitative research study, focusing on the learning and change of two trainee therapists over a nine‐month period, was conducted by the trainees themselves. In collecting and analysing their data, the researchers made use of the heuristic methodology, to which some of the principles of the co‐operative inquiry methodology were added. The findings shed light on some of the ways in which trainee counsellors and psychotherapists might learn through their work with clients, the forms and contexts in which this learning may arise, and how the learning might affect the trainees. The findings additionally highlight some of the possible benefits of engaging in research for trainee counsellors and psychotherapists, in terms of their roles as practitioners. These include positive changes in the ways in which they work with clients, and changes in the ways they think about their practice.     

Moving beyond counselling and psychotherapy as it currently is – taking therapy outside

Research was undertaken by the author in order to describe, interpret and explain what happens when counsellors and psychotherapists who have been trained to work indoors with their therapy clients take their therapy practice into outdoor natural spaces. A central research question addressed ‘What happens when counsellors and psychotherapists, who have been trained to work indoors with their therapy clients, take their therapy practice in to outdoor natural spaces?’ Semi-structured interviews were undertaken with therapists who practised outdoors. Three dominant themes emerged critiquing aspects of current counselling and psychotherapy practice. These were related to the unfolding ecological crisis, the context of the work and moving beyond current conceptions of distress and the role of therapy in addressing this.     

Between the idea and the reality: A study of the counselling experiences of bereaved people who sense the presence of the deceased

There have been many theories of the process of loss and bereavement, from Freud, to the present day. Early theories of bereavement described a process which, following various stages and associated tasks, ended at the relinquishment of the bond to the deceased. In more recent years theories have taken different directions, identifying how bereaved people re‐learn life, recreate biographies, and continue relationships to the deceased. Some research studies of bereavement have investigated the counsellors’ perspective, but there are very few studies of the client's experience and most studies have focussed on outcomes of counselling. This qualitative study, using semi‐structured interviews, provides an insight into the bereaved client's perspective on the content and process of their counselling experiences. Taking as its focus the client's sense of the presence of the deceased, this study aimed to identify whether or how counsellors facilitate exploration of this experience and which theories they use in client work. The main finding is that 80% of the counsellors were not perceived by participants to have worked with them satisfactorily in relation to their sense of presence of the deceased or in relation to the story of the death itself.     

“Out on the edge of my comfort”: Trainee counsellor/psychotherapists' experiences of spirituality in therapy—A qualitative exploration

The integration of spirituality into counselling and psychotherapy poses complex challenges. Personal spirituality, professional competency and ethical considerations may impact on trainees' experiences of integrating spirituality into therapy. This study adopted an inductive, qualitative approach to explore trainee counsellor/psychotherapists' experiences and perceptions of integrating spirituality into therapy. Six trainee counsellors and psychotherapists were recruited using purposive sampling from a professional counsellor and psychotherapist training institution in the UK. In‐depth, semi‐structured interviews were conducted, audio‐recorded and transcribed verbatim. Thematic analysis of the interviews revealed two overarching themes: spirituality provides support but needs a warning; and spirituality is relevant but undervalued. These themes encompass a wide range of trainee concerns associated with integrating spirituality into therapy. Participants reported that they felt unprepared to work therapeutically with clients' spiritual beliefs. However, the value of spirituality in providing support to both the trainee and their clients was highlighted by several participants. Some participants described integrating clients' spirituality as having a positive impact on the therapeutic relationship, but often felt threatening to the trainee. This research has implications that are important for counselling and psychotherapy training and developing enhanced consideration of client spirituality and the interpersonal environment in which therapy is delivered.     

Counsellors' experiences of changing their practice: Learning the psychodynamic‐interpersonal model of therapy

Seven counsellors were interviewed about their experiences of learning and applying a new approach to therapy: the psychodynamic‐interpersonal model. These interviews were analysed using grounded theory — a qualitative approach. Under the core category of ‘changing counselling practice: applying the PI model of therapy’, the material was organised into 10 major categories: difficult feelings; new awareness; therapeutic identity; identifying reasons for choosing how to work; experiencing difficulties in adherence; attributing causes of difficulties; ways through the difficulties; understanding how change in practice occurs; changing interventions; and specific other inputs. Examples from the interviews are used to cast light on the difficulties experienced by counsellors in the process of changing their practice.     

How Separable Are Spirituality and Theology in Psychotherapy?

The authors respond to D. A. Helminiak's (2001) article “Treating Spiritual Issues in Secular Psychotherapy.” They focus particularly on Helminiak's argument for secular spirituality (whether spirituality can be independent of theology/religion) and his inherent biases in discussing the nature and existence of spirituality. The authors argue that all spiritual conceptions have theological implications—and thus a theology, broadly defined—and that theology, in this sense, pervades the theory and practice of all psychotherapists, whether or not they are religious.     

A third language in therapy: deconstructing sameness and difference

The paper draws on recent research and the first author’s personal story to show what happens when the language difference between therapist and client is brought to mutual awareness in the therapy room. Individual lived experiences of migrant psychotherapists and counsellors and the issues that arise in therapy practice when the practitioners use their second language as the means of communication with clients are explored. The notion of a third language – a dynamic communication system that is a result of developing a professional identity through a second language – is introduced. Unlike the psychoanalytic third, it is often conscious and may be used either defensively or purposefully as a concrete third point of reference in the intersubjective encounter. The paper explores how the concept of a ‘Third Language’ can be used as a tool to negotiate perceived sameness or difference in therapeutic encounters and to build a common language with a client, both literally and metaphorically. The study featured in the paper has implications for practice, theory and research.     

Innovative Moments in Humanistic Therapy I: Process and Outcome of Eminent Psychotherapists Working with Bereaved Clients

This project entailed an intensive qualitative analysis of six-session psychotherapies conducted by three eminent humanistic psychotherapists working with bereaved clients. The Innovative Moments Coding System (IMCS), rooted in narrative therapy, is designed to measure change across therapy orientations. Research using the IMCS suggests that the psychotherapy change process occurs through the emergence, elaboration, and expansion of identifiable change moments for a client—innovative moments (IMs)—which present as exceptions to a client's presenting problematic narrative. There are five identified types of IMs: action, reflection, protest, reconceptualization (RC), and performing change (PC). The current study aimed to inform theory regarding the patterns of IMs across three humanistic approaches—constructivist, person-centered, and existential—when working with bereaved clients, while linking these patterns to observable change in each client's functioning. The alliance between each client and therapist was also assessed across the therapy process, showing consistently strong alliances across the three cases. Findings from the current study reinforce the salience of reflection, RC, and PC IMs in successful grief therapy cases, and also suggest the importance of meaning-making interventions in grief therapy. Clinical implications and suggestions for future research are also addressed.     

Intuition: A special kind of knowing?

It is argued that while counsellors have adopted the principle tenets of phenomenology—consciousness and meaning—they have built their work on an interpretation of intuition which is contrary to phenomenological rationale and presents it as a form of knowing which is esoteric and mystical. Phenomenologically, intuition differs from no other way in which sense is made of the world. Intuitions should then, in principle, be accessible to conscious understanding so as to allow counsellors to reflect (cognitively?) on their practice. If the process of intuition were really unknowable, then reflective practice in counselling would not be possible.     

Developing research‐informed practitioners – an organisational perspective

Background: Two current trends are making it increasingly important for counsellors and psychotherapists to be more engaged with research. Evidence of effectiveness is being increasingly demanded by those who fund our therapies and also by our clients. Meanwhile therapy research is offering practicable ways for therapists to improve their practice. Therapy organisations have an opportunity, perhaps even a duty, to meet the research needs of their members. Methods: This paper reports on a survey conducted by the UK Council for Psychotherapy (UKCP) to help it plan the activities of its Research Faculty. Findings: Key findings from the survey were that the most common ways of UKCP practitioners engaging with research were through reading, discussions with colleagues and doing research. Engaging with research collaboratively with other therapists, having more time, and access to user‐friendly web‐based research resources and updates, were the factors most commonly cited as supporting practitioner engagement with research. Conversely, lack of time, difficulties accessing resources and materials and feeling not competent were the major barriers to practitioner engagement with research. Discussion: Implications for therapists, for training, and for therapy organisations are considered.     

Collaboration,meaning‐making and therapy: What practitioners can learn from recent developments in qualitative research

Recent developments in qualitative research provide a rich resource of ideas and insights for counsellors and psychotherapists interested in postmodern approaches to theory and practice. The second edition of the landmark Handbook of Qualitative Research (Denzin and Lincoln, 2000) is discussed in terms of its potential value for therapists.     

Integrating counselling, psychotherapy and healing: An inquiry into counsellors and psychotherapists whose work includes healing

A qualitative study of 30 counsellors or psychotherapists whose work also includes healing was conducted using semi-structured interviews. Seven of the participants then joined the researcher in a human inquiry group. Participants in the research had been practitioners for a mean of over 10 years. The main themes that emerged were: the transition by the practitioner towards the use of healing; the taboo concerning talking about spiritual and healing experiences reported by the participants; the nature of healing as distinct from therapy; the supervision difficulties that arose when participants engaged in both counselling/psychotherapy and healing with their clients; and the concept of spiritual space. Some very experienced psychotherapists and counsellors are now including healing in their work. This raises a number of important issues, particularly relating to supervision.     

Sailing between Scylla and Charybdis1: Incorporating qualitative approaches into child psychotherapy research

Starting from the acknowledged gap between research and practice in child psychotherapy, this paper offers an historical perspective on the relation between these two activities, and suggests that qualitative approaches to research may offer new ways of bringing them together. After introducing the fundamental concepts of qualitative analysis, three areas where qualitative forms of research may be useful to child psychotherapists are explored: relevant but non-psychotherapy research; accounts of therapy research; and therapy process research. Examples of all of these types of research are presented, and some of the challenges to incorporating qualitative approaches into child psychotherapy research are discussed.     

An Ecological Perspective: Therapist Practices with Children who Experienced Abuse and Trauma

This qualitative study explores experiences of psychotherapists working in public settings with children who experienced abuse and trauma. The study sought to investigate and understand factors which intruded upon and or supported the capacity for psychotherapists in a community clinic to cognitively process and understand supportive and constraining aspects of the professional context. An important focus was the organisational context of psychotherapists. Nine psychotherapists were interviewed to gain an understanding of their experiences with and perceptions of the needs of children including factors considered important in therapy, the influences of their organisational context, and challenges and rewards of the work. An Interpretative Phenomenological Analysis of interview data revealed three broad themes identified as relational, organisational, and systemic. An ecological metaphor was used to conceptualise these themes as they related to psychotherapists and the children with whom they worked. The findings demonstrated the importance of the psychotherapist's organisational context on how they experienced their work. This study also considered the need to conceptualise therapy with children who have experienced trauma within the interaction of the child and therapist's relational, organisational, and systems context.     

Counsellors' experiences of working with suicidal clients: An exploratory study

Counselling is increasingly available in a wide variety of contexts, including mental health and psychiatric services. As a consequence, counsellors increasingly work with clients who present with suicidal ideation, expressing either suicidal thought and/or intent in the counselling session. This paper describes an exploratory study that examined the experience of counsellors when working with suicidal clients. The paper considers counsellors' behavioural, cognitive and emotional responses to such suicidal expression, both on a personal and professional level. The research employed semi‐structured interviews. A constant comparative method was used in analysing the transcribed interview text. Results suggest that counsellors experience a range of responses when their clients express suicidal thought, including fear, anxiety, anger and professional impotence. The interviewees also expressed self‐doubts about their professional competence. In addition, they identified the threat of litigation for negligent practice and the lack of confidence in appropriate risk assessment approaches as significant causes for concern. The implications for further research, and practice, are discussed.