The Handbook of Individual Therapy

‘[This] is essential reading for all who aspire to professional practice to ensure that knowledge and
skills are up to date in order to best serve their clients.’

Professor Sue Wheeler, University of Leicester
‘[It] continues to be the book that one turns to when looking for a clear introduction to the broad
range of therapies that are offered in the UK today.’
Dr Nick Midgley, Anna Freud Centre
This classic text has helped over 50,000 students wishing to understand the key counselling and
THE HANDBOOK OF
INDIVIDUAL
psychotherapy approaches. This sixth edition is the most comprehensive update since it was first published
INDIVIDUAL THERAPY
in 1984, with 15 newly contributed chapters and 8 updated chapters. Each approach now includes a new
Research section summarising the research findings, an in-depth Case Study illustrating how that approach
works in practice, and an extended Practice section. Also covered:
EDITED BY
n historical context and development
THE HANDBOOK OF
n main theoretical assumptions
THERAPY
SIXTH EDITION
n which clients will benefit most
DRYDEN AND REEVES

n strengths and limitations.
New chapters include Compassion-Focused Therapy, Interpersonal Therapy, Mindfulness in Individual

Therapy, Pluralistic Therapy and The Transpersonal in Individual Therapy.
This is an ideal one-stop shop for trainees of counselling, psychotherapy, counselling psychology, psychology
and other allied professions wanting to learn about the most commonly practised therapies today.
Windy Dryden has worked in the fields of counselling and psychotherapy since 1975. He is author/editor
of over 200 books.
SIXTH EDITION
Andrew Reeves is a BACP Senior Counsellor/Psychotherapist at the University of Liverpool and a freelance
writer, trainer and supervisor. He is former Editor of the Counselling and Psychotherapy Research journal. EDITED BY
WINDY DRYDEN AND ANDREW REEVES
Cover image © iStockPhoto | Cover deisgn by Lisa Harper-Wells
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THE HANDBOOK OF
INDIVIDUAL
THERAPY
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00_Dryden & Reeves_Prelims.indd 1 08-Oct-13 10:32:07 AM
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THE HANDBOOK OF
INDIVIDUAL
THERAPY SIXTH EDITION
EDITED BY
WINDY DRYDEN AND ANDREW REEVES
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SAGE Publications Ltd Editorial arrangement, Preface Chapter 14  Mark Dunn
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First edition published 1984 as Individual Therapy in Britain

Editor: Susannah Trefgarne Second edition published 1990 as Individual Therapy: A Handbook
Editorial assistant: Laura Walmsley Third edition published 1996 as Handbook of Individual Therapy
Production editor: Rachel Burrows Fourth edition published 2002 as Handbook of Individual Therapy.
Copyeditor: Martin Noble Reprinted 2003, 2005, 2006
Proofreader: Martin Noble Fifth edition published 2007 as Dryden’s Handbook of Individual
Indexer: Martin Hargreaves Therapy. Reprinted 2010, 2011 (twice)
Marketing manager: Tamara Navaratnam
Cover design: Lisa Harper Apart from any fair dealing for the purposes of research or private
Typeset by: C&M Digitals (P) Ltd, Chennai, India study, or criticism or review, as permitted under the Copyright,
Printed and bound in Great Britain by Ashford Designs and Patents Act, 1988, this publication may be reproduced,
Colour Press Ltd stored or transmitted in any form, or by any means, only with the
prior permission in writing of the publishers, or in the case of
reprographic reproduction, in accordance with the terms of licences
issued by the Copyright Licensing Agency. Enquiries concerning
reproduction outside those terms should be sent to the publishers.
Library of Congress Control Number: 2013937639
British Library Cataloguing in Publication data
A catalogue record for this book is available from

the British Library
ISBN 978-1-4462-0136-7
ISBN 978-1-4462-0137-4 (pbk)

Windy: For Louise
Andrew: For Diane, Adam, Katie and Emily

Contents
List of Figures xi
List of Tables xiii
About the Editors and Contributors xv
Preface xxi
Acknowledgements xxii
1 The Cultural Context of British Psychotherapy 1

Colin Feltham
Part I The Psychodynamic Tradition 19
2 Psychodynamic Therapy: Contemporary Freudian Approach 21

Jessica Yakeley
3 Psychodynamic Therapy: The Independent Approach 49

Kevin Jones
4 Psychodynamic Therapy: Jungian and Post-Jungian Approaches 75

Ann Casement
5 Psychodynamic Therapy: The Kleinian Approach 101

Julia Segal
Part II The Humanistic-Existential Tradition 127
6 Person-Centred Therapy 129

Mike Worrall
7 Existential Therapy 155

Emmy van Deurzen
8 Gestalt Therapy 179

Dave Mann
9 Transactional Analysis 207

Charlotte Sills

viii Contents
Part III The Cognitive-Behavioural Tradition 241
10 Cognitive Therapy 243

Stirling Moorey
11 Rational Emotive Behaviour Therapy 271

Windy Dryden
12 Compassion-Focused Therapy 301

Paul Gilbert and Chris Irons
13 Behavioural Activation 329

Pierce J. O'Carroll
Part IV Other Specific Approaches 359
14 Cognitive Analytic Therapy 361

Mark Dunn
15 Solution-Focused Therapy 387

Alasdair J. Macdonald
16 Interpersonal Therapy 415

Susan Howard
Part V Broader Developments in Individual Therapy 443
17 Mindfulness in Individual Therapy 445

Jody Mardula and Frances Larkin
18 Narrative Therapy 469

Martin Payne
19 The Transpersonal in Individual Therapy 497

John Rowan
20 Integrative Therapy 519

Henry Hollanders
21 Pluralistic Therapy 547

John McLeod, Julia McLeod, Mick Cooper and Windy Dryden

Contents ix
Part VI Professional Issues 575
22 Research in Individual Therapy 577

Andrew Reeves
23 The Training and Supervision of Individual Therapists 603

Greg Nolan, Jane Macaskie and Bonnie Meekums
Appendix 1 625
Index 631

List of Figures
Figure 8.1 Continuums of contact and withdrawal 188
Figure 9.1 Ego states 210

Figure 9.2 The comparative script system 212
Figure 9.3 The development of script 214
Figure 9.4 A healthy cycle 215
Figure 9.5 Functional modes of ego states 217
Figure 9.6a Complementary transactions 218
Figure 9.6b Crossed transactions 219
Figure 9.6c Ulterior transactions 219
Figure 9.7 The drama triangle 220
Figure 9.8 Psychological theories 221
Figure 9.9a Relational field 222
Figure 9.9b Relational field 222
Figure 9.10 ‘Contamination’ of the adult ego state 223
Figure 9.11 The therapeutic transaction 230
Figure 9.12 Stan – a negative cycle 231
Figure 9.13 Stan's script-reinforcing interaction with his manager 233
Figure 9.14 Who is who? What is going on? 235
Figure 10.1 Perpetuation of panic disorder 248

Figure 10.2 Conceptualisation of factors maintaining Cindy’s problems 264
Figure 12.1 Three types of affect regulation system 304

Figure 12.2 Attributes and skills of compassion 310
Figure 13.1 General BA formulation for depression 335

Figure 13.2 General BA formulation and BA therapy formulation 343
Figure 14.1 SDR: Franko 379
Figure 21.1 Simplified example of the use of a time-line collaborative formulation 567


List of Tables
Table 10.1 Cognitive distortions 246
Table 11.1 Irrational and rational beliefs in REBT theory 274
Table 12.1 David’s threat-based CFT formulation 322
Table 13.1 Lara’s scores every 2nd session. Beck Depression Inventory Revised
(BDI-II: range 0–63); Behavioural Activation Depression Scale–Short
Form: BADS-SF BA (behavioural activation: range 0–36) and BADS-SF
AV (avoidance/rumination: range 0–18). 350
Table 22.1 Summary of findings 586

Table 22.2 Summary notes 589

About the Editors
and Contributors
Windy Dryden is Professor of Psychotherapeutic Studies at Goldsmiths University of

London, and is a Fellow of the British Psychological Society and of the British Association
for Counselling and Psychotherapy. He has authored or edited 200 books, including the
second edition of Counselling in a Nutshell (Sage, 2011) and Rational Emotive Behaviour
Therapy: Distinctive Features (Routledge, 2009). In addition, he edits 20 book series in
the area of counselling and psychotherapy, including the Distinctive Features in CBT
series (Routledge) and the Counselling in a Nutshell series (Sage). His major interests are
in rational emotive behaviour therapy and CBT; the interface between counselling and
coaching; pluralism in counselling and psychotherapy; and writing short, accessible self-
help books for the general public.
Andrew Reeves has worked as a social worker and then as a therapist for over 25 years. His
previous books include: Key Issues for Counselling in Action: Second Edition (Sage, 2008 –
co-edited with Windy Dryden); Counselling Suicidal Clients (Sage, 2010); An Introduction to
Counselling and Psychotherapy: From Theory to Practice (Sage, 2013); and Challenges in
Counselling: Working with Self-Harm (Hodder Education, 2013). He has produced (with Jon
Shears and Sue Wheeler) an award-winning training DVD, Tight Ropes and Safety Nets:
Counselling Suicidal Clients. He is a former Editor of Counselling and Psychotherapy
Research journal.
Ann Casement LP is a Senior Member of the British Jungian Analytic Association and an
Associate Member of the Jungian Psychoanalytic Association. She is currently the Chair of
the Ethics Committee of the International Association for Analytical Psychology. She has
published widely, contributes articles and reviews to The Economist, and is on the editorial
board of several psychoanalytical journals. She is also on the jury of the 2013 Gradiva
Awards in New York.
Mick Cooper is Professor of Counselling at the University of Roehampton and a Chartered

Counselling Psychologist. Mick is author and editor of a wide range of texts on person-centred,
existential, and pluralistic approaches to therapy, including The Handbook of Person-centred
Psychotherapy and Counselling (Palgrave, 2013, 2nd edn), Working at Relational Depth in
Counselling and Psychotherapy (Sage, 2005, with Dave Mearns) and Pluralistic Counselling and

xvi About the Editors and Contributors
Psychotherapy (Sage, 2011, with John McLeod). Mick has written extensively on research find-
ings and their implications for therapeutic practice, including Essential Research Findings in
Counselling and Psychotherapy: The Facts are Friendly (Sage, 2008), and has led research on
school-based counselling in the UK. Mick lives in Glasgow with his partner and four children.
Mark Dunn is a consultant psychotherapist. Mark trained as a psychotherapist at Guys

Hospital and specialises in CAT. He teaches psychotherapy and is an experienced clinical
practitioner and supervisor in a range of therapeutic models. He retired from the NHS in 2004
and leads a private psychotherapy clinic. In addition he works with many organisations in
coaching, employee assistance and executive support roles. He can be contacted at: mark@
bridgepsych.com and www.bridgepsych.com.
Colin Feltham is Emeritus Professor of Critical Counselling Studies, Sheffield Hallam

University and Associate Professor of Humanistic Psychology at the University of Southern
Denmark. He has authored and edited many publications including Counselling and
Counselling Psychology: A Critical Examination (PCCS, 2013), The SAGE Handbook of
Counselling and Psychotherapy (3rd edn, with Ian Horton; SAGE, 2012) and Critical
Thinking in Counselling and Psychotherapy (SAGE, 2010).
Paul Gilbert OBE is Professor of Clinical Psychology at the University of Derby and
Consultant Clinical Psychologist at the Derbyshire Health Care Foundation Trust. He has
researched evolutionary approaches to psychopathology for over 35 years with a special
focus on shame and the treatment of shame based difficulties – for which compassion focused
therapy was developed. In 2003 he was president of the BABCP and a member of the first
NICE depression guidelines for depression. He has written/edited 20 books and over 150
papers. In 2006 he established the Compassionate Mind Foundation charity with the mission
statement To promote wellbeing through the scientific understanding and application of
compassion (www.compassionatemind.co.uk). He was awarded an OBE in March 2011.
Henry Hollanders has worked as a therapist in community, pastoral, medical and educational
settings over many years. He founded and directed the Professional Doctorate in Counselling at
the University of Manchester where he was a lecturer for 20 years prior to his partial retirement
in 2006. Currently, he continues to lecture on counselling and psychotherapy, and provides con-
sultancy and supervision for an Occupational Health organisation in the North of England.
Susan Howard is a clinical psychologist and psychoanalytic psychotherapist with a life-long

interest in attachment theory. She works as a therapist and supervisor in private practice and
teaches psychoanalytic approaches, attachment theory and Interpersonal Psychotherapy
(IPT) on the PsychD Clinical Psychology training course at the University of Surrey. After
training as an IPT supervisor and trainer, she established the Surrey University IPT training
course in 2010 and now teaches and trains IPT nationally. She is currently developing Group
IPT. Her previous publications have been in the psychodynamic field.

About the Editors and Contributors xvii
Chris Irons is a clinical psychologist working in the NHS with adults with severe and endur-
ing mental health problems. He is a board member of the Compassionate Mind Foundation, a
charitable organisation set up to ‘promote wellbeing through the scientific understanding
and application of compassion’. He has been working for over 10 years in researching,
teaching and training Compassion Focused Therapy (CFT).
Kevin Jones is a psychoanalytic psychotherapist registered with the Institute of Psychotherapy

and Social Studies (IPSS) and the United Kingdom Council for Psychotherapy (UKCP). He
is also an HCPC registered Art Psychotherapist. Kevin is currently Head of Therapeutic
Studies in the Department of Social Therapeutic and Community Studies (STaCS),
Goldsmiths, University of London.
Frances Larkin is an experienced accredited psychotherapist and supervisor, drawing

on a range of therapeutic models including sensori-motor, gestalt, person-centred and
mindfulness approaches. Until 2012 she was a psychotherapist with the National
Counselling Service (HSE) for adults who experienced childhood trauma, where she
developed group-based self-care interventions using mindfulness. She was recently
appointed a Coordinator of the HSE Counselling in Primary Care initiative being rolled
out in Ireland in 2013. She has an MA in Mindfulness Based Approaches in Healthcare
at the Centre for Mindfulness Based Research and Practice, Bangor University, where
her research explored Mindfulness in Individual Therapy. She teaches MBSR and MBCT
and has developed and facilitated mindfulness-based training inputs for psychotherapists
and other health care professionals. She has a private psychotherapy and supervision
practice based in North West Ireland.
Jane Macaskie is a Teaching Fellow in Counselling and Psychotherapy at the University of

Leeds, with particular interests in contemporary intersubjective theory and practice, Jungian
concepts, spirituality and psychotherapy, practitioner training and development and practitioner-
based research. She is a BACP Senior Accredited Counsellor/Psychotherapist, on the BACP
Register of Counsellors/Psychotherapists, and a UKCP Registered Psychotherapist. Jane has
taught in HE for many years (initially in languages and linguistics before training as a counsellor)
and practised as a counsellor and psychotherapist in the voluntary sector, student counselling
services and independently.
Alasdair Macdonald is a consultant psychiatrist and family therapist. He is a former Medical

Director of Trusts in the North of England and Scotland. He currently holds a part-time contract
with Children’s Services in Dorset while working as a trainer and consultant to a Chinese research
team. He is a former office bearer of the Board of the European Brief Therapy Association with
a special interest in psychotherapy research, and a Trustee of a local counselling charity. His pub-
lications include Solution-focused Therapy: Theory, Research and Practice (SAGE, 2011 2nd
edn) (Mandarin edition 2011) and 100 Useful Words in 37 Languages: The Essential Vocabulary
To Travel The World (Olympia Publishers, 2010, with M. Popovic) See www.solutionsdoc.co.uk.

xviii About the Editors and Contributors
John McLeod is Emeritus Professor of Counselling at the University of Abertay Dundee and
adjunct Professor of Psychology at the University of Oslo, Norway. His writing has influ-
enced a generation of trainees in the field of counselling and psychotherapy, and his books
are widely adopted on training programmes across the world.
Julia McLeod is Lecturer in Counselling at the University of Abertay Dundee. She has inter-
ests in the role of counselling in long-term health conditions, and the issues involved in train-
ing in pluralistic and integrative approaches to therapy.
Dave Mann is a UKCP registered gestalt psychotherapist, supervisor and trainer. He is a

Training and Supervising Member of The Gestalt Psychotherapy Training Institute (UK)
and The Sherwood Psychotherapy Training Institute. Dave is a former assistant editor of
the British Gestalt Journal. He is author of Gestalt Therapy: 100 Key Points and
Techniques (Routledge/Taylor and Francis, 2010). Having worked as a gestalt psycho-
therapist in the psychiatric services in the British National Health Service for many years
he now works with a broad cross-section of clients in private practice in Nottingham, UK,
has supervision practices in Nottingham and Birmingham, UK and delivers training and
clinical supervision nationally and internationally. Email: dp.mann@virgin.net
Jody Mardula is a UKCP registered psychotherapist in Transactional Analysis adopting

an integrative approach that is informed by mindfulness, and has a private psychotherapy
and supervision practice in North Wales. She was formerly director of the Centre for
Mindfulness Research and Practice, Bangor University, where she is a mindfulness teacher
and supervisor, lecturing on the Mindfulness Masters programmes, including Mindfulness
in Individual Therapy. She has managed and developed addiction counselling services in
the voluntary sector and was a co-director of The Cheshire Institute for Psychotherapy
Training and has extensive experience in training and supervising counsellors and psycho-
therapists.
Bonnie Meekums is a UKCP registered psychotherapist. She is the Programme Leader for
the University of Leeds MA Psychotherapy and Counselling, researcher and author of
numerous peer reviewed publications and book chapters as well as two sole authored books
(Dance Movement Therapy, Sage; and Creative Group Therapy for Women Survivors of
Child Sexual Abuse, Jessica Kingsley). She is also Symposium Co-Editor for the British
Journal of Guidance and Counselling. Bonnie has extensive experience as a psychotherapist
and dance movement psychotherapist, in the NHS, third sector organisations and private
practice. She has a special interest in embodied and creative approaches to client work,
training and research, and contributed to the development of the National Occupational
Standards for psychological therapies.
Stirling Moorey is Consultant Psychiatrist in CBT and Head of Psychotherapy for the South
London and Maudsley NHS Trust. He trains psychiatrists and other professionals in CBT. He

About the Editors and Contributors xix
is currently researching the efficacy of CBT in palliative care and is co-author of The Oxford
Handbook of CBT for People with Cancer (with S. Greer; Oxford University Press, 2011).
Greg Nolan is Teaching Fellow in Counselling and Psychotherapy at the University of

Leeds, BACP Senior Accredited Counsellor and on the BACP Register of Counsellors and
Psychotherapists (PSAHSC approved). He has a career spanning over 40 years teaching in
secondary, FE and HE sectors, in the last 25 years additionally as a therapist, manager of
Counselling Services, freelance counsellor, clinical supervisor and trainer and currently has
a small private practice; has contributed to development of Skills for Health NOS (National
Occupational Standards) for Psychological Therapies and the BACP supervision training
curriculum; researches and is published on the process of clinical supervision and acts as
research supervisor for PhD and Masters research students.
Pierce O’Carroll is a Chartered Clinical Psychologist and Associate Fellow with the
British Psychological Society (BPS), member of the British Association for Behavioural and
Cognitive Psychotherapies (BABCP) and registered with the Health Professions Council (HPC).
He is currently Senior Clinical Psychologist at the University of Liverpool, leading the
Psychological Support Service for Student Practitioners (PSSSP). He has previously held
an Applied Psychology lecturing posts at Liverpool John Moores University and a joint
post as Programme Leader for a MSc Cognitive Behavioural Therapy (CBT) course at
University College Chester and Consultant Clinical Psychologist at Cheshire and Wirral
NHS Trust. He is currently engaged in research exploring mental health problems in health
care professionals in training.
Martin Payne counsels in Norwich. Initially trained as a person-centred counsellor, he later

undertook training in Narrative Therapy with Michael White. His publications include arti-
cles for Context, Counselling and the British Journal of Guidance and Counselling. Sage has
published his Narrative Therapy: An Introduction for Counsellors (2nd edn, 2006) and
Couple Counselling: A Practical Guide (2010).
John Rowan is a qualified individual and group psychotherapist (UKAHPP and UKCP), a
Chartered counseling psychologist (BPS) and an accredited counsellor and supervisor (BACP).
He is a Fellow of both the British Psychological Society and the British Association for
Counselling and Psychotherapy and Honorary fellow of UKCP. John Rowan started to write about
the transpersonal in his book The Reality Game (Routledge, 1983, 2nd edition 1998), and fol-
lowed it up with The Transpersonal: Spirituality in Psychotherapy and Counselling (Routledge,
1993, 2nd edition 2005). His latest book, Personification: The Dialogical Self in Psychotherapy
and Counselling (Routledge, 2010), goes further than before into the spiritual realm.
Julia Segal After 30 years working as a counsellor for people with neurological conditions,
their relatives and the professionals involved with them, first for a charity and then in the
NHS, Julia Segal now works as a freelance counsellor and trainer. She is a Fellow of BACP.

xx About the Editors and Contributors
Her books include Phantasy in Everyday Life (Penguin Books; Karnac) and Melanie Klein:
Key Figures in Counselling and Psychotherapy (Sage).
Charlotte Sills is a psychotherapist and supervisor and former Head of the Transactional
Analysis Department at Metanoia Institute, UK where she is still a member of faculty. She is
also a tutor on the Ashridge Business School Masters in Coaching and a Visiting Professor at
Middlesex University. She has published widely in the field of psychotherapy including with
Phil Lapworth An Introduction to Transactional Analysis (Sage) and she is co-editor with
Heather Fowlie of Relational Transactional Analysis – Principles in Practice (Karnac).
Emmy van Deurzen is a philosopher, existential psychotherapist and counselling psycholo-

gist, with a dozen books to her name. She founded both the School of Psychotherapy and
Counselling at Regent’s College and the New School of Psychotherapy and Counselling, of
which she continues to be Principal. She has established a philosophical form of existential
therapy known as the European School. Her work has been translated into over a dozen lan-
guages and she lectures worldwide. She is visiting Professor of Psychotherapy with
Middlesex University and has been a professor with Regent’s College, an honorary professor
with Schiller International University and with the University of Sheffield as well as a visit-
ing fellow of Darwin College, Cambridge. She was the first chair of the United Kingdom
Council for Psychotherapy and external relations’ officer to the European Association for
Psychotherapy and representative to the European Commission and the Council of Europe
for many years. Amongst her books are the bestseller Existential Psychotherapy and
Counselling in Practice (3rd edn, Sage, 2012), Psychotherapy and the Quest for Happiness
(Sage, 2009) and Everyday Mysteries (2nd edn, Routledge, 2010).
Mike Worrall lives in London and works as a therapist, trainer and consultant. He is a
Primary Tutor at the Metanoia Institute and on the Editorial Board of Person-Centred &
Experiential Psychotherapies, the Journal of the World Association for Person-Centred and
Experiential Psychotherapy and Counselling. He is co-editor, with Keith Tudor, of two col-
lections of papers on supervision, and co-author of two further books on person-centred
philosophy, theory and practice.
Jessica Yakeley is a Consultant Psychiatrist in Forensic Psychotherapy at the Portman Clinic,

Tavistock and Portman NHS Foundation Trust, and Fellow of the British Psychoanalytic
Society. She is the Editor of the journal Psychoanalytic Psychotherapy, and author of Working
with Violence: A Contemporary Psychoanalytic Approach (Palgrave MacMillan, 2010).

Preface
The first edition of this handbook was published in 1984 and attempted to fill a gap in the
market at that time by having British authors write on well-established approaches to indi-
vidual therapy for a British readership. The four subsequent editions published at roughly
six-year intervals carried on this tradition. In this, the sixth edition, the most successful ele-
ments of the previous editions have again been retained. Contributors of chapters detailing
specific therapeutic approaches and broader developments were once again asked to keep to
a common structure (Appendix 1) in writing their chapters (Chapters 2–21); there is a chapter
placing therapy in a cultural social context (Chapter 1) and chapters are included on research
and training as they pertain to individual therapy (Chapters 22 and 23).
While there have been a number of changes to this edition (to be discussed below), the
biggest change is one that I (WD) initiated with respect to my role as editor. I decided that
this edition of the Handbook would be the last that I would edit and that I would take on a
co-editor with whom I would work on this edition with a view that he would take over the
sole editorship of subsequent editions. To that end, I (AR) joined the project and have taken
the lead in editing this edition under the guiding hand of WD.
The previous edition of the Handbook went through the publisher’s rigorous textbook
development, which resulted in the inclusion of new chapters on: the independent approach
within psychodynamic therapy; compassion-focused therapy; behavioural activation (which
replaces the broader chapter on behaviour therapy); interpersonal therapy; mindfulness in
individual therapy; transpersonal therapy; and pluralistic therapy. These inclusions inevitably
meant that we had to lose chapters on approaches that have become less influential in indi-
vidual therapy in Britain. Thus, this time we have not included chapters on Adlerian therapy
and personal construct therapy. We have also improved the internal structure of the Handbook,
which is now divided into six parts. All extant chapters on approaches and developments
have been updated or completely rewritten and each has a new case example.
We thank all at Sage for their unstinting help on this Handbook and hope that readers will
join us in thanking all the contributors for a job very well done.
Windy Dryden, London

Andrew Reeves, Liverpool

Acknowledgements
The publishers would like to extend their warmest thanks to the following individuals for
their invaluable feedback on the fifth edition and the shaping of the sixth edition.
Kirsten Amis, Lecturer in Counselling, Glasgow Clyde College

Aaron Balick, University of Essex
Paula Hixenbaugh, Emeritus Professor, University of Westminster
Gail King, Lecturer in Counselling and Psychotherapy (retired), University of Leicester
Melanie Mitchell, Senior Lecturer in Psychology, Northumbria University
Jane Simmons, Clinical Psychologist, NHS
David Winter, Professor of Clinical Psychology and Programme Director of the Doctorate in Clinical
Psychology, University of Hertfordshire
Wendy Wood, Programme Leader, PG Cert Compassion Focused Therapy, University of Derby

1
The Cultural Context of
British Psychotherapy
Colin Feltham
Psychotherapy and counselling1 happen most commonly between two individuals, in private.
Not only is therapy private when it happens but is also confidential later, so that relatively
little of the actual phenomena of therapy, in spite of some consumers’ write-ups, disguised
case studies, transcribed tape-recordings and conversational analyses, find their way into
publications. This book presents the theories of various mainstream therapies structured
according to certain historical, conceptual, professional and clinical frameworks, along with
case studies. A focus on research, training and supervision is provided in later chapters. In
order to provide some wider and integrating balance, this introductory chapter looks at a
number of transtheoretical areas to contextualise this most private of activities.
1 THE NATURE OF HUMAN SUFFERING AND PSYCHOLOGICAL NEED
Some of the literature on therapy sustains the impression that it arrived a little over a century
ago with Freud and perhaps his immediate predecessors and contemporaries, and that not much
of interest or relevance existed or is worth talking about from before that time. But clearly
1
Given ongoing debates about nomenclature in the talking therapies, and in the spirit of this book, I
have used the term ‘therapy’ interchangeably with psychotherapy, counselling, etc.
01_Dryden & Reeves_Ch-01.indd 1 08-Oct-13 10:32:10 AM

2 THE CULTURAL CONTEXT OF BRITISH PSYCHOTHERAPY
human beings have suffered and have had emotional or spiritual needs and aspirations for mil-
lennia, even if these have manifested in very different ways. During that time many remedies
or solutions have been practised (Ellenberger, 1970). Today’s needy or help-seeking client and
trained therapist did not appear in a vacuum and we deceive ourselves if we imagine they did.
There are several reasons for including this brief overview. First, while therapeutic theorists
are asked to consider their ‘image of the person’ and human nature, this area of theory is argu-
ably one of the weakest in many models of therapy, probably due to therapists’ background
lying in psychology rather than philosophy or historically grounded disciplines, and to their
naturally prioritising urgent, practical, clinical concerns. Messer (1992) discusses therapists’
‘belief structures’ and ‘visions of reality’ and the very language used betrays a certain subjec-
tive tenor. Secondly, this weakness is not merely an intellectual inelegance but arguably a
potential pitfall for the advance of theory and clinical understanding and for the status of
therapy. Thirdly, since the development of evolutionary psychology and psychotherapy, rela-
tively few writers from the ranks of different therapeutic models have kept pace with this trend
(exceptions including Burns, 2007; Stevens and Price, 2000). Fourthly, another weakness in
most theories of therapy has been in their definitions of the scope of what they can do in rela-
tion to what clients need; in other words, a failure to define ‘suffering’ or deficit or, if this
terminology is disliked, then an alternative nomenclature and set of explanations. Fifthly, it is
doubtful whether progress can be made towards the integration of therapeutic models without
a better philosophical and scientific focus on what it means to be human and to have psycho-
logical needs, if indeed any consensus can be achieved in our so-called postmodern era.
There is considerable agreement that we have existed for about 100 000 to 150 000 years
in our homo sapiens sapiens form. Our ancestors’ upright gait probably came about some
4 million years ago, notable increases in brain size took place about 2.5 million years ago,
coinciding with significant meat-eating. Some writers have speculated on such distant events
and our modern problems with birth difficulties – long, dependent and vulnerable childhoods,
over-cognitivisation and environmental rapaciousness. Even now, in our contemporary theo-
retical models of therapy, we are sometimes obliged to make judgements as to whether cog-
nition or emotion is the primary mode of human functioning, the latter being more evident
earlier in our evolution and probably having some female bias, the former arguably having
connotations of emotion-suppression, control and detachment – some models urge us to think
more rationally, others to feel more deeply.
Our original ancestors, probably from Africa, were hunter-gatherers who lived coopera-
tively in quite small groups. Suggestively, however, use of alcohol is recorded from 7000
years ago and opium 5000 years ago. There is ample evidence of violence and, alongside
geographical expansion and technological progress, common anxieties about death. A drastic
decline in the nomadic, hunter-gatherer lifestyle occurred about 4000 years ago, coinciding
roughly with the advent of the Abrahamic religions. In short, there is a recognisable human
story comprising both progressive and destructive, and myth-making and knowledge-seeking
elements. We have become increasingly technologised, urbanised and overpopulated (pro-
jected to rise towards 8 billion by 2020) and we have not overcome our warring tendencies,
although many live in conditions of relative peace and prosperity.

THE CULTURAL CONTEXT OF BRITISH PSYCHOTHERAPY 3
All religions offer accounts of human beings losing deep contact with spiritual identity,
suffering as a consequence, and needing guidance or succour. Whether certain individuals
hanker pathologically for a bygone age or for lost intrauterine bliss (Freud’s ‘oceanic feel-
ing’) when they present for therapy is a moot point. In roughly the last 200 years, the domi-
nance of industry and capitalism with their attendant effects on working lives is extremely
significant. Those forms of unhappy servitude, or what Marx termed ‘immiseration’, associ-
ated with capitalist growth, may or may not be compensated for by the advantages provided
by medicine and technology, such as disease reduction and prevention, higher rates of suc-
cessful births and greater longevity. While some argue that we now live in and need to adjust
to a ‘post-emotional society’, others are alarmed at the loss of emotional intelligence and
humanness, qualities that are of course the bread and butter of most forms of therapy.
Many now argue that there is no universal human nature at all, that we cannot speak mean-
ingfully of a human nature but only of different theoretical versions, different cultures and
individuals. Others argue that we have an all too obvious set of determined characteristics –
many of them, like aggression, jealousy, greed and deception, highly negative – which paral-
lel a range of freedoms (Pinker, 2003). Today’s debates echo the unresolved nature–nurture
debates of past decades. But we can say with confidence that it is in our common nature to
be dependent when young, to grow, to couple, to age and die, and along the way most of us
struggle and experience non-physical suffering to some extent. If, therefore, we have any
human condition shared by all 7 billion of us, it is this – that we must negotiate our way
across the lifespan with whatever resources we possess, and most of us are driven to avoid
suffering and maximise pleasure, as Freud wrote. Even then, none of us can avoid ageing and
physical death and many have far more than their share of loss and sorrow, depending on
genetic inheritance, formative experiences, life events, luck, exercise of choices, cultural and
idiosyncratic factors. Kleinian and existentialist therapies take some such realities on board
more obviously than most other models of therapy. It is also the case that most of us define
ourselves and are closely supported by families and communities; and that insufficiencies in
care, abuse, shame, loss and rupture in the social domain explain the formation of many of
our psychological problems.
Insofar as distinct images of human nature, or pertinent aspects of it, can be identified in
the approaches outlined in this book, we might select the following: self-deception, struggle,
dualism, trustworthiness, existential becoming, experiencing, OK-ness, cognitive processing,
hedonism, storytelling, solution-building, attachment-oriented and evolved. Some approaches
have no single clear view of human nature and many regard us as complex biosociopsycho-
logical beings. Key questions for exponents of different models of therapy include the
following: To what extent is there an agreement on any essence of human nature and its
problematic aspects? To what extent does each model either address this and explain how it
is incorporated, or dismiss it as irrelevant, and why? Where does each model lie on the spec-
trum from conceiving human beings as being ‘wholly determined’ to ‘wholly free’? To what
extent is each model optimistic or pessimistic in its outlook? To what extent does each model
remain open to new information from scientific or other disciplines? Significant differences
in answers to these (and one would expect humanistic approaches to be somewhat more

optimistic than psychoanalytic approaches, for example) indicate their implicit philosophies
of human nature and potential.
2 ROOTS OF THE PSYCHOLOGICAL THERAPIES
Ellenberger (1970) traces the rise of therapy from the ‘primitive psychotherapy’ of the Guyanan
medicine man and the use of drugs, ointments, massage and diet. He also acknowledges therapeu-
tic work with loss of the soul, spirit intrusion, breach of taboo and sorcery across many cultures.
Possession and exorcism are phenomena associated with the Christian church as well as many
non-Western cultures, Ellenberger making links with the ‘hysterical neurosis’ and attempted cures
of late nineteenth century Europe. Ellenberger also lists confession, gratification of frustrated
wishes, ceremonial healing, incubation, hypnosis and magical healing, and temple healing and
philosophical psychotherapy as forerunners to contemporary scientific psychotherapy. Hence, we
can see the seeds of today’s methods in distant history – we can also see, in certain epochs, rivalry
between schools of therapy or healing, as in early Greek schools of healing. Albert Ellis’s repeated
tribute to the Stoic philosopher Epictetus (55–135 CE) demonstrates a clear link across almost
2000 years between original Stoicism and the modern, psychological, clinical therapy of rational
emotive behaviour therapy and cognitive-behavioural therapy (CBT) generally. (See also
Nussbaum, 2009.) Many similar ideas are found in the teachings of the Buddha more than 500 years
before Epictetus. Let us recall too that Frank’s (1974) anthropologically informed study of psy-
chotherapy acknowledged such sources as well as contemporary transcultural likenesses, arguing
that certain common factors could be found universally. The superiority of Western, talking
therapy is easily assumed but this is being questioned by some, such as Moodley and West (2005),
and arguments put forward for an integration of psychological with traditional healing methods.
Physical, medical or biological models of therapy have early roots and include herbal rem-
edies, blood-letting, emetics, trepanning, acupuncture, neurosurgery, electroconvulsive ther-
apy (ECT) and psychopharmacology among others. Even homeopathy must be considered a
form of physical intervention. In the west, psychiatry developed as the extension of medical
analysis and treatment into the domain of severe psychological or emotional problems.
Psychiatric abuses and failures – unwarranted incarceration, indiscriminate and damaging
use of ECT, drugs used as a ‘chemical cosh’ with highly negative side-effects, and crude,
botched lobotomies – created much vociferous opposition from patients and formed part of
the drive against the ‘biomedical model’ (Bentall, 2010). Today, psychopharmacological
treatment for schizophrenia and bipolar disorder, for example, is partly accepted but also
strongly objected to by some groups. While a great deal of therapy has been criticised for
targeting the self-indulgent ‘worried well’, psychological therapy has been increasingly
appropriated and boosted by those suffering from depression, anxiety and similar conditions
wanting to talk in an exploratory, cathartic and social learning manner rather than (or as well
as) ingesting medication. There is growing research evidence in support of the use of certain
medications alongside psychological therapies and in some cases a demonstrated superiority
of talking therapy over medication.

The prefix psyche comes from the Greek for breath, soul or life. The psychological thera-
pies clearly did not properly begin with Freud in 1896, who regarded himself as a neurologist
and his discovery, psychoanalysis (the ‘talking cure’), as his own creation. Many regard
psychoanalysis as having its conceptual and inspirational origins in religious and romantic
aspects of the Judeo-Christian tradition. Many of the founders of contemporary mainstream
psychotherapies themselves have Judeo-Christian origins. The term psychotherapy appeared
in 1853 but did not refer to an applied discipline necessarily drawing from psychology.
Psychology itself appeared as a technical term in 1748 and even then had overtones associat-
ing it with ‘soul’. Psychology has of course had its internal battles over identity and has
moved significantly from its early insistence that it should scientifically exclude subjectivity.
What we generally mean by ‘psychological therapy’ is an essentially talking-and-listening
form of help that does not primarily utilise medical or physical means. While this could
broadly include any spiritual or philosophical concepts and techniques (these are, after all,
not medical or physical), it tends not to. Since psychology is promoted as a scientific disci-
pline, clinical psychology, and latterly counselling psychology, have been advanced as
applied scientific professions, in turn suggesting a superiority over earlier religious and
philosophical traditions of helping people with their problems in living.
3 CURRENT SOCIOCULTURAL CONTEXTS OF THERAPY IN BRITAIN
Cushman’s (1995) seminal text on the historical development of psychotherapy within the
American context remains highly instructive but no directly comparable British text exists.
Cushman’s analysis problematises the rise of the peculiarly Western sense of self and Rose’s
(1989) analysis of British trends in the rise of psychology and its influences on our sense of
a private self has some resonances (see also Wright (2011) for an Australian-based but widely
applicable view). Significantly, in spite of a decades-long tradition of couple counselling and
group therapy, individual therapy remains by far the preferred choice. We were told by the
authors of one piece of (market) research (BACP/FF, 2004) that 21 per cent of the British
population had had some form of counselling or psychotherapy and that up to 82 per cent of
people would willingly have therapy if they thought they needed it. Previous estimates of the
numbers experiencing therapy had been around 5 per cent at most and there may be reasons
to doubt a figure as high as 21 per cent. Nevertheless, since the struggling 1970s, when coun-
sellors and psychotherapists encountered a great deal of public and media resistance, accept-
ance has continued to grow. The visibility and accessibility of counsellors in many GP prac-
tices and Improving Access to Psychological Therapies (IAPT) schemes means that therapy
is no longer perceived as an elitist, unaffordable or dubious activity but as potentially avail-
able and beneficial to the entire adult population. Availability has been buttressed by the
presence of free counselling in many colleges and universities, employee assistance pro-
grammes and voluntary organisations such as Relate, Cruse and Mind.
Twentieth-century therapeutic provision was driven by a combination of factors: early
psychoanalytic pioneers promoting their ideas via medical training, by the personnel of voluntary

agencies and others exploiting American therapeutic practices and by a general enthusiasm
for theories focusing on the inner life of individuals and its improvement. Britain became
home to several eminent psychoanalysts, the Tavistock Clinic and Institute of Psychiatry
were very influential in the dissemination of therapeutic theory and practices. Attachment
theory and object relations therapy, driven by Klein, Winnicott, Bowlby, Fairbairn and others,
owe much to the British empirical tradition of infant observation; and key figures like R.D.
Laing promulgated original views on the limits of psychiatric treatment and the promise of
talking therapy.
The sociologist Halmos is well known for his thesis that counselling and therapy came into
their own around the 1950s as formal religion and politics were often perceived as not meet-
ing individual needs: ‘at least to some extent, the counsellors have been responsible for a
revival of interest in the rehabilitation of the individual, and a loss of interest in the rehabili-
tation of society’ (Halmos, 1978: 7). Perhaps the 1960s, 1970s and early 1980s were charac-
terised by a certain secularism, hedonism and optimism (which paralleled the humanistic
psychology movement), and respect for formal politics declined markedly in the 1990s and
early 2000s alongside a steady turn against left-leaning politics and towards acquisitiveness.
But at the same time the growing impact of feminist freedoms, the rise of multiculturalism
and gradual acceptance of homosexuality made for an openly diverse society in which con-
sumer demands and health reforms have combined to favour certain forms of counselling and
psychotherapy, as well as witnessing a growth of interest in spirituality and transpersonal
therapies.
Can it be said that the contemporary social and psychological problems of the British have
a character distinct from those of other nations? In some surveys of self-assessed happiness
the UK rates relatively highly. Yet some commentators have assessed Britain as a society
populated by somewhat depressed citizens who cannot keep pace with the heavy expectations
placed on them and who sense that ever greater acquisition and pleasure-seeking do not result
in satisfaction but in compromised mental health. Obesity too has become a marked problem
for the British. Layard (2003) cites a figure of about 35 per cent for British happiness across
the past 40 years but points out that we deserve to be much happier given our level of afflu-
ence compared with eastern European nationals. Marked depression and anxiety as national
characteristics paint a gloomy picture and one that inexplicably contradicts the more optimis-
tic happiness survey cited above. Trite though the conclusion is, we must assume that UK
citizens are pulled between a kind of stoicism and frank demoralisation. George Cheyne’s
The English Malady, published in 1733, celebrated for its portrayal of depression as a very
common characteristic, shows that this is nothing new.
The UK has been a major importer of American therapy models, as of most other American
commodities. In turn, Britain has provided inspiration for many other countries in developing
their own therapy services and professions, as well as a certain positive energy devoted to
professionalised therapy and links with social justice. Psychotherapists and Counsellors for
Social Responsibility was formed in 1995 to promote the political dimension of therapy, to
challenge oppression and to champion better and fairer provision of therapy. Decades ago
Reich sought to integrate psychoanalytic with Marxist concepts. Adler, Horney, Fromm and

others attempted to bring social conditions into the aetiological equation. In the heyday of
humanistic therapy, Re-evaluation co-counselling had begun to promote the discharge of
social as well as individual distress. Groups like Red Therapy sought to combine radical
individual and group therapy with social action. Many Jungians in particular focused their
analyses on the intrapsychic causes and threats of war. Some practitioners, largely in the
urban USA, have created models of ‘social therapy’ using community group activities in
place of individual therapy to help address problems of racism and addiction among others.
In recent decades many therapists have drawn attention to the different psychological needs
of ethnic minorities, sexual minorities, disabled people and women, all of which groups tra-
ditionally fell outside standard models of the aetiology of psychological distress and need.
The movement known as critical psychology stands firmly behind such developments. The
journal Psychotherapy and Politics International, launched in 2003, also attests to a level of
commitment to address these concerns. But while these continue, a certain lack of vigour is
apparent, possibly explained by the increasing success of counselling and psychotherapy in
mainstream health care and their weakness politically.
Smail (2005) is highly sceptical that therapy or therapists will make any serious inroads on
the extent of social distress. World events, pivoting around ‘9/11’, subsequent wars, eco-
nomic downturns and environmental concerns, undermine any naïve fantasy we may have
had that daily life is getting better due to therapeutic insights and treatment. No connection
is made between increasing worldwide depression and waiting lists for therapy, for example,
and the demoralisation and anxiety generated by environmental degradation, employment
insecurity and war. Ritzer (2004) shows the prevalence of social problems worldwide –
including population growth, inequalities in wealth distribution, ethnic conflicts, family
breakdown, disease, crime and so forth – of which diagnosed mental health problems, while
extremely serious, are merely one small part. What has been referred to as the ‘upstream’
aspect of psychological problems (social, economic and political causes) remains unad-
dressed by the professional bodies in the therapy field, the focus remaining, naturally but
unsatisfactorily, on the downstream aspects (the impact on the well-being or otherwise of the
individual). As with the question of human nature, it may be that theoreticians and trainers
need to explain far better how their models of therapy might answer valid questions about the
social context.
3.1 Epidemiological context

Therapy has responded to, indeed been forged by, urgent and obvious psychological distresses
and needs. It has developed like many services in an ad hoc rather than a planned way. The
awareness of any need for or creation of an epidemiology of psychological distress has there-
fore been slow to emerge. Clearly, it would be useful to know the extent of the problem we
are dealing with on a national scale, if not to be able to predict future needs. But this is com-
plicated by the breadth and non-specificity of the kinds of problems and concerns brought to
counsellors and psychotherapists and by their not uncommon indifference to and suspicion of
matters of psychodiagnosis and quantification. While the Diagnostic and Statistical Manual

of Mental Disorders, Fifth Edition (DSM-V, APA, 2013) may confidently list hundreds of
psychological or psychiatric disorders, counsellors and psychotherapists will dispute many or
even all these. Sanders (2005), for example, gives a radical account of person-centred opposi-
tion to the ‘medicalisation of distress’. And many of the concerns brought to therapists do not
qualify as disorders by compilers of the DSM. The pain of marriage breakdown, bereavement,
work stress, relocation – common issues for counsellors in the voluntary sector and employee
assistance programmes, for example – may well be considered ‘subclinical’ presentations by
psychiatric colleagues.
Abernathy and Power (2002) confirm the methodological difficulties in and slow develop-
ment of the field of the epidemiology of mental distress, the first rigorous UK study
appearing only in the mid-1990s. This identified significant degrees of fatigue, sleep prob-
lems, irritability, worry, depression, anxiety, obsession and panic, and women as experienc-
ing almost all these to a higher degree than men. Other surveys have identified problematic
levels of alcohol abuse and suicide (rising among older men) that have led to the short-term
stepping up of specific government health policies to tackle them. Layard (2005) has iden-
tified the significance of mental distress both in terms of individual suffering and health
economics and the struggle continues to have psychological distress recognised – and its
treatment duly funded – on a par with physical illness. Many surveys of the benefits of
counselling within companies attempt to quantify distress, its relationship with occupa-
tional inefficiency and the likely benefits of therapy in addressing it. Worldwide increases
in depression are regularly publicised.
The implications of epidemiological surveys, however crude, seem to have been noted
belatedly by those overseeing the profession and training of counsellors and psychothera-
pists. While training courses have flourished, it has been apparent (‘on the ground’, contrary
to Aldridge and Pollard, 2005) that employment for many therapists – in relation to numbers
graduating each year – remains relatively scarce: full-time jobs are few, most employment is
part-time and many therapists maintain quite small, part-time private practices alongside
other work. Rigorously planned psychotherapy and counselling services (planned, that is, on
the basis of estimates of the public’s psychological needs and of numbers of clinicians needed
to meet these) are to date a rarity, although clinical psychology training and provision are
guided by such considerations. Almost certainly, the growth of seriousness with which evi-
dence-based practice is taken will inevitably coincide with the development of better epide-
miological estimates; and all this in turn is likely, eventually, to impinge on training numbers
and theoretical models. To the best of my knowledge, no analysis of mental health problems
by aetiology exists. That is to say, extraordinarily difficult though it is, if we were able even
broadly to assign psychological problems to clusters of predisposing factors (e.g. biological
propensity, perinatal complications, problematic parent–child interactions, early years and
later life negative events, impaired life chances, expectable and unexpected losses, individual
coping differences and so on), we could hypothetically design and deliver accurately person-
alised psychological therapy accordingly. Some such attempts have been made, in some cases
attempting to factor in gender, but the likelihood is that much more knowledge and time are
required before this becomes a significant clinical reality.

3.2 The professional and stakeholders’ context

Pilgrim (2002) structured his brief history of British therapy into three phases, with the rel-
evant professional bodies duly making their various appearances throughout this period. His
categorisation has psychoanalysis and behaviourism as co-existing and competing between
1920 and 1970, ‘third force psychology’ (the humanistic approaches), pluralism and eclecti-
cism appearing largely after 1970, and a return of professional authority and postmodern
criticism after 1980. Let us set over those periods the births of the British Psychological
Society (1907); British Psychoanalytic Society (1901); Medico-Psychological Association
(becoming the Royal College of Psychiatrists in 1970); Alcoholics Anonymous (1935); the
National Marriage Guidance Council (1938, now Relate); first Standing Conference for the
Advancement of Counselling in 1970 (becoming the British Association for Counselling in
1977, to which the term ‘Psychotherapy’ was added in 2000); the British Association of
Behavioural and Cognitive Psychotherapies (BABCP) was founded in 1972; the UK Standing
Conference on Psychotherapy in 1989 (becoming the United Kingdom Council for
Psychotherapy in 1993); the British Confederation of Psychotherapists, breaking away from
the UKCP as the more ‘purist’ psychoanalytic training institutes (1991) renamed itself the
British Psychoanalytic Council (BPC) in 2004.
A few key events should be picked out here. Just as Freud had to engage in a battle with
the medical establishment over ‘the question of lay analysis’, so Rogers had to fight against
the psychological establishment to launch and legitimately practise his model, a fight which
partly fuelled the growth of ‘counselling’. In 1971 a government report concerned about the
activities of scientologists (Foster, 1971) spurred action among therapists, resulting in the
publication of a call for statutory regulation (Sieghart, 1978). This process has had some
dramatic ups and downs. Occasional embarrassing events, such as the comedian Bernard
Manning’s publicised gaining of BAC membership, the failure of the Alderdice Bill, and
opposition from many within the psychotherapy world itself, have both stimulated and
dogged the professionalisation of therapy.
This small slice of professional history may show some of the emergence of interest
groups, how interests cluster and endure, and how the politics of the ‘psy-professions’ oper-
ate. While some bodies represent quite wide spectrum interests (e.g. BACP and UKCP),
others such as the BABCP and BPC focus on well-defined schools of practice. Some of these
contain individuals and organisations as members, others represent only training institutes.
Some, like the BACP, have very large memberships, while others are relatively small. Of
BACP’s membership, over 80 per cent are female. Overlapping memberships mean that it is
difficult to estimate how many active therapists there are in the UK and no accurate figure is
available. One crude estimate from a journalistic source had it that in 1993 there were 30 000
paid therapists, 140 000 volunteer counsellors and 140 000 people using counselling skills in
their work. Aldridge and Pollard (2005) allude to 37 500 members of pertinent professional
bodies, but other estimates raise a figure of 70 000 therapists (Feltham, 2012).
Statutory regulation of therapy has been on the agenda for many years. At the time of writ-
ing (late 2012), plans for regulation by the Health Professions Council of psychotherapy and
counselling had been abandoned and new strategies to embrace regulation by the Council for

Healthcare Regulatory Excellence/Professional Standards Authority were being embraced.

According to Aldridge and Pollard (2005) practitioner training courses numbering 570 were
identified, with a variety of titles among these which the authors say ‘can only cause confu-
sion to the public’ (2005: 7). The title of ‘counsellor’ was being used by 54 per cent of those
sampled, with 26 per cent using ‘psychotherapist’ and others designating themselves as
‘therapist’, ‘analyst’, ‘psychoanalyst’ or ‘hypnotherapist’: of these 61.4 per cent work with
their clients for up to 20 sessions.
4 DIFFERENTLY CONCEIVED AND NAMED THERAPEUTIC APPROACHES
In Aldridge and Pollard’s (2005) survey self-designated humanistic and integrative practi-
tioners represented 57.34 per cent of those responding, 18.25 per cent analytic, 10.52 per cent
cognitive, 2.4 per cent systemic and 2.25 per cent NLP/ hypnotherapeutic. In a more detailed
section, although still not precise, it appears that the most commonly self-identified
approaches are, in order of popularity with practitioners: integrative, person-centred, psycho-
dynamic, cognitive-behavioural, humanistic and then psychoanalytic and eclectic about
equal. Each approach is in a sense a different offer of explanation and help for psychological
challenges – each is a product of its time, place and creative personalities and each will have
some measure of appeal, success and shelf-life. Some will in time be modified, some will
become dominant and some will become obsolete. Interestingly, a large discrepancy appears
to exist between practitioner preferences and evidence-based indications, and this data cannot
tell us what clients’ preferences are.
Broadly speaking, psychoanalysis was dominant at the turn of the twentieth century and
challenged only gradually by the rise of the cognitive-behavioural and humanistic therapies
from about the 1970s onwards. But we know that even within Freud’s lifetime it proved
impossible to develop a model that attracted consensus, with early fall-outs by Adler and
Jung being legendary and many subsequent schisms following these. Historians of psycho-
therapy will continue to analyse such developments but we can speculate with some confi-
dence that departures from the original Freudian model were driven by sincere differences of
viewpoint and aspiration, different professional and cultural backgrounds and markedly dif-
ferent personalities. The development of therapy models has been neither primarily collabo-
rative nor scientifically focused and accountable: it has largely hinged on the energy and
inspiration of outstanding male figures and their professional intimates. One count has it that
a mere 36 named therapeutic approaches existed in the 1950s, this increasing to 250 by 1980
and over 400 by the end of the twentieth century. Some critical commentators suggest that
the creation of so many models reflects the scientific indiscipline of a field in which, it seems,
‘anything goes’; the competitive nature of the society from which most therapy models have
arisen, that is, the USA; and the idiosyncrasies, proprietorial nature and fame- and profit-
seeking motives of their authors.
Whatever the true picture, we have a scenario of proliferation of therapeutic models that
some consider unwieldy, confusing and not credible. One text has referred to this as ‘therapy

wars’ (Salzman and Norcross, 1990). On the other hand, the integrative movement has con-
tinued to seek common ground and rapprochement between therapies. Yet another perspec-
tive has it that many apparently different models are in fact quite similar and merely slight
variations on common themes. One simplification is to speak simply of cognitive-behavioural
and interpersonal models, for example. Interestingly, while one research thrust commends
common relationship factors in all therapy as pivotal, another appears to have underscored
CBT, perhaps the least of the relationship-focused therapies, as of superior effectiveness; thus
leaving us potentially confused as to the relative merits of the relationship-focused and the
technique-focused therapies. Lambert (1992) has argued from evidence that a mere 15 per
cent of client improvement is accounted for by techniques specific to designated therapy
models. By contrast, 30 per cent is due to common factors (empathy, acceptance, warmth,
etc.), 40 per cent to extratherapeutic factors (client’s ego strength, helpful events and social
support) and 15 per cent to placebo factors. Carr (2012: 322–7) summarises evidence that
finds even less potency within model-specific and common factors. By their very nature,
distinct models of therapy do not convey a picture of this kind.
This book presents the case, as it were, for us to take seriously 15 distinct therapy mod-
els and a further five broader developments. Although no mud-slinging competitiveness is
in evidence, an implicit difference of views exists on human nature, psychological distur-
bance, therapeutic techniques and style, change process and so on. Also, each purports to
have some sort of original edge. Let us ask first what they have in common, and secondly
on what grounds they differ. Most obviously, all these models but one (Kleinian) are
mainly male-created (Laura Perls is sometimes credited with co-creating gestalt therapy;
and many women appear more visibly as second-generation proponents of cognitive, per-
son-centred and other approaches). A majority stem from the initiative of one dominant
founder, that is, not from lengthy, painstaking research and scientific committee-style
deliberations. All but the original psychoanalytic models were created in the second half of
the twentieth century. A majority of the founders have Judeo-Christian origins. All have
Euro-American origins, with American predominance. All models agree on the taboo
against sexual contact with clients and on confidentiality, and most on traditional profes-
sional boundaries. All share the view that their approach requires rigorous training and
high levels of skill. Most share the view that their model is capable of addressing a wide
array of presenting concerns. Some agree on the mixed (determined and free) nature of
being human but vary in their views on how free or genetically ‘pre-determined’ we are.
All tend to see therapy as quite necessary, despite sharing the view that individuals have
personal responsibility and efficacy independently of therapists.
When we turn to the differences, however, these are much larger. Some approaches (person-
centred therapy and behavioural activation) have psychological roots. Many have psychoana-
lytic affiliations or origins (gestalt, transactional analysis and cognitive analytic therapies most
obviously, after the earliest psychoanalytic models); and even the founders of models as non-
psychoanalytic as cognitive therapy and rational emotive behaviour therapy originally have
psychoanalytic affiliations. One (existential therapy) has a primarily philosophical affiliation.
The newest, solution-focused and narrative therapies, draw from systemic and constructivist

views. Some, such as Freudian, Kleinian and person-centred, are ‘purist’ in what they are
composed of (that is, minimal integration from elsewhere) and how they are practised, while
others, such as Gestalt, cognitive analytic and rational emotive behaviour therapy, have a
greater integrative make-up and capacity. Some, such as cognitive and behaviour therapy, and
interpersonal psychotherapy, are readily researched and others far less so. They differ in typi-
cal length of treatment (compare long-term psychoanalysis with very brief behaviour therapy
or solution-focused therapy, for example). They differ with regard to whether therapy is man-
datory in the therapist’s own professional development, Freudian, Kleinian and Jungian train-
ing most emphatically demanding this, while the more cognitive and behavioural approaches
generally do not. Active or passive (client-led) style of therapy is another defining feature
(compare Ellis’s with Rogers’s in this regard, for example), as is temporal focus – past, present
or future orientation. Most psychoanalytically oriented approaches inevitably focus strongly
on past patterns, for example, while existential, Gestalt and cognitive therapies tend to main-
tain a strong focus on current life and solution-focused therapy an orientation towards the
future. Interestingly, compassion-focused therapy draws from the most distant past (human
evolution) and applies this to the present.
Whether goals or symptoms are paramount (see the cognitive and behavioural therapies),
as opposed to being regarded as implicit or surface features (as in most psychoanalytic and
humanistic therapies), is also a key distinguishing feature. Similarly, the extent of therapeutic
ambition differs. While behavioural activation is clearly aligned with problem-assessment
and goal-attainment, for example, psychoanalysis is ambivalent about specific aims. Freud
aspired to mere ‘common unhappiness’, while Rogers wrote hopefully of the ‘fully function-
ing person’ and ‘the person of tomorrow’. Inclusion or predominance of certain personality
and technical modalities – cognition, behaviour, emotion, dreams, meaning, spirituality, etc. –
also helps to define each approach. We might say that each approach is constructed and
promoted on the basis of a different clinical epistemology; that is, each approach claims to
know best how to understand ailing human beings and how to reduce suffering or maximise
personal resourcefulness or happiness. What we cannot say is that the popularity of each
model equates with theoretical elegance or clinical effectiveness. The person-centred
approach, for example, ranking high with many practitioners, has often been criticised as
being theoretically light and has relatively little empirical evidence to support claims to reli-
able positive outcomes.
In spite of decades of effort towards integrative rapprochement, no slowing down of the
proliferation of therapeutic approaches is evident. Explicitly constructed integrative models
such as cognitive analytic therapy have appeared since the 1970s but have unintentionally
added to the sum total of therapies rather than reducing it. Integrative literature and confer-
ences abound but this is not reflected in any obvious movement towards practical conver-
gence. Heart can be taken from the number of practitioners, however, who report practising
integratively based on professional experience, clinical wisdom and responses to client needs
in busy and diverse practice settings. Observers of the initiatives towards a unified profession
have sometimes used the simile of ‘herding cats’ to highlight the difficulty of bringing
together practitioners who often have fiercely defended affiliations and negative views about

others. We have no rigorous analysis of who the pragmatic integrationists are and who the
partisan, politically entrenched are but the attractions and indeed ongoing uncertainties about
statutory regulation versus voluntary registration may well exert some influence on the
dynamics of the different approaches to therapy.
5 THERAPY AND ITS CRITICS
Psychotherapy and counselling are not self-evidently vitally necessary, scientifically justifi-
able, universally helpful or palatable. The validity of therapy – and of different therapeutic
approaches – must be clarified to its funders and consumers. Therapists tend to enter the field
as enthusiastic believers (often originally as successful clients themselves) whose belief is
reinforced by investment in their own personal training therapy, immersion in self-funded
training and personal economic prospects. Historically, therapy has emerged as a set of prac-
tices and specialised vocabularies in which adherents are immersed and which have been
offered to a public who knows little about them. Indeed, many ‘insiders’ (therapists) do not
have an accurate grasp of theoretical approaches other than their own and those charged with
conducting public relations exercises for the professional bodies sometimes struggle to con-
vey in accessible terms what is in fact a highly complex field. When it is said that ‘therapy’
works, this is shorthand for ‘we believe that our (dozens of different) therapies work’.
Objective research into what troubles people psychologically, why, and what best helps them,
has been slow to arrive on the scene (see Chapter 22).
One of the oldest of critiques, famously championed by Hans Eysenck, is simply that
therapy does not work, or has insufficient evidence to claim that it works, any better than a
placebo or time itself ‘works’. In fact Eysenck really meant that only behaviour therapy
worked reliably and psychoanalysis and its derivatives did not. Much subsequent research
has eroded the Eysenckian critique. On empirical grounds, critics have expressed scepticism
about the actual existence or validity of cornerstone concepts such as the unconscious,
Oedipus complex, inner child, repressed memory, actualising tendency, automatic negative
thoughts and so on. The propositions of therapists commonly derive from clinical observation
and inspiration rather than rigorous experiments or philosophically robust theorising, and
often do not express themselves in ways that can be readily tested and verified scientifically.
Unfortunately, since so many divergent (aetiological and therapeutic) concepts exist in this
field, significant and credible progress in verification is impeded.
Following his own disillusioning therapy as a trainee and his critique of Freud’s seduction
theory, Masson (1990) exposed many examples of neglect, malpractice and outright abuse
by therapists that he used as a basis for arguing that (a) therapy itself is riddled with abuses
of power and (b) this abuse is intrinsic to any asymmetrical therapeutic practice based on
expertise, it is endemic and it cannot be corrected. All Masson could suggest for those suf-
fering from mental health problems was non-specific mutual help. His critique has helped
to spawn greater efforts to stress accountability and strengthen complaints procedures but,
if anything, the voice of the discontented client is getting louder (Bates, 2006). Meanwhile,

there is obviously little the profession can do to assuage the likes of Masson and even the
anti-professionalisation lobby among therapists cannot satisfactorily address the implica-
tions of his total condemnation of therapy.
Another major source of critiques lies in the socioeconomic and sociocultural domain.
While therapy may indeed help individuals to be somewhat happier or more personally
resourceful, it cannot modify the social conditions that foster unhappiness (Smail, 2005).
It can be argued that the mitigating effects of therapy act positively in a ripple-like manner
from individuals outwards to society; but it can equally be argued that a world of 7 billion
individuals, or even a country like Britain of 62 million, facing constant, stress-inducing
socioeconomic pressures, will not be significantly improved by individual therapeutic
efforts. Even more seriously, the energy expended on micro-remedial individual analysis
and change is likely to divert attention from the need for the macro-remedial. In other
words, therapy in this analysis is seen as somewhat narcissistic, undermining of social
change efforts and, indeed, as ultimately futile. It is interesting that Layard (2003, 2005)
portrays conditions in Britain, contra Smail, as favourable to greater happiness, given bet-
ter support from CBT.
Therapy has also remained until recently quite stubbornly indifferent or even opposed to
questions of multicultural spirituality or religion and religious adherents’ critique of therapy
as self-centred rather than community-focused and God-centred. Add to this the rising costs
of training for therapy, most of which (with the exception of clinical psychology training) are
met by trainees themselves, which reinforces the middle-class nature of therapy provision,
and it is clear that therapy is not usually a naturally active ally against poverty, racism, sexism
and other domains of oppression. The charge that therapy remains Eurocentric, if not
Anglocentric, is not easily dismissed. Therapists may talk about empowering their clients,
say critics, but this is naïvety at best. All such trends are summarised in Feltham (2013).
6 EMERGING AND FUTURE TRENDS
Simultaneously encouraging and potentially undermining, the growth of acceptance of psy-

chological counselling and psychotherapy in the British NHS signals a turning point in the
development of the field. Increasing job opportunities in this domain went hand in hand with
an emphasis on statutory regulation. Growth of demand from the public and for evidence in
support of therapy is generally accompanied by a demand for greater evidence of exactly
what works best and why (Roth et al., 2006). The UK’s National Institute for Health and
Clinical Excellence (NICE) requires and facilitates the collection of evidence and its dis-
semination in the form of best practice guidelines on what is considered safe and effective.
This has not become ‘dictatorial’ – and indeed reassurances are given that it will not compro-
mise practitioners’ own creative autonomy – but has become influential. Evidence-based
practice (or ‘empirically supported therapy’ in North America) is an international trend with
certain advantages and disadvantages and, however disliked by many therapists, is unlikely
to be reversed in the short-term.

In 2005 Lord Richard Layard argued for significantly greater funding for mental health
treatment (‘now our biggest social problem’), and called specifically for the creation of
new mental health centres employing an additional 10 000 therapists. Basing his call
both on careful economic estimates and the moral case that psychological suffering be
treated as effectively as physical illness, within acceptable waiting times, Layard also
detailed a perceived need for a specified kind of training focusing on time-limited CBT
as the treatment of choice, based on available research findings. At the time of writing,
the CBT-emphasis remains but is slowly yielding to argument and counter-evidence. The
principle of ‘absence of evidence of effectiveness’ has tacitly and incorrectly been taken
to mean ‘ineffectiveness’ (vis-à-vis many humanistic and psychodynamic approaches)
and anecdotal evidence of cognitive behaviour therapists cherry-picking clients and
cases of long-term relapse following CBT have been ignored or played down (House and
Loewenthal, 2008).
The early dominance of psychoanalysis and psychoanalytic models has gradually given
way to the pluralism of psychological therapies available today. This proliferation is wel-
comed and celebrated by some as mirroring diversity, individuality and trends in postmodern-
ism (Cooper and McLeod, 2011). Others, both critics and custodians of the profession, regard
proliferation as a danger, a sign of lack of order. But there is no abatement in the growth of
distinct therapies. Models of brief, integrative, systems and constructivist therapy in particu-
lar have been growing, as well as evolution-informed approaches such as compassion-
focused therapy. Yet alongside this outward appearance of unchecked and credulity-straining
multiplicity, it seems likely that many practitioners have been learning to adapt their internal-
ised training models to the demands of their unique clients in their local settings. This is
especially true of primary care counsellors who have adapted to work in multidisciplinary
teams with short-term contracts with clients presenting with a range of mild to moderate
psychological problems.
Another area of growth in model-building and practice adaptation connects what is
broadly termed ‘spirituality’ (and more commonly transpersonal) with psychological
therapy. Interest in clients’ spiritual and religious lives and the possibility of drawing from
spiritual themes to enhance therapeutic progress goes back to Jung and Assagioli, and
transpersonal therapy is well established among humanistic practitioners. A combination
of changing demographics (the rise of multiculturalism and increasing longevity), cri-
tiques of Western therapy as too technical-rational and individual-centred, and a gradual
worldwide spread of therapy is highly likely to make an impact. West (2004) uncovered
prejudices against discussing the use of prayer and other spiritual practices in clinical
supervision, for example, and Moodley and West (2005) present possibilities of greater
integration of Western with ‘traditional healing’ practices. While it is not surprising that
Freudians have inherited Freud’s extreme scepticism towards religion and scientifically
grounded therapists have emphasised rationality in their work, there is a danger of becom-
ing alienated from the client population served. Indeed Rowan (2005) believes that only
those therapies that embrace but go beyond the instrumental and relational towards the
transpersonal are doing justice to the whole person. Also, of some surprise in recent years
has been the successful experimental integration of meditation techniques into forms of

cognitive behavioural therapy such as mindfulness-based cognitive therapy and dialecti-

cal behaviour therapy.
At the more materialist, scientific and technological end, we witness continuing research
into – as well as controversy over – psychopharmaceuticals, with doctors heavily subscribing
anti-depressants alongside or in lieu of counselling and CBT. The trend towards prescribing
medication for young people (e.g. primarily Ritalin for attention deficit and hyperactivity
disorder, and anti-depressants for low mood among children) has been sharply criticised.
Likewise, increasing research in neuroscience can either bring out in force those in favour of
identifying and remedying genetic deficits or those seizing on any evidence of links between
kindly early experiences and later optimal brain development and mentally healthy behav-
iour. The field of epigenetics, demonstrating how, for example, certain genes may be
switched on in response to traumatic life events and such responses transmitted to subsequent
generations, could still vindicate some therapeutic insights. The growth of email counselling
and cybertherapy – either in the form of individualised therapist responses or therapeutic
computer packages (e.g. CBT programmes for depression) – is probably driven by both a
fascination with technology generally and a preoccupation with costs. But it is growing and
becoming refined, however many therapists may object to its apparently depersonalising
effects and undermining of traditional relationship values.
We might wonder in what ways if any of the more conservative trends of evidence-based
practice coincide with much newer and often countercultural initiatives in the therapy field.
For example, significant progress has been made by therapy-promoting health economists
like Layard (2005) in the UK and Lazar (2010) in the USA, with confident predictions being
made about cost-effectiveness. But those who regard our malaise as having much deeper and
more extensive roots propose both evolutionary-informed (Gilbert, 2010) and ecotherapeutic
approaches (Totton, 2011). It is in the nature of such developments, however, that it takes
years for solid results to percolate through the system.
The UK government has used CBT packages to help the unemployed regain confidence
and re-enter the job market but this has been thwarted by widespread negative economics.
Swelling interest in the positive psychology movement, in neuroplasticity and flourishing,
also fits well here philosophically and clinically. Although subject to democratic and eco-
nomic vicissitudes, such developments if materialised are welcomed by therapists gener-
ally. However, some therapists and commentators on the therapy scene would caution
against premature and uncritical hopes for universal ‘happiness on the NHS’ or a cradle-
to-grave ‘nanny state’ or ‘therapy state’. It would be a supreme irony if the therapy movement
that commenced with Freudian radicalism, reinforced by humanistic counterculturalism,
spending several decades in a relative wilderness, finally culminated as a victim of its own
success in becoming an unwitting instrument of government-engineered socialisation. Put
differently, therapy (particularly humanistic therapy) may be in danger of selling out to the
values of the medically-oriented marketplace after many years of opposing it and champi-
oning the humanly subjective. Therapy watchers will as ever be observing with great inter-
est to what extent the field concedes thus or continues to assert its own insights, values and
pluralistic practices.

7 REFERENCES
Abernathy, J. and Power, M. (2002) The epidemiology of mental distress. In C. Feltham (ed.), What’s the Good of
Counselling and Psychotherapy? The Benefits Explained. London: Sage.
Aldridge, S. and Pollard, J. (2005) Interim Report to the Department of Health on Initial Mapping Project for
Psychotherapy and Counselling. Rugby: BACP and UKCP.
APA (2013) Diagnostic and Statistical Manual of Mental Disorders (5th edn). Washington, DC: American
Psychiatric Press.
BACP/FF (2004) The Age of Therapy: Exploring Attitudes Towards and Acceptance of Counselling and
Psychotherapy in Modern Britain. London: British Association for Counselling and Psychotherapy and the Future
Foundation.
Bates, Y. (ed.) (2006) Shouldn’t I Be Feeling Better by Now? Client Views of Therapy. Basingstoke: Palgrave.
Bentall, R.P. (2010) Doctoring the Mind: Why Psychiatric Treatments Fail. London: Penguin.
Burns, J. (2007) The Descent of Madness: Evolutionary Origins of Psychosis and the Social Brain. London: Routledge.
Carr, A. (2012) Clinical Psychology: An Introduction. London: Routledge.
Cooper, M. and McLeod, J. (2011) Pluralistic Counselling and Psychotherapy. London: Sage.
Cushman, P. (1995) Constructing the Self, Constructing America: A Cultural History of Psychotherapy. Cambridge,
MA: Perseus.
Ellenberger, H.F. (1970) The Discovery of the Unconscious: The History and Evolution of Dynamic Psychiatry. New
York: Basic Books.
Feltham, C. (2012) Settings and opportunities for employment. In C. Feltham and I. Horton (eds), The Sage
Handbook of Counselling and Psychotherapy (3rd edn). London: Sage, pp. 16–19.
Feltham, C. (2013) Counselling and Counselling Psychology: A Critical Examination. Ross-on-Wye: PCCS Books.
Foster, J.G. (1971) Enquiry into the Effects and Practice of Scientology. London: HMSO.
Frank, J.D. (1974) Persuasion and Healing: A Comparative Study of Psychotherapy (rev. edn). New York:
Schocken.
Gilbert, P. (2010) Compassion-Focused Therapy: Distinctive Features. London: Routledge.
Halmos, P. (1978) The Faith of the Counsellors. London: Constable.
House, R. and Loewenthal, D. (eds) (2008) Against and For CBT: Towards a Constructive Dialogue? Ross-on-Wye:
PCCS Books.
Lambert, M.J. (1992) Psychotherapy outcome research: implications for integrative and eclectic practice. In
J.C. Norcross and M.R. Goldfried (eds), Handbook of Psychotherapy Integration. New York: Basic Books.
Layard, R. (2003) Happiness: Has Social Science a Clue? Lecture 1: What Is Happiness? Are We Getting Happier?
London School of Economics: Lionel Robbins Memorial Lectures 2002/03.
Layard, R. (2005) Therapy for All on the NHS. Sainsbury Centre (London) Lecture, 12 September.
Lazar, S. (ed) (2010) Psychotherapy is Worth It: A Comprehensive Review of its Cost-Effectiveness. Washington,
DC: American Psychiatric Publishing.
Masson, J.M. (1990) Against Therapy. London: Fontana.
Messer, S.B. (1992) A critical examination of belief structures in integrative and eclectic psychotherapy. In
J.C. Norcross and M.R. Goldfried (eds), Handbook of Psychotherapy Integration. New York: Basic Books,
pp. 130–65.
Moodley, R. and West, W. (eds) (2005) Integrating Traditional Healing Practices into Counseling and Psychotherapy.
Thousand Oaks, CA: Sage.
Nussbaum, M.C. (2009) The Therapy of Desire: Theory and Practice in Hellenistic Ethics (3rd edn). Princeton, NJ:
Princeton University Press.

Pilgrim, D. (2002) The cultural context of British psychotherapy. In W. Dryden (ed.), Handbook of Individual
Therapy (4th edn). London: Sage.
Pinker, S. (2003) The Blank Slate: The Modern Denial of Human Nature. London: Penguin.
Ritzer, G. (ed.) (2004) Handbook of Social Problems: A Comparative International Perspective. Thousand Oaks, CA:
Sage.
Rose, N. (1989) Governing the Soul: The Shaping of the Private Self. London: Routledge.
Roth, A., Fonagy, P., Parry, G., Target, M., Woods, R. (eds) (2006) What Works for Whom? A Critical Review of
Psychotherapy Research (2nd edn). New York: Guilford.
Rowan, J. (2005) The Future of Training in Psychotherapy and Counselling. London: Routledge.
Salzman, N. and Norcross, J.C. (eds) (1990) Therapy Wars: Contention and Convergence in Differing Clinical
Approaches. San Francisco, CA: Jossey Bass.
Sanders, P. (2005) Principled and strategic opposition to the medicalisation of distress and all of its apparatus. In
S. Joseph and R. Worsley (eds), Person-Centred Psychopathology: A Positive Psychology of Mental Health. Ross-
on-Wye: PCCS Books.
Sieghart, P. (1978) Statutory Regulation of Psychotherapists: a Report of a Profession’s Joint Working Party.
Cambridge: Plumridge.
Smail, D. (2005) Power, Interest and Psychology: Elements of a Social Materialist Understanding of Distress. Ross-
on-Wye: PCCS Books.
Stevens, A. and Price, J. (2000) Evolutionary Psychiatry: A New Beginning (2nd edn). London: Routledge.
Totton, N. (2011) Wild Therapy: Undomesticating Inner and Outer Worlds. Ross-on-Wye: PCCS Books.
West, W. (2004) Spiritual Issues in Therapy: Relating Experience to Practice. Basingstoke: Palgrave.
Wright, K. (2011) The Rise of the Therapeutic Society: Psychological Knowledge and the Contradictions of Social
Change. Washington, DC: New Academia.

PART I
The Psychodynamic Tradition
02_Dryden & Reeves_Ch-02_Part-1.indd 19 08-Oct-13 10:32:14 AM

2
Psychodynamic
Therapy: Contemporary
Freudian Approach
Jessica Yakeley
1 HISTORICAL CONTEXT AND DEVELOPMENT
Psychodynamic psychotherapy, sometimes called psychoanalytic or exploratory psychotherapy,

is based on the principles and methods of psychoanalysis. The origins of psychoanalysis began
with its founder, Sigmund Freud, a Viennese neurologist who invented the ‘talking cure’ as a
treatment for hysteria in the 1890s. Freud first experimented with hypnosis to discover the
power of ‘abreaction’, a technique of hypnotic suggestion that enabled the patient to recover
repressed memories of childhood traumatic events. Through verbalising the feelings associated
with the original trauma, Freud discovered that the patient’s hysterical symptoms disappeared.
This led Freud to conceptualise hysteria as the repression of ideas and wishes that are unac-
ceptable to the conscious mind and expressed through bodily symptoms. Freud, however, soon
abandoned this cathartic method when he found that many patients appeared to be resistant to
hypnosis, and replaced it with the technique ‘free association’, a method that remains a corner-
stone of psychoanalytic therapy today (see below, Section 3.6.2).
Psychoanalysis has evolved significantly in both theory and practice since Freud with the
development of different theoretical schools. In the British Psychoanalytic Society (BPAS)

22 PART I: THE PSYCHODYNAMIC TRADITION
theoretical disagreements occurred between Freud’s daughter Anna and the Viennese psycho-
analyst Melanie Klein, which culminated in the ‘Controversial Discussions’, heated scientific
meetings held during the Second World War, which led to the emergence of three distinct
psychoanalytic groups: the Contemporary Freudians, the Kleinians and the Independents.
Although the three groups are no longer formally represented within the structure of the
society, many psychoanalysts nevertheless continue to identify themselves within a particular
group. Within the Contemporary Freudian group, a few psychoanalysts continue to identify
themselves as ‘Classical Freudians’, carrying on the ideas and practice of Anna Freud, but
most Contemporary Freudian psychoanalysts have incorporated ideas from other schools,
including contemporary Kleinian thinking. Nevertheless, distinctive features of a
Contemporary Freudian approach are identifiable and might include: emphasising a develop-
mental approach across the life-span; interest in child psychoanalysis and psychotherapy;
interest in sexuality and the body; empirical research and links with other disciplines espe-
cially neuroscience and attachment theory; and some distinct differences in technique.
An important development within psychoanalysis as a whole has been the application of
psychoanalytic ideas in different treatment settings and the development of less intensive
therapies. Psychodynamic psychotherapy utilises similar techniques to psychoanalysis but
sessions are less frequent, provided once or twice a week over a shorter time span, and ‘face
to face’, with the patient sitting up rather than lying on the couch, as in psychoanalysis. In
the UK, most psychodynamic psychotherapists, many working broadly within a Contemporary
Freudian approach, practise in the private sector. Psychodynamic psychotherapy is also avail-
able in the National Health Service (NHS), traditionally provided in departments of psycho-
therapy run by psychoanalytically trained psychiatrists. However, the viability of these ser-
vices has been threatened in recent years by the growing popularity of other therapeutic
interventions available in the NHS, particularly cognitive behavioural therapy.
2 THEORETICAL ASSUMPTIONS
2.1 Image of the person

Freud’s view of human nature was harsh. The Freudian image of the person is one who is not
in control of the conscious mind, but is driven by unconscious sexual and aggressive impulses
seeking gratification, which must be tamed in the service of civilisation. Despite the neces-
sary developmental adaptations to reality, including inevitable experiences of frustration,
disappointment and loss, human beings remain subject to unconscious vicissitudes of desire,
and conflict remains at the heart of the psyche.
Over a century later, although psychoanalysis has evolved significantly, several of Freud’s
core principles remain fundamental to a Contemporary Freudian view of the person. These
include: the notion of unconscious mental activity; psychic determination; the role of con-
flict, sexuality and aggression; and the idea that childhood experiences are critical in shaping
the adult personality.

CONTEMPORARY FREUDIAN APPROACH 23
One of the most important Freudian principles is the concept of the dynamic uncon-
scious, the notion that parts of our minds are inaccessible to us and that mental processes
occur outside of conscious awareness. Although Freud did not discover this observation,
he made the unconscious arena of the mind into the main object of investigation in psy-
choanalysis. In Freud’s first topographical model, the mind was divided into three sys-
tems: the conscious, the preconscious and the unconscious. In the preconscious, mental
activity can easily be brought to conscious awareness by shifting attention, whereas the
contents of the unconscious are unacceptable to the conscious mind and are therefore
kept from conscious awareness by the forces of repression. In Freud’s second model of
the mind, the structural model, the psychical apparatus is divided into three parts: id, ego
and superego. The id is a reservoir of unconscious ideas, wishes, impulses, feelings and
memories governed by its own laws, which are unacceptable to the conscious moral and
ethical values of society. The ego mediates between the conflicting demands of id, super-
ego and reality, and controls motility, perception and contact with reality. It also contains
the defence mechanisms, located in its unconscious part. The superego evolves from the
ego as the child negotiates the Oedipus complex, with the internalisation of parental
standards and expectations to form the child’s moral conscience and self-esteem. Freud
never fully replaced the topographical model with the structural model in his theorising,
and Contemporary Freudians today continue to use elements from both models when
conceptualising their clinical work.
Psychic determination challenges our notions of free choice by implying that our con-
scious thoughts and actions are shaped and controlled by unconscious forces beyond our
control. These unconscious motivations, determined by childhood experiences, will influence
our choices as adults in our work, leisure interests and relationships. Moreover, Freud pro-
posed that a single behaviour or symptom was multi-determined, in that it could contain
multiple complex meanings and serve several functions in responding to the demands of both
reality and the unconscious needs of the internal world.
Following Freud, Contemporary Freudians stress the importance of a developmental
approach in understanding the adult personality. Here, the role of childhood experiences,
interacting with the child’s genetically determined temperament, are critical in shaping the
adult’s personality. Although most Contemporary Freudians would now highlight the impor-
tance of the pre-oedipal period more than Freud did, and specifically the first year of life and
attachment experiences between the mother and infant, they also recognise the significant
effects that later developmental experiences in childhood and adolescence with the wider
family, peers, teachers and other significant figures can have in either potentiating or mitigat-
ing the effects of earlier infantile adversity or deprivation.
2.2 Conceptualisation of psychological disturbance and health

2.2.1 Psychological disturbance
Freud embedded his psychological models of the mind in biology with his instinct or
drive theory. For Freud, the sexual and aggressive drives were representations in the

mind of sexual and aggressive bodily instincts. Freud focused on the psychopathology of
neurosis, which he believed was the result of unconscious conflict. He proposed that we
are all neurotic to greater or lesser degrees, but in some individuals who cannot relin-
quish anxieties and defensive responses originating from their past, neurotic illness
results. The Freudian view of psychological disturbance is that it results from conflict
between the instinctual drives and the external world, or between different parts of the
mind. Conflict between the ego and id can result in psychopathology when unacceptable
pleasure-seeking sexual and aggressive wishes originating in early childhood seek dis-
charge and try to break through the ego’s censorship barrier into consciousness. The
resulting conflict triggers a variety of defence mechanisms of the part of the ego to limit
psychic tension, whilst allowing as much gratification as possible by converting the
impulses into compromise formations. Depending on the type of defence mechanism
employed, these may emerge as a variety of hysterical, phobic, obsessional or psychoso-
matic symptoms. Conflict between the ego and superego can give rise to feelings of low
self-esteem, shame and guilt due to the ego’s failure to live up to the high moral stand-
ards imposed by the superego.
Whilst Freud acknowledged the existence of other defence mechanisms, he focused mostly
on that of repression – the expelling or withholding from consciousness of unacceptable ideas
or feelings – as the main defence mechanism producing neurosis. Anna Freud and the ego
psychologists added to the list of defence mechanisms and made the analysis of defence a
cornerstone of psychoanalytic technique, a tradition continued by many Contemporary
Freudians. We all use defence mechanisms, which can be classified according to a hierarchy
from the most immature or pathological to the most mature or healthy. Psychological distur-
bance may result when the person predominantly utilises immature defence mechanisms such
as projection, dissociation, denial, or splitting to defend against real or imagined threats to
the self, which may cause neurotic illness or harden into more ingrained and long-term char-
acter pathology.
2.2.2 Psychological health

Freud believed that children had sexual drives, and proposed that psychosexual development
consisted of a series of stages in which particular bodily functions, such as feeding and bowel
control, were associated with particular erotogenic zones and corresponding developmental
stages of the body, with the sequential acquisition of particular functions and objectives par-
ticular to each stage. Development proceeds from oral to anal to phallic to genital stages,
building on the accomplishments of the preceding stage. Failure to negotiate the emotional
demands of each stage causes pathological character traits in adult life.
The oedipal phase of childhood is a critical time in this developmental trajectory. Freud
named the Oedipus complex after the Greek tragedy in which Oedipus unknowingly killed
his father and married his mother. Freud proposed that the Oedipus complex was a normal
stage of development occurring between the ages of 3–5 years, where the boy develops
feelings of love and possessiveness towards his mother and feelings of rivalry and jealousy

towards his father. The boy’s fear of his father’s punishment for his desire for the mother
leads to castration anxiety. Resolution of the Oedipus complex, through the child relin-
quishing these hostile infantile feelings and identifying with the same-sex parent, results
in the formation of the superego. Failure to negotiate the Oedipus complex results in
deficits in the capacity to enjoy healthy loving and sexual relations and predisposes to
neurotic illness.
Although most Contemporary Freudians would continue to stress the importance of the
oedipal phase in the genesis of psychological health or disturbance, like other psychoanalytic
schools, they also consider the effects of the child’s pre-oedipal development to be critical to
later psychological functioning. Moreover, Contemporary Freudians today would consider
other motives for psychopathology apart from the danger of sexual and aggressive drives,
including threats to a sense of safety (Sandler, 1960), feelings of guilt and shame, and real
threats in the external world. However, Contemporary Freudians have arguably continued
Freud’s focus on linking psychic functioning with sexuality and the body more than other
psychoanalytic schools.
2.3 Acquisition of psychological disturbance

Most Contemporary Freudians today believe that psychological disturbance is acquired in
early life as the result of a complex interplay between constitutional factors and adverse
environmental experiences, such as trauma. Freud himself oscillated in his writings between
prioritising the role of innate factors over that of the environment in the genesis of psycho-
pathology, the most well-known example being his shift from believing that his patients’
neurotic illnesses were the result of real sexual seductions in childhood, to believing that
their symptoms were the product of sexual fantasy. Moreover, Freud’s changing theories of
anxiety and trauma illustrate his increasing recognition of the importance of object relation-
ships. In his earlier model, anxiety is a direct expression of blocked sexual libido. He later
revised this theory to see anxiety as the response of the ego to the danger of internal and
external threats, including those relating to loss of an object (e.g. death of a parent) or of
the object’s love (e.g. through rejection or emotional abuse). In the case of massive trauma, the
excitation released by the traumatic situation causes massive anxiety which overwhelms the
ego, breaking through its defences and rendering it helpless and unable to function. These
shifts in Freud’s theorising paved the way for the shift in Contemporary Freudian thinking
from Freud’s one-person psychology towards a two-person psychology in which biological
drives are no longer the primary motivational force, and the role of object relationships
assume equal importance.
Freud’s observation that people unconsciously tended to repeat painful or self-destructive
behaviours, which he termed the repetition compulsion, led him to propose the death instinct,
a biological force that works insidiously in opposition to the life instinct towards destruction
and an inorganic state, and underlies all aggression. However, many Contemporary Freudians
reject the concept of the death instinct, and believe that aggression, whilst biologically

rooted, arises as a defensive response to threats to the psychological self, particularly those
arising in the early mother–infant relationship. Here, many Contemporary Freudians have
been influenced by the work of Winnicott, Bion and Bowlby in their emphasis on the impor-
tance of the mother in providing adequate maternal sensitivity and attunement for the infant,
failures of which in the form of neglect, loss or abuse, predispose to more severe psycho-
logical disturbance, such as personality disorder or psychosis. This also involves a shift in
recognising that such disturbance may be the result of deficit (i.e. a primary lack of funda-
mental elements necessary for healthy development such as sensitive and empathic care-
giving), rather than being due to conflicts between instinct and defence, as may be the case
for less severe neurotic illnesses.
2.4 Perpetuation of psychological disturbance

2.4.1 Intrapersonal mechanisms
One of Freud’s greatest discoveries was that of resistance – that many patients, whilst con-
sciously wishing to change and seeking therapy, appear to oppose attempts to help them in
an unconscious attempt to keep things as they are. Although resistance is a clinical concept,
it can be used more broadly as an explanatory construct to understand some of the intra- and
interpersonal defence mechanisms that human beings use to perpetuate psychological distur-
bance. Freud (1926) identified several types of resistance, which he called repression resist-
ance, secondary gain resistance, transference resistance, repetition-compulsion resistance and
superego resistance.
Repression resistance is due to the individual resisting the emergence of unconscious
fantasies, memories and feelings into consciousness for fear that these would destabilise
his psychological equilibrium. Superego resistance can occur in individuals who have
developed harsh and inflexible superego functioning. Here, the person unconsciously
adopts a punitive and judgemental attitude to the self, resulting in an unconscious masochistic
tendency to suffer, a state that is fulfilled by the person’s psychological illness and would
have to be relinquished if their symptoms were cured. Freud discovered that the develop-
ment of a harsh superego was not solely dependent upon experiencing and internalising
harsh parental attitudes in early childhood, but could arise in individuals who had experi-
enced benign parenting, pointing, Freud thought, to the influence of innate aggression in
the development of the mind. His attempts to explain the phenomenon of repetition-
compulsion resistance, in which the patient continued to repeat painful experiences from
the past, for example, repeatedly becoming involved in abusive relationships, led him to
posit the existence of the death instinct.
2.4.2 Interpersonal mechanisms

A Contemporary Freudian understanding of the repetition compulsion elaborates some of
Freud’s earlier theorising of this self-destructive tendency as an effort to master separation
and trauma, and as a defensive fixation of the mind against earlier painful situations, which

continues, despite the removal of real external threats. Here the role of object relating and
interpersonal mechanisms become more relevant in the perpetuation of psychological dis-
turbance. Sandler (1960) suggested that the primary motivational element is the regulation
of feeling states, rather than drives, to maintain a sense of security, which he called the
background of safety. Even distressing or abusive relationships can be safety-giving, reas-
suring and affirming, because what is familiar feels safer, even if this is painful. Where such
early pathological modes of relating have been internalised to form character traits, the
individual is pre-disposed to sadomasochistic types of relationships and may unconsciously
seek out abusive environments in adulthood, which can form a potent source of resistance
to change.
2.4.3 Environmental factors

Secondary gain is another reason why psychological disturbance may be perpetuated. Instead
of welcoming the primary gain of relief and pleasure in the removal of neurotic symptoms,
the sufferer may, consciously and unconsciously, gain satisfaction from their illness in the
social function and response from others that it may acquire. For example, by being ill the
sufferer feels he can gain sympathy and attention from his family, and at the same time cov-
ertly exact revenge for feeling neglected or maltreated by making others look after him.
Secondary gain may become a lifetime condition in cases of compensation neurosis where
the individual adopts a position of long-term suffering in order to gain compensation follow-
ing occupational and industrial injuries.
2.5 Change
The early Freudian model of psychological development is underpinned by the principle of
determinism, in which all of our conscious actions and choices are controlled by unconscious
motivations, determined by childhood predispositions and experiences. People are unable to
change because they are fixated at a particular stage of psychosexual development, or they
are unable to relinquish the psychic status quo in which the intrapsychic conflict is contained
by the ego’s defences, even if these are pathological and compromise the person’s function-
ing. People often present for therapy when their habitual and lifelong pathological defences
do not work so well any more, or break down altogether to reveal underlying anxieties rooted
in their early developmental histories. This may be triggered by a stressful event such as
bereavement, or due to a more gradual realisation as one gets older that the mode of life they
are leading is no longer sustainable.
However, the deterministic viewpoint, based on an essentially linear and causal stance
reflecting a one-person psychology, is unable to explain why some people may be able to
move from psychological disturbance to psychological health despite negative predisposing
factors. Although much evidence points to the importance of early relationships in determin-
ing psychopathology or psychological health in adulthood, any change is inevitably com-
plex, multi-determined and occurs in a non-linear fashion. Many other factors, including the

person’s interpersonal relationships at later stages of the life-cycle as well as a myriad of

occupational, societal, cultural and political events and influences, may shape the course of
a person’s development in a positive direction, in which for some, psychoanalytic psycho-
therapy may be another, but not the only mutative intervention.
3 PRACTICE
3.1 Goals of therapy

Freud’s aims for psychoanalysis were modest, or even pessimistic: ‘much will be gained if
we succeed in transforming your hysterical misery into common happiness. With a mental
life that has been restored to health you will be better armed against that unhappiness’ (Freud,
1895: 305). Freud’s reticence about what could be achieved by psychoanalytic treatment
reflected his ambivalence about whether psychoanalysis should concern itself with cure at all,
or whether its primary aim was to analyse and understand the human condition regardless of
therapeutic success. Freud’s legacy in this respect has been a persistent difficulty in psycho-
analysts being able to articulate the goals or aims of their treatment.
Freud’s changing views of therapeutic action reflected his evolving conceptualisation of
his models of the mind. With his initial model of catharsis, Freud’s mechanism of change was
simply to ‘transform what is unconscious into what is conscious’. The development of the
topographical model led to his emphasis on the interpretation of defence and resistance as
techniques to allow the unconscious mental contents into consciousness. In his structural
model, however, therapeutic effect now depended on alteration and redistribution of energy
between the three mental agencies of ego, id and superego, and in particular the strengthening
of the ego. Change now involved an increase in the resilience of the ego to cope not only with
internal demands from id and superego, but also with the inevitable stresses, traumas and
disappointments that occur in the course of a lifetime without having to resort to infantile
impulses or defensive compromises. From a structural point of view, this involves the relin-
quishment of pathological defence mechanisms, a lessening of the strength of the superego
and its tyrannical hold over the ego, and an increased flexibility in the ego’s ability to tolerate
a greater range of emotional responses and to allow previously unacceptable wishes and
fantasies into consciousness – ‘where id was, there ego shall be’ (Freud, 1933: 80).
The structural model promoted understanding or insight into the origin of unconscious
conflicts, achieved via the interpretations of the analyst, as one of the main goals of therapy.
Change involves resolving the conflicts of the past and lessening the unconscious hold that
the past exerts on present functioning, so that actions are no longer dominated by the repeti-
tion compulsion and the patient has more conscious choice over the direction of his life.
Unhelpful defences and character traits, which may have defended against real anxieties and
been essential to psychic survival early in development, are now recognised as no longer
being proportionate to current reality and impeding healthy functioning and relationships.
Change also involves the relinquishment of omnipotent and idealistic fantasies and a more

realistic acceptance of life’s compromises and uncertainties, to which more adaptive solu-
tions may be found.
As well as acknowledging these intrapsychic changes, Contemporary Freudians, reflecting
the influence of an object relations perspective and recognition of the mutative effects of
non-verbal aspects of the therapeutic relationship, would also stress the importance of
improvements in the person’s relationships with others, particularly an enhanced capacity for
emotional intimacy.
3.2 Selection criteria

3.2.1 Unsuitability criteria
Freud was clear that psychoanalysis was a treatment for neurosis, and was contraindicated
for patients with psychotic illness, addictions or serious character pathology, whom he
thought lacked sufficient ego strength to withstand the psychoanalytic method. However,
from the 1950s onwards, discussions of indications, prognosis and ‘analysability’ led to the
‘widening scope’ of psychoanalysis and its application to the treatment of psychological
conditions and pathological behaviours other than neurosis, including delinquency, perver-
sions, personality disorders and even psychotic illnesses such as schizophrenia.
Nevertheless, most psychoanalytic psychotherapists today would advocate a cautious
and modified approach for patients with severe mental illnesses or personality disorders,
often in a more supportive, rather than interpretative, direction. Such patients may be
thought of as having fragile egos and using predominantly primitive defences such as pro-
jection, which hold in check anxieties of a psychotic intensity. Exploration of the roots of
their difficulties in psychotherapy and analysis of their defences risks undermining this
precarious psychic equilibrium and releasing anxiety which might drive the patient to act
on his impulses in self-destructive or violent ways, or become psychotic. People with vio-
lent or suicidal tendencies, or those with drug and alcohol addictions, may therefore not be
suitable as their problematic behaviours may worsen, at least in the short term, with psy-
chotherapeutic treatment.
3.2.2 Suitability for individual therapy

Patients with neurotic conditions, such as anxiety and depression, or those with mild to mod-
erately severe personality difficulties, particularly in the interpersonal realm, are most likely
to benefit from individual therapy. However, a formal psychiatric diagnosis is less helpful as
a suitability indicator than an ability to engage in the therapeutic process and be able to form
and sustain a psychotherapeutic relationship. This requires the patient to have sufficient ego
strength to withstand the anxiety that exploration of one’s difficulties entails, a willingness to
accept that they have difficulties and need help, some curiosity into the nature of these dif-
ficulties and interest in their own internal world, and an ability to reflect and understand their
difficulties in psychological terms. The latter has been termed psychological mindedness, the
various components of which include an acknowledgment of the unconscious, awareness of

emotionally significant historical events and capacity to recall memories with appropriate
affect, use of imagination, capacity to dream, some signs of hope and self-esteem, curiosity
about internal reality and capacity to tolerate internal anxiety, and ability to make links
between past and present (Coltart, 1988). Factors in the external world are also important,
such as the presence of other supportive relationships in the patient’s life which may sustain
him between sessions, and whether the patient can afford the time and money that psycho-
analytic psychotherapy may entail.
3.3 Qualities of effective therapists

3.3.1 The personal characteristics of effective therapists
Positive qualities of an effective therapist will include a genuine curiosity in the motivations
of human behaviour, a capacity for empathy and putting oneself in the shoes of another per-
son, a capacity to tolerate states of uncertainty and ambivalence, a flexibility in attitude and
openness to discovery, an ability to sustain long-term work in which the pace of change may
be very slow or the goals of treatment modest, and an ability to withstand and tolerate intense
emotional responses without acting on these. Most of these qualities may reflect pre-existing
personal characteristics and interpersonal skills of the therapist, which cannot be taught, but
may be developed into specific psychotherapeutic skills with training and experience, such
as an ability to be in tune with the non-verbal and more unconscious communications
between the patient and therapist.
3.3.2 The skills shown by effective therapists

An essential skill of the therapist is the ability to maintain a non-judgemental attitude of
neutrality and openness, in which the therapist’s personal views and moral values do not
impinge upon the patient. Many therapists are attracted to the profession because of a wish
to help others, often stemming from the person’s own psychological difficulties, or those in
the person’s family. Although this may facilitate the therapist in being able to empathise with
others who experience psychological problems, the therapist needs to have a good under-
standing and resolution of her own personal difficulties to the extent that they do not interfere
with her ability to treat patients. This is one of the reasons why all psychoanalytic psycho-
therapists are required to have their own psychoanalysis or psychoanalytic therapy as part of
their training.
3.4 Therapeutic relationship and style

3.4.1 The therapeutic relationship
The therapeutic relationship is one of the cornerstones of psychodynamic psychotherapy with the
relationship, and in particular the concept of transference, becoming the focus of treatment. Freud
first became aware of the powerful affective and unconscious dimensions of the interchanges
between patient and analyst after experiencing his patients’ unexpected positive or negative

emotional reactions to him. He first coined the term transference as an unconscious displace-
ment by the patient onto the analyst of ‘new editions’ of old feelings and fantasies, which the
patient originally experienced towards a significant figure, often a parent, in his childhood
(Freud, 1905a). For example, even if the analyst believes he is behaving in a helpful and non-
judgemental way towards the patient, the latter may experience the analyst as critical and
undermining, as he did his father when he was a child. Transference thus represents a repeti-
tion of the past, in accordance with the principle of the repetition compulsion. In classical
Freudian analysis, successful treatment involved the patient’s regression in analysis to expe-
riencing a transference neurosis based on the patient’s original or ‘infantile’ neurosis. When
the analyst does not react to or gratify the patient’s demands and expectations with his atti-
tude of abstinence and neutrality, the patient’s key unconscious conflicts and dynamics which
underpin his relationships with others may become more evident in the relationship between
analyst and patient and can be interpreted and understood.
Freud initially viewed the transference as a resistance to the process of free association and
hindrance to effective treatment, but later proposed that transference interpretation was in
fact essential for analytic cure. Freud distinguished between the positive transference, which
is comprised of warm, trusting and hopeful feelings in the patient towards the analyst, and
the negative transference where the patient develops angry or hostile reactions. He also cau-
tioned against the seductive power of the erotic transference, where the patient may express
erotic feelings or behaviour towards the analyst and the need for the latter to abstain from
reciprocating in professionally inappropriate ways. Whilst most Contemporary Freudians
would today view the positive transference as a basis for the development of a good thera-
peutic relationship, they would also be wary of neglecting its pathological aspects such as
idealisation of the therapist which may be a defence against the expression of underlying
negative transference feelings.
The therapeutic relationship will also be influenced by the countertransference, which
comprises the feelings and emotional reactions that the therapist develops towards the
patient. This affective response of the therapist is not always conscious, and is a result of both
unresolved conflicts in the therapist, as well as the projections of the patient. As with the
transference, Freud originally saw countertransference as a resistance to treatment, but con-
temporary analysts see it as an essential tool to gaining information about the patient’s uncon-
scious communications and internal object relations (see below, Section 3.6.2).
The classical view of transference as ‘false connection’, in which the past intrudes into the
present, has been gradually replaced by a more modern view held by many psychoanalysts
today of transference as a continual expression of the patient’s object relational world in rela-
tion to the analyst. However, whilst most Contemporary Freudians would agree that the
transference is not just a repetition but is a new experience infused by both past and present
influences, many would not view everything that occurs in the therapeutic relationship as
transference, as do some proponents of the Kleinian school, but would acknowledge the
existence of a ‘real’ relationship between patient and therapist. Both Anna Freud (1954) and
Greenson (1967) proposed that the full analytic relationship was an intermingling of three
levels: the ‘transference relationship’; the ‘therapeutic alliance’; and the ‘real relationship’.

Greenson believed that a trusting relationship with an analyst who showed ordinary human
responses was essential to the development and interpretation of the transference. If the
therapist can initially ally himself with more healthy aspects of the patient’s ego that can be
identified and nurtured, these can be used to strengthen the ego and contribute to a good
working alliance or therapeutic relationship with the therapist, that will form the foundation
from which insights can emerge.
3.4.2 Therapeutic style

The patient’s therapeutic experience is determined not just by the techniques employed by
the therapist, but the personal style in which these techniques are delivered. Freud empha-
sised the importance of an analytic attitude of abstinence, anonymity and neutrality. The
analyst should abstain from responding to the patient’s demands in inappropriate actions or
an over-gratifying attitude so that the patient does not derive any substitute satisfaction from
the therapeutic relationship, which would delay the emergence of the patient’s unconscious
conflicts and inhibit progress. The principle of anonymity and non-disclosure of any aspect
of the analyst’s personal life allowed the analyst to function as a mirror or ‘blank screen’ onto
which the patient could project his conflicts and transference reactions, which were uncon-
taminated by any knowledge of the real person of the analyst and a more accurate reflection
of the patient’s original infantile neurosis. Neutrality refers to the impartial attitude of the
analyst who should not assume the role of teacher, mentor or judge and refrain from offering
the patient advice or direction in their life choices.
Contemporary analysts accept that the patient will inevitably accurately pick up and be
influenced by some of the analyst’s individual characteristics and idiosyncrasies. Within the
same school, therapists’ individual styles will vary according to both their conscious choice
of technique and the more unconscious influence of their personality and manner of relating
to others. Some will be experienced as more silent and serious whereas others may adopt a
more interactive approach. However, whilst most Contemporary Freudians today would con-
tinue to adhere by the general principles of non-disclosure, abstinence and neutrality, most
will adopt a more flexible approach in practice and be sensitive to how the patient perceives
them. This may include, for example, smiling to engage the patient and deepen the therapeu-
tic relationship, adopting a more conversational style in which questions are asked and
aspects of the patient’s current external life are discussed, or the judicious use of humour.
However, most Contemporary Freudians would also be wary of self-disclosure and revealing
too much about their personal lives as could be intrusive to the patient and an impingement
of the analytic space.
3.5 Assessment and case formulation

3.5.1 Assessment
Assessment for psychodynamic psychotherapy is a skilled and multi-layered process com-
prised of several functions, including: diagnosis; formulating the patient’s problems in

psychodynamic terms; assessing the patient’s suitability and motivation for psychodynamic
therapy; consideration of issues regarding risk, for example self-harm; and providing an
opportunity for the patient to get a feel for the psychodynamic approach so that an informed
decision can be made about treatment. The assessment interview may be the first exposure
the patient has to a psychoanalytic way of thinking, which for some may be a strange or even
threatening experience. How the therapist conducts these first meetings is critical for future
engagement in therapy. Psychoanalytic assessment puts most emphasis on the clinical inter-
view with the patient, rather than other methods of assessment such as psychometric testing,
as attending to the experience within the interviews and the nature of the relationship that
emerges between patient and assessor can yield the most meaningful information regarding
the unconscious fantasies and functioning of the patient.
The nature of the assessment, including the ways in which a patient is referred, will vary
according to the setting in which it occurs. The way in which the patient is referred may
reveal useful information about their motivation and predict subsequent engagement in
therapy. Patients are sometimes referred for psychotherapy by other mental health profession-
als, or are ‘sent’ by concerned spouses or relatives to address their problematic behaviours
(e.g. drinking, gambling), whereas the patient himself has little inclination to change. Even
seemingly highly motivated patients who are actively seeking therapeutic help may have lit-
tle idea of the hard work required of psychodynamic therapy, which will inevitably involve
periods during which the patient feels more disturbed as his defences are challenged and
underlying anxieties revealed.
The clinical interviews form the fulcrum of the assessment process. The task of the asses-
sor is two-fold and alternates between the subjective and the objective: on the one hand she
must empathically elicit the patients’ difficulties by creating an atmosphere conducive to the
emergence of the unconscious material; and on the other hand she must objectively gather
sufficient factual information to make an informed decision about the patient’s strengths and
weaknesses and determine his suitability for psychodynamic psychotherapy.
Ideally, the assessor should arrange to see the patient on more than one occasion to allow
the space and freedom to address the various factors that should be examined during the
assessment process. These include a thorough appraisal of the patient’s ego strength, defences
and motivation for therapy, to discover what the patient makes of the meetings, whether the
patient is capable of reflection between sessions, and whether he is able to tolerate the anxi-
ety associated with the open-ended process of psychotherapy which offers an attempt at
understanding rather than immediate advice let alone cure. Many patients come with the wish
that their overt symptoms or current difficulties in their external life will be removed, rather
than being prepared to explore the unconscious meaning of their symptoms and the link to
underlying and often longstanding difficulties.
It is useful for the initial meeting to take the form of an unstructured interview to observe
how the patient responds to silences, the ability to free associate and to assess the presence
and quality of emotional contact within the session and degree of access to his internal world.
However, some patients may find such an unstructured situation anxiety provoking or perse-
cutory, and the assessor may need to intervene sooner than with a person whose ability to

tolerate anxiety is greater. In subsequent interviews, the assessor can focus on more active
history taking and obtaining essential information about the patient, including a full personal
and family history. Details of the patient’s past psychiatric history are particularly important
in assessing the risks that the patient might present in treatment, and should include asking
about self-harm, previous psychiatric or psychological treatment, alcohol or substance mis-
use, and any psychiatric diagnosis such as depression, psychosis or personality disorder that
the patient has received.
An extended assessment allows time for the careful introduction of different technical
stances and observation of the patient’s responses, including the effect of trial interpreta-
tions. This is an intervention based upon a tentative psychodynamic hypothesis that is offered
to the patient to see if he can think about himself in a different way. Other key features that
the psychodynamic assessor will be looking for in the patient and that are positively corre-
lated with good outcomes in treatment are the ability to form a good rapport or working
alliance, and the capacity to respond affectively within the assessment sessions, for example
allowing the expression of feelings of anxiety, sadness or anger.
The psychodynamic formulation incorporates a hypothesis that that will inform the choice
and goals of treatment and brings together common themes emerging from the three main
areas covered in the assessment: the patient’s current difficulties, the patient’s history of
infantile or childhood conflicts or deficits, and the transferential relationship with the asses-
sor. A comprehensive psychodynamic formulation should include a description of the prob-
lem as seen by the patient; contextualising the problem in a developmental framework and
identifying the genetic origins of their difficulties; identifying recurring themes or conflicts
in the patient’s relationships to identify dominant object relationships and defences; and
identifying the aims of treatment. A psychodynamic formulation may also include reference
to psychiatric diagnosis, but will not be confined to a phenomenological description of the
patient’s symptoms, but will elaborate their dynamic meaning and link to the patient’s char-
acter structure and significant stages of development.
3.5.2 Case formulation

The final stage of the assessment process is the outcome, first reaching a decision regarding
the patient’s suitability and willingness to engage in psychodynamic psychotherapy, and
secondly a consideration of the treatment options and referral on if the assessor is not plan-
ning to see the patient herself. This should involve a collaborative discussion with the patient
about the availability and practicalities of treatment, including the setting, times and fre-
quency of sessions, fees, breaks in therapy, and the expected length of treatment, particularly
if it is time-limited. Psychodynamic psychotherapists do not usually set explicit goals or get
the patient to sign contracts or treatment plans, but gaining the patient’s informed, if implicit,
consent is good practice by giving sufficient information regarding the general nature of the
therapy offered as well as some information about alternative approaches, such as cognitive-
behavioural therapy (CBT). This should also include some discussion of the possible risks of
therapy, such as feeling more disturbed at times or an increased risk of acting out behaviours
depending on the patient’s history. If it is thought that there is a significant risk, for example

of self-harm or psychotic breakdown, other professionals may need to be involved such as

the patient’s general practitioner (GP) or psychiatrist, particularly during breaks in treatment,
paying careful attention to issues of consent and confidentiality.
3.6 Major therapeutic strategies and techniques

3.6.1 Major therapeutic strategies
The over-riding therapeutic strategy is to create a protected psychic space in which the
patient’s unconscious material, dreams, wishes, conflicts and fantasies, may safely emerge to
be interpreted and understood. This is achieved by maintaining the parameters of the analytic
setting, which include the reliability and consistency of the physical setting as well as the
analyst’s attitude of neutrality, anonymity and abstinence. In psychoanalytic treatment
patients are encouraged to lie on the couch, with the analyst sitting behind them. The relative
sensory deprivation and inability to see the analyst’s facial expressions facilitate the patient
in being able to focus on inner thoughts and feelings and encouraged to express in free asso-
ciation, the cornerstone of classical Freudian psychoanalytic technique. Here, the patient is
encouraged to follow the fundamental rule and say whatever is in their mind, without censor-
ing thoughts, however embarrassing, disturbing or seemingly trivial these may be. The psy-
choanalyst’s task, through a corresponding type of evenly suspended listening that Freud
called free-floating attention, is to discover the unconscious themes that underlie the patient’s
discourse via the patient’s slips of the tongue, associative links and resistances to speaking
about certain topics that the patient himself is unaware of.
In a once-weekly psychoanalytic setting, the patient is usually sitting up and therapy con-
ducted ‘face to face’. Other boundaries of the setting remain important in creating a safe
environment, including the consistency of the physical environment in which the therapy
takes place, the reliability of regular 50-minute sessions that begin and end on time, and the
clearly defined interpersonal boundaries between patient and therapist, in which the therapist
minimises self-disclosure and maintains confidentiality.
3.6.2 Major therapeutic techniques

Psychoanalytic psychotherapy is primarily a talking therapy in which the key interventions
are the therapist’s verbal communications, which can be categorised along a spectrum of
interventions that moves from the supportive to interpretive as the therapy progresses. Thus
the therapist may initially make empathic comments; moving to clarifications, questioning or
rephrasing to elucidate what the patient means; via confrontations, where the therapist will
point out inconsistencies in the patient’s account or draw his attention to subjects he may be
avoiding; to interpretations.
Psychoanalytic interpretations are considered to be one of the major interventions used in
psychoanalytic therapy that promote insight. An interpretation is a verbal intervention, which
makes something that is unconscious conscious and by doing so offers a new formulation of
meaning and motivation. Continuing the tradition of classical Freudian analysis, most

Contemporary Freudians will focus on the interpretation of unconscious intrapsychic conflict

and defence. A Contemporary Freudian therapist will usually be careful to work from surface
to depth, analysing the patient’s resistances and defences (for example, his lateness to ses-
sions, or silences) before interpreting the content of underlying unconscious fantasies.
Dream interpretation was an important element of classical Freudian technique, believed
by Freud to be ‘the royal road to the unconscious’ (Freud, 1905b). The manifest content of
the dream is believed to conceal unconscious latent meaning, which may be revealed by ask-
ing the patient to give his personal associations to individual elements of the dream story.
Although dream analysis no longer holds central place within psychoanalytic technique
today, Contemporary Freudians would nevertheless view dreams as an important source of
discovery about the patient’s unconscious fantasy life.
Broadly speaking, there are two main types of interpretation: genetic or reconstructive; and
transference or here-and-now interpretations. A reconstructive interpretation links the
patient’s current thoughts or behaviour to their developmental or historical origins, making
an explicit link with the past. Such an interpretation aims to help the patient understand how
his current difficulties have been influenced by his history. In a transference interpretation
the therapist makes explicit reference to the patient-therapist relationship, in which patient’s
current constellation of affects and behaviour towards the therapist point to conflicts from the
past that are being re-enacted in the transference situation. The therapist draws attention to
the ‘here-and-now’ of what is currently happening in the therapeutic interchange, focusing on
what appears to be the affective focus, or most emotionally charged moments in the therapy
session.
Alongside transference interpretations the use of the therapist’s countertransference as a
tool to access the patient’s internal world has become ubiquitous across all psychoanalytic
schools. The emotional feelings and responses, including enactments, of the therapist to the
patient can be understood as reflecting the patient’s unconscious mental states, a process
which is often explained by the patient’s use of the primitive defence mechanisms of projec-
tion and projective identification. Here, the patient cannot bear to recognise their affects and
object relationships as internal to themselves and therefore projects and attributes them to
others. The person who has been invested with these unwanted aspects may unconsciously
identify with what has been projected into them and may be unconsciously pressurised by the
patient to act out.
Sandler (1976) offered a helpful Contemporary Freudian elucidation of this process in his
concept of role responsiveness. At any particular time, the patient will unconsciously create
a specific ‘role relationship’ involving a role in which he casts himself, and a complementary
role in which he casts the therapist. This role relationship is based on a dominant unconscious
wishful fantasy rooted in the patient’s historical relationships with significant objects, and is
enacted or ‘actualised’ by the patient in the transference. Such actualisation involves the
patient unconsciously manipulating the therapist to feel or behave in a particular way, result-
ing in unexpected countertransference experiences or enactments.
Within the psychoanalytic world there has been an extensive debate regarding the hierar-
chy of efficacy of different interpretations. Drawing on Strachey’s (1934) seminal paper, and

influenced by the Kleinian school, many psychoanalysts today believe that transference
interpretations are the most mutative in effecting psychic change, and that remembering and
reconstructing historical events may become a therapeutic pitfall that functions as a displace-
ment from the affectively charged transferential focus of the session. Reconstruction as a
therapeutic technique has therefore become relatively neglected in recent years in psychoa-
nalysis in favour of interpretation within the transference–countertransference paradigm.
However, many Contemporary Freudians continue to find value in reconstructive interpreta-
tions in helping the patient construct a meaningful narrative of his past history and to make
sense of his current difficulties.
Other differences in technique distinguish the Contemporary Freudian approach.
Contemporary Freudian therapists may wait longer before interpreting the transference, hold-
ing back until the patient himself is aware of the feelings he has towards the analyst.
Contemporary Freudians may also differ in their use of countertransference, and do not nec-
essarily believe that this encompasses all of the therapist’s reactions to the patient or that all
countertransference feelings originate in the patient. Keeping in mind Freud’s view of coun-
tertransference as reflecting the analyst’s own blind spots may mitigate against the risk of
neglecting to attend to the actual experience of the patient which may not always be mirrored
by the therapist’s experience. Finally, Contemporary Freudians also believe that extra-
transference interpretations, that is, exploration and interpretation about the patient’s current
external life without reference to the transference, may be helpful without minimising the
importance of his internal world and unconscious fantasies.
Finally, Freud emphasised the importance of working through – that patients need suffi-
cient time between being told something by the analyst and for them to make sense of it and
feel it with conviction. This involves the linking of intellectual insight with emotional knowl-
edge, aided by transference interpretations in which intellectual verbalisation is turned into
immediate experience.
3.7 The change process in therapy

Since Freud, psychoanalysts have been preoccupied with the nature of therapeutic action.
Although it is now widely accepted that psychoanalysis and psychoanalytic therapy do work
(e.g. Fonagy, 2002), there is still much debate as to how. Most contemporary psychoanalytic
theorists, including those of a Contemporary Freudian orientation, now acknowledge that
there is no one view of psychic change but that it is likely to be a complex process and the
interventions that facilitate change may be multiple and simultaneous. Interventions may fall
into three categories: those that foster insight (e.g. interpretation, especially of transference
phenomena, free association); those that make use of aspects of the therapeutic relationship
(e.g. experiencing a different kind of relationship, internalisation of function, identification
of prominent transference–countertransference paradigms); and ‘secondary strategies’ (e.g.
confrontation and suggestion, examination of dysfunctional beliefs, exposure, problem solving,
affirmation and empathic validation) (Gabbard and Westen, 2003).

Gabbard and Westen observe the waning in the contemporary psychoanalytic discourse of
the ‘interpretation versus relationship debate’ (Gabbard and Westen, 2003: 824) in favour of
multiple modes of therapeutic action, and they highlight the shift of emphasis from recon-
struction to the ‘here-and-now’ interactions between patient and therapist and focus on the
transference. Recent research findings indicating that autobiographical memory is unreliable,
and that very early experiences cannot be remembered at all, but are encoded in implicit
procedural systems means that notions of change in psychoanalytic treatment are no longer
dependent upon the recovery of repressed memories.
Psychoanalysts today are more interested in how patients construe and ascribe meaning
to their historical experiences rather than trying to reconstruct historical facts accurately.
Change occurs through identifying and making explicit the patient’s implicitly coded rela-
tional templates via understanding the new relationship formed with the analyst. This will
also involve an increased capacity for mentalisation or self-reflection. Such a capacity,
which has shown to be disrupted in individuals who have experienced early attachment
disruptions and environmental adversity, may develop within the safe attachment relationship
to the therapist. However, it is important not to neglect more classical psychoanalytic tech-
niques of reconstruction, free association and dream interpretation that may also contribute
to change.
4 CASE EXAMPLE
4.1 The client

Marie was a woman in her early thirties with a diagnosis of ‘borderline personality traits’ who
was seen by me for 18 months of individual once weekly psychodynamic psychotherapy in
an NHS psychological therapies department. Marie complained of long-standing periods of
depression during which she spent days in bed obsessed with thoughts of suicide and death.
At other times she would feel out of control and have violent outbursts, which involved
smashing mirrors, windows and glasses. She also self-harmed in the form of superficial
scratching of her wrist, but had never made a suicide attempt. During the four weeks between
referral and assessment, her husband rang the department angrily requesting that his wife
should be seen immediately, as the situation was ‘urgent’.
4.2 The therapy

4.2.1 Assessment and formulation of the client’s problems
Marie was referred by her GP and assessed by a senior male consultant psychotherapist who
met with her on two occasions. She initially attributed her depression to the breakdown of
her marriage to her husband, whom she said was twenty years older and disinterested in her.
On further enquiry she also related her depression to worries about her mother who had
recently been diagnosed with myalgic encephalomyelitis and spent her time lying in a dark

room at their family home. At this point the assessor asked her about her relationship with
her mother, and she spontaneously told him about her family history. Marie was from an old
upper-class family who had lost their fortune but continued to live in the family home in
relative poverty. She was the youngest of five children. Her father was a poet of some
renown, although unable to sustain a steady income. He was much older than her mother, and
experienced by Marie as a remote figure, emerging from his study only at mealtimes, during
which he was mostly silent. Marie remembered her mother, by contrast, as a sociable woman
always surrounded by people. However, she also recalled, as a young child, hearing her
mother cry in the next-door room and trying to block it out, and wondered whether her
mother had been depressed.
Marie’s older siblings went to private boarding schools, but the family inheritance had
run out by the time she arrived, so that she had to attend the local state school. She
recalled a lonely childhood, playing on her own in the woods. As a teenager she became
rebellious, smoked, drank and stayed out late as a way of trying to gain attention from
her parents, who nevertheless remained detached and somewhat amused by her behav-
iour. Her mood swings and self-harming behaviour started around this time. She left
home to go to art school but felt very lonely and returned home frequently. She became
closer to her mother in her twenties, until she met her husband, following which her
mother became ill and withdrew from Marie’s approaches for contact. Marie had worked
intermittently teaching as a supply teacher in a primary school, but had not worked since
being married.
Marie presented as an attractive, petite woman who appeared lively and flirtatious yet at
the same time projected a waif-like vulnerability and seemed younger than her age. She
appeared to choose her words carefully, giving an articulate and often eloquent account of
her problems, her conversation interspersed with literary quotations, including poetry. At
times the assessor felt she was relating an amusing story about her life that was somehow
detached from her real self. At the same time, she appeared nervous with a visible tremor,
which she referred to as her ‘shaking’. She said that this only ever ceased when she was alone
or with her family.
Marie appeared psychologically minded and motivated to explore the origins of her diffi-
culties. She responded to a trial interpretation by the assessor when he suggested that she had
come for help now as her mother’s recent illness had perhaps triggered feelings of depression
and despair that dated from early childhood when her mother was also unavailable to her. At
this point, Marie’s eyes swelled with tears and she admitted that she couldn’t contemplate
having her own children, as she was terrified that she would also suffer from depression and
damage her child. Marie readily accepted the assessor’s recommendation of psychotherapy,
but appeared momentarily disappointed when he clarified that it would be with another
therapist. The assessor noted, but did not interpret, this as a transference reaction to him as a
wished-for paternal figure who would save her.
The assessor’s tentative formulation was that she had suffered emotional deprivation as
a child due to her mother’s depression and her father’s emotional unavailability, which she
had unconsciously repeated in her own choice of an emotionally distant older husband. Her

manner of presentation reflected an unconscious identification with her father, but also
characterological defences against more unacceptable and conflicting feelings of vulnera-
bility and anger, which emerged in her depressive and aggressive outbursts as well as being
continuously betrayed in her physical tremor. Her illness could be thought of as over-
determined and serving simultaneous unconscious functions in representing: a regression
to a wished for infantile state in which she would be cared for, an identification with a
depressed maternal object, and an expression of feelings of rage, resentment and retaliation
towards her objects who are forced to worry about her.
4.2.2 Development of the therapeutic relationship

When I saw Marie, I was a young trainee therapist in the Department. However, Marie
never commented on my youth and initially related to me as if I were a wise older sister
who was sympathetic and not disapproving. Marie regularly attended and was open in
discussing her current difficulties and links to her childhood. She quickly reported feeling
less depressed and more hopeful about her future, and that her tremor had disappeared.
However, any tentative transference interpretations on my part were routinely dismissed,
claiming she had no thoughts or feelings towards me. The only hints of a negative trans-
ference were in occasional contemptuous comments about her new female GP being ‘too
young to know anything’, and a vague countertransferential feeling in me of anxiety and
that despite her apparent progress, something was missing. The therapeutic relationship
changed dramatically, however, six months into treatment when I had to unexpectedly
take a three-week break. When I returned, she said she did not want to talk, and was vis-
ibly very angry, although she would not acknowledge my interpretation that she was
angry with me. She then cancelled the next session, following which her GP telephoned
the department, concerned that Marie was becoming psychotic and needed to see a psy-
chiatrist as she had smashed up her flat.
There followed a difficult period in which Marie cancelled almost every other session and
when she attended was sullen and uncommunicative, although I heard snippets of her over-
drinking and sleeping with a stranger she met in a bar. I interpreted how difficult it was for
her to openly express her anger with me, which we could nevertheless see in her tremor, but
also that she needed me to be there, to notice her worrying behaviour and to be concerned
about her. She gradually became more able to acknowledge her dependence on me and wish
for my attention, and to link this with the lack of attention she received from her parents now
and historically.
4.2.3 Therapeutic strategies and techniques

Marie initially appeared not to respond to transference interpretations, so in the first few
months of therapy my interventions mainly consisted of empathic comments, clarifications
and reconstructive interpretations linking issues in her current life to difficulties in childhood.
She initially blamed most of her problems on her unsatisfactory relationship with her hus-
band, but soon began to explore feeling emotionally neglected by her parents and that her

husband represented both mother and father to her. She admitted that she sometimes called
him ‘Mummy’ as he tucked her into bed or listened to her problems, and had an intense nos-
talgia for a fantasy of family life that she had never had, but in which she remained the little
girl who would be cared for. Although she initiated divorce proceedings during the therapy,
she continued to enjoy her husband’s attentions and found it difficult to sign the final papers.
She blamed her inability to make decisions on her parents, especially her father who avoided
confrontation and lacked assertiveness, characteristics she deplored in herself. However, as
the therapy progressed, she also acknowledged my interpretation that she also identified with
her depressed mother who needed to be looked after, and with whom she was furious for not
looking after her.
Another important area that was explored was her confused sense of self and understand-
ing her inner feelings as opposed to those of others. As a child she resented not belonging to
the privileged boarding school world of her siblings, yet was conscious of class differences
that distanced her from the local village children. As an adult she was terrified of being alone,
yet complained that she only existed through other people. We explored how terrified she was
of fully acknowledging her own powerful feelings of anger and destructiveness, and she
frequently described herself as walking a precarious tightrope between control and chaos.
Beginning to own these feelings of rage and destructiveness only became possible follow-
ing my unexpected break and the eruption of these feelings into the transference arena. This
period of therapy could be thought of as my absence precipitating a sudden breach in her
defences resulting in the development of a transference neurosis in which I was experienced
as the abandoning maternal object. She could no longer deny having any feelings towards
me, and also became more able to access feelings of anger, rather than pity, towards her
mother, not only for neglecting her as a child, but for narcissistically withdrawing yet again
to psychosomatic illness when Marie felt she needed her most.
Although Marie reported few dreams, a dream she had a few weeks before the end of
therapy seemed significant. In the dream, she had gone home to discover the house empty
and on fire, so she ran to the fire station, but all the firemen were too busy on the telephone
and no-one took any notice of her. Her initial associations to the dream were that she would
have no-one to talk to once therapy finished. I interpreted that perhaps the dream also repre-
sented the only way in which she could express angry feelings towards me for leaving her,
in the fire that burnt down the ‘home’ she felt she had with me in therapy. She responded with
tears, saying that she would really miss me.
4.2.4 Therapeutic outcome

By the end of therapy, Marie was more able to assert her independence in no longer regarding
her family home as a sanctuary from all her problems, and being less preoccupied with her
mother’s illness. Her increasing self-confidence also became manifest in her work: during the
therapy, at her own initiative she sought and obtained her first full-time job as a teacher’s
assistant with the aim of becoming an art teacher. She also had the strength to continue
divorce proceedings in the face of resistance from her family. I believe these changes were

facilitated by experiencing me as a new transference object, who could survive her attacks
and not retaliate, yet remain available and interested in her. However, due to limited NHS
resources, the therapy was time-limited and the ending felt premature, which did not allow
sufficient time for the working through, consolidation and integration of intellectual insight
with concurrent affective changes. There was also insufficient time in which to explore the
oedipal and pre-oedipal dynamics operating in the transference which reflected the uncon-
scious constellation of her early internalised object-relationships. The same assessor reviewed
her three months following the cessation of my therapy with her and, as she was thought to
have made good use of the therapy, he referred her for more long-term intensive therapy
within the low-fee scheme of a psychoanalytic therapy training organisation.
5 OTHER PRACTICE CONSIDERATIONS
5.1 Developments
5.1.1 Brief therapy
Although the Contemporary Freudian tradition formally originated within the British
Psychoanalytic Society as one of three distinct groups, it has developed into a looser and
wider umbrella term for a diverse group of psychodynamic therapists working broadly within
a Freudian perspective in a range of settings which require various adaptations to the
approach. Many therapists, particularly those working within the NHS, have adapted their
technique to the confines of a time-limited or brief therapy. Brief dynamic therapies may be
more appropriate for less disturbed patients whose difficulties can be thought of as originat-
ing from a neurotic or oedipal level, rather than patients with more borderline or pre-oedipal
disturbance. Brief therapies need to be more focused and how the patient might experience
termination should be explored early in treatment. More recently, Dynamic Interpersonal
Therapy (DIT) has been developed from the Contemporary Freudian stable as a manualised
time-limited psychodynamic treatment for anxiety and depression (Lemma, Target and
Fonagy, 2011).
5.1.2 Working with diversity

Other significant developments within the Contemporary Freudian tradition have been
around working with more disturbed patients, including those diagnosed with psychosis,
personality disorder, sexual perversions and gender identity disorders. Contemporary
Freudian psychoanalysts working at the Portman Clinic in London have pioneered work
with violent and perverse patients and contributed to the foundations of the emerging disci-
pline of forensic psychotherapy. Such patients who lack the capacity for self-reflection and
tend to act out their impulses through attacking their body or those of others, require a
modification of psychoanalytic technique in order to foster the therapeutic alliance, such as
avoiding long periods of silence, using supportive and mentalising techniques, and using
analyst-centred interpretations. Transference interpretations, especially those addressing the

negative transference, should be avoided too early in therapy particularly with more para-
noid patients. Some of these technical adaptations have been incorporated into new and
specific psychodynamic treatments for personality disorder such as such as mentalisation-
based treatment (MBT). MBT has been developed in the UK for the treatment of patients
with borderline personality disorder and has been shown to be clinically effective in ran-
domised controlled trials (Bateman and Fonagy, 2008).
5.2 Limitations of the approach

Psychotherapy is sometimes presented as a benign and well-meaning enterprise but like any
other effective treatment it carries unwanted side-effects and risks, particularly for more
disturbed patients with mental illness or personality disorder whose condition may deterio-
rate with treatment. A further limitation is the lack of clear referral pathways in the private
sector with many therapists working independently in relative silos, and the lack of availa-
bility of psychodynamic psychotherapy in the public sector. The situation is complicated by
political and theoretical rivalries between practitioners of psychoanalysis, psychotherapy
and counselling where the more intensive therapies are often promoted as superior treat-
ments if only they were more available, rather than creating an informed debate highlighting
the skills needed to conduct less intensive therapies and linking frequency of sessions with
specific psychopathology.
5.3 Criticisms of the approach

Psychoanalysis has often been criticised for being more akin to a religious cult (Szasz, 1978)
rather than a credible discipline worthy of serious scientific enquiry. This reputation has
unfortunately been perpetuated by some of its own practitioners whose attitudes and internal
professional rivalries have promoted a culture in which a ‘narcissism of small differences’
proliferates at the expense of pursuing the more pressing task of meaningful engagement with
the outside world. Furthermore, many psychoanalysts have argued persuasively that psy-
choanalysis belongs more with the art-based, historical and hermeneutic disciplines rather
than the world of science, and have actively eschewed empirical enquiry into its methods.
This has laid the profession justifiably open to a positivist critique that it is an ideological
closed belief system and claims that patients treated with psychoanalysis gained no more
improvement than untreated controls (Eysenck, 1952).
It could be argued that in the UK, the Contemporary Freudian school has taken the lead
on addressing these criticisms in opening the profession to empirical research in order to
test the validity of its theoretical concepts and efficacy as a treatment and by making links
with its relevant sister disciplines such as cognitive neuroscience and developmental psy-
chology, in particular in the field of attachment (notably in the work of Peter Fonagy and
Mary Target). A dialogue between the neurosciences and psychoanalysis spearheaded by
the Contemporary Freudian psychoanalyst Mark Solms has blossomed into a successful

neuropsychoanalysis movement that has provided convincing evidence for the neurobio-
logical mechanisms that underpin aspects of unconscious processes such as dreams and
repression. However, psychoanalysts and psychoanalytic therapists also need to be willing
to adapt or relinquish aspects of their theories and treatments in the light of empirical
research findings.
5.4 Controversies
Controversies within the psychoanalytic profession have historically revolved around the
merits of different theoretical approaches, each believing that they hold the ‘true’ way of
practising. A paradoxical situation that has developed within the recent psychoanalytic move-
ment is that the rise of pluralism and tolerance of different approaches appears to have given
sway to a more unspoken belief that we are all operating within the same fundamental rules
of psychoanalysis. Nevertheless, real differences continue to exist, the most marked being the
place that transference interpretations are given within the hierarchy of mutative interven-
tions. Some Contemporary Freudians feel that the pendulum has swung too far in prioritising
interpretation of the transference at the neglect of a more classical approach, which would
include reconstructive, supportive and extra-transference interpretations.
A wider area of recent controversy causing considerable concern to all psychoanalytic psy-
chotherapists working within the public sector is how best to counteract the rapid dismantling
of psychoanalytic psychotherapy services that is occurring within the NHS in this era of finan-
cial austerity and rationing of treatment. While some organisations have been politically active
in raising the profile of the profession, more work needs to be done to convince patients, com-
missioners and policy-makers of the efficacy and cost-effectiveness of psychoanalytic psycho-
therapy. This requires more psychoanalytic therapists to actively engage in outcome monitoring
and researching their treatments which, in some cases, may include the manualisation of their
treatment approach and encouraging patients to participate in randomised controlled trials.
6 RESEARCH
Despite the methodological difficulties inherent in conducting outcome research on intensive

psychoanalytic treatments, there is now a large body of empirically sound studies that dem-
onstrate the efficacy of psychoanalytic psychotherapy. Recent meta-analyses (e.g. Leichsenring
and Rabung, 2011) show that the effect sizes for psychoanalytic therapy are as large as those
reported for other evidence based therapies such as CBT. Well-constructed randomised con-
trolled trials have demonstrated the efficacy of psychodynamic psychotherapy for a large
range of disorders including depression, anxiety, panic disorders, somatoform disorders,
substance misuse and personality disorders (Shedler, 2010). Moreover, these studies show
that patients who receive psychoanalytic therapy maintain therapeutic gains and continue to
improve after cessation of treatment.

The results of these outcome studies have gone some way in challenging the ‘equiva-
lence paradox’ – the finding in psychotherapy research that despite the vast array of dif-
ferent psychotherapeutic methods, no one therapy was consistently found to be more
effective than another. This led to the suggestion that ‘common factors’ (Frank, 1986) to
all psychotherapies, such as providing hope, the offering of a relationship with a therapist
and providing a rationale and set of activities, accounted for improvement in health rather
than any modality-specific strategy. There is also recent evidence to suggest that part of
the efficacy of non-psychodynamic psychotherapies is due to therapists utilising, often
unwittingly, psychodynamic skills and concepts that have long been core, centrally defin-
ing features of psychodynamic psychotherapy (Shedler, 2010). These include facilitating
an unstructured and open dialogue, identifying recurring themes in the patient’s discourse,
linking the patient’s feelings and perceptions to their past experiences, interpreting defen-
sive manoeuvres and unconscious material, focusing on the relationship between patient
and therapist, and drawing parallels between this relationship and relationships in the
patient’s external life.
More recent process research has looked at specific techniques within psychoanalytic
psychotherapy and attempted to correlate different interventions with outcome. These have
included qualitative methodology that can provide information about the subjectivity, pro-
cesses, interrelations and meanings that are intrinsic to the psychoanalytic enterprise that
quantitative evidence-base research often disregards. One of the most well-known attempts
to identify psychodynamically meaningful data about the inner world was the Core
Conflictual Relationship Theme (CCRT) (Luborsky and Crits-Christoph, 1990), a measure
of key unconscious personal themes, which can be identified through studying the process
notes of psychotherapy sessions. The CCRT provided one of the first scientific and objec-
tive measures of the concept of transference and was used to demonstrate that individuals
have only a few basic transference patterns, that these derive from early parental relation-
ships, and that these patterns may gradually change during the course of therapy. These
findings have been corroborated by an instrument based on the principles of attachment
theory, which has been widely used in psychodynamic psychotherapy research in the last
two decades. This is the Adult Attachment Interview (AAI) (Main and Goldwyn, 1994), a
psychodynamically informed assessment interview that produces a narrative measure of
the person’s attachment experiences and relational disposition. The AAI has been used to
track changes in psychoanalytic psychotherapy to show how patients can move from
pathological attachment patterns (dismissive or enmeshed) to more secure attachment pat-
terns as therapy progresses (Fonagy et al., 1995).
Such research underscores the importance of the therapeutic relationship. Many other
studies have demonstrated that the presence of a strong therapeutic alliance, or positive
transference experiences of the patient seeing the therapist as warm, supportive, sensitive,
understanding and possessing a sense of humour, is correlated with good outcome (e.g.
Leichesenring, 2005). This would suggest that promoting a positive transference, at least
in the early stages of treatment to establish a secure therapeutic alliance, is important.
Although research studies specifically examining the relationship between transference

interpretation and outcome of therapy are limited, recent evidence suggests high rates of
transference interpretations may be associated with a better outcome for more disturbed
patients who show poor therapeutic alliance, and a poorer outcome for patients with more
mature object relations who establish a strong therapeutic alliance (Hoglend et al., 2011).
This contradicts conventional clinical wisdom that patients with more mature relation-
ships will benefit from transference interpretation more than patients with more severe
psychopathology. The authors suggest that this surprising result is in fact compatible with
the classical Freudian admonition that one should not interpret transference until it
becomes a resistance, and that a therapist who is overly zealous in interpreting transfer-
ence may appear to be narcissistically and needlessly focusing the patient’s attention on
the therapist. However, the authors warn that the relationships between therapist tech-
nique, patient characteristics, therapy process and outcome are complex, and examination
of any one of these variables in isolation may be misleading. Further studies are needed
to elucidate the effects of specific techniques and to provide a more informed critique
regarding the superiority of any one psychoanalytic approach over another.
7 FURTHER READING
Bateman, A. and Holmes, J. (1995) Introduction to Psychoanalysis: Contemporary Theory and Practice. London:
Routledge.
Gabbard, G.O. (2010) Long-term Psychodynamic Psychotherapy: A Basic Text (2nd edn). Arlington, VA: American
Psychiatric Publishing.
Greenson, R. (1967) The Technique and Practice of Psychoanalysis, Vol.1. London: Hogarth Press.
Lemma, A. (2003) Introduction to the Practice of Psychoanalytic Psychotherapy. Chichester: Wiley.
Sandler, J., Dare, C., and Holder, A. (1992) The Patient and the Analyst. London: Karnac Books.
8 REFERENCES
Bateman, A. and Fonagy, P. (2008) 8-year follow-up of patients treated for borderline personality disorder: men-
talization-based treatment versus treatment as usual. American Journal of Psychiatry 165(5): 631–8.
Coltart, N. (1988) The assessment of psychological-mindedness in the diagnostic interview. British Journal of
Psychiatry 153: 819–20.
Eysenck, H. (1952) The effects of psychotherapy: An evaluation. Journal of Consulting Psychology 16: 319–24.
Fonagy, P. (2002) An Open Door Review of Outcome Studies in Psychoanalysis (2nd rev. edn). IPA.
Fonagy, P., Steele, M., Steele, H., Leigh, T., Kennedy, R. (1995) Attachment, the reflective self and borderline states;
the predictive specificity of the adult attachment interview and pathological development. In S. Goldberg (ed.),
Attachment Theory: Social, Developmental and Clinical Perspectives. New York: Academic Press.
Frank, J. (1986) Psychotherapy: The transformation of meanings. Journal of the Royal Society of Medicine 79:
341–6.
Freud, A. (1954) The widening scope of indications for psycho-analysis. Journal of the American Psychoanalytic
Association 2: 607–20.

Freud, S. (1895) The psychotherapy of hysteria. In J. Breuer and S Freud, Studies on Hysteria. Standard Edition 2,
pp. 253–305.
Freud, S. (1905a) Fragment of an Analysis of a Case of Hysteria. Standard Edition 7.
Freud, S. (1905b) Three Essays on the Theory of Sexuality. Standard Edition 7.
Freud, S. (1926) Inhibitions, Symptoms and Anxieties. Standard Edition 20.
Freud, S. (1927) Analysis Terminable and Interminable. Standard Edition 23.
Freud, S. (1933) New Introductory Lectures. Standard Edition 22.
Gabbard, G.O. and Westen, D. (2003) Rethinking therapeutic action. International Journal of Psychoanalysis 84:
823–41.
Greenson, R. (1967) The Technique and Practice of Psychoanalysis, Vol.1. London: Hogarth Press.
Høglend, P., Hersoug, A.G., Bøgwald, K-P., Svein, Amlo, S., Marble, A., Sørbye, Ø., Røssberg, J.I., Ulberg, R.,
Gabbard, G.O., Crits-Christoph, P. (2011) Effects of transference work in the context of therapeutic alliance and
quality of object relations. Journal of Consulting and Clinical Psychology 79: 697–706.
Leichsenring, F. (2005) Are psychodynamic and psychoanalytic therapies effective? A review of empirical data,
International Journal of Psychoanalysis 86: 841–68.
Leichsenring, F. and Rabung, S. (2011) Long-term psychodynamic psychotherapy in complex mental disorders:
update of meta-analysis. The British Journal of Psychiatry 199: 15–22.
Lemma, A., Target, M., Fonagy, P. (2011) Brief Dynamic Interpersonal Therapy: A Clinician’s Guide. Oxford: Oxford
University Press.
Luborsky, L. and Crits-Christoph, P. (1990) Understanding Transference: The CCRT Method. New York: Basic
Books.
Main, M. (1995) Adult attachment classification system. In M. Main (ed.), Behaviour and the Development of
Representational Models of Attachment: Five Methods of Attachment. Cambridge: Cambridge University Press.
Main, M. and Goldwyn, R. (1994) Adult attachment scoring and classification system version 6. Department of
Psychology, University of California at Berkeley, Berkeley, CA. Unpublished work.
Sandler, J. (1960) The background of safety. In J. Sandler (ed.), From Safety to Superego. New York: Guilford,
1987; London: Karnac Books, 1987.
Sandler, J. (1976) Countertransference and role-responsiveness. International Review of Psycho-Analysis 3: 43–7.
Shedler, J. (2010) The efficacy of psychodynamic psychotherapy. American Psychologist 65: 98–109.
Strachey, J. (1934) The nature of the therapeutic action of psychoanalysis. International Journal of Psychoanalysis
(1969), 50: 275–91.
Szasz, T. (1978) The Myth of Psychotherapy. Syracuse, NY: Syracuse University Press.

3
Psychodynamic Therapy: The
Independent Approach
Kevin Jones
1 HISTORICAL CONTEXT
The early years of the British Psychoanalytic Society (BPS) saw a bloody power struggle
arising out of a conflict between tradition and innovation in psychoanalysis, out of which the
Independent Group, ‘Between Freud and Klein’, was formed. The legacy of the struggle and
the development of the Independent Group was charted by Kohon (1986) and Rayner (1991).
They described the development of child psychoanalysis in the 1920s by Melanie Klein in
Berlin and Anna Freud in Vienna, which saw the formation of increasingly divergent psycho-
analytic theories and practices. The BPS was sympathetic to Klein’s ideas and had invited her
to England in the mid 1920s and, when in 1938 the Freud family fled to Britain to escape
Nazi persecution in Europe, the two tendencies came together in the BPS. Kohon (1986)
described how the new arrivals found a membership dissatisfied with the undemocratic man-
agement structure of the BPS and concerned at the increasing polarisation around scientific
disagreements between Melanie Klein and Anna Freud.
In 1943 the society debated these scientific disagreements in the ‘Controversial
Discussions’, particularly the question of whether or not Melanie Klein’s theories represented
a continuation or a new development of Freudian theory. These scientific differences were
also equated with cultural differences between the ‘Continental’ analysts represented by
Anna Freud and the ‘British Schools’, receptive to Klein. The discussions were marked by a

duality of acute clinical and theoretical debate carried out with a rancour and hostility arising
from entangled, passionate allegiances to particular thinkers. No scientific resolution to these
differences was found, but an administrative and political compromise was reached that sat-
isfied the democratic aspirations of its members and which allowed the different tendencies
within the BPS to co-exist (Kohon, 1986). The ‘middle group’ emerged from those analysts
who did not identify with either the Kleinians or the Anna Freudians and, despite being a
majority in the society, initially resisted becoming an organised group. It was not until 1973
that the ‘middle group’ was formally constituted as the ‘The Independent Group’ as a way of
participating in the formal structure of the BPS alongside the Contemporary Freudian and the
Kleinian groups (Rayner, 1991).
The newly emerging Independent group was decisively shaped by the traumatic experi-
ence of the controversial discussions and the marked cultural and scientific differences
within the BPS. Limentani (1999) describes how, after having fled political persecution in
Europe, he was not attracted to the ideological and sectarian nature of the group conflicts
and loyalties acted out in the controversial discussions. Kohon (1986) draws a link between
the organisational structure of the BPS, which allowed the different groups to work together,
and the parliamentary democracy that had welcomed psychoanalysts escaping fascism in
Europe. This political background contributed to an outlook that valued anti-authoritarian-
ism and tolerance and which Rayner linked to an intellectual tradition in Britain influenced
by political liberalism, philosophical empiricism and an interest in the individual in their
environment influenced by Darwin (1991: 8–9). The commitment of the Independents was
to using ideas for their ‘use and truth value’ reflecting an ‘affinity with the scientific attitude’
(1991: 8) rather than a commitment to specific theoretical positions.
The legacy of the power struggle in the BPS led the Independents to use the ideas of both
Anna Freud and Klein in a ‘creative interplay’; developing different perspectives based on
their clinical experience and allowing the emergence of a distinctive style of thought and
practice. Rayner (1991) compared the Independents to a school of painters who, despite their
different individual styles and temperaments, nevertheless have a shared sensibility and
address a set of common problems in their work. The Independents tradition included many
prominent analysts within the BPS, including Balint, Fairburn and Winnicott alongside other
less well-known analysts such as Bollas, Coltart, Milner, Rycroft and Sharpe, who also made
important contributions.
For the independents, the infant is born seeking an object that will meet its need to expe-
rience dependency in a relation of intimacy and nurture. The initial motivation of the infant
is to seek relationships with others and human development takes place in the interaction
between the individual and their environment. The environment is initially understood in
terms of the infant’s relationship with its ‘primary object’ – the mother – and broadens to

THE INDEPENDENT APPROACH 51
include the other objects – father, siblings, grandparents and other members of the extended
family and friends. The family is in turn situated and shaped in relation to the wider net-
work of object relations possible in the wider sphere of culture and society.

The experience of dependency in relation to the object in early infancy will shape the adult
and their relationships in later life. Before there can be someone who might be called a ‘per-
son’ the infant depends upon a relationship with an external object to enable the integration
of its biological and psychological maturation.
The infant is born with an ego, an aspect of the conscious personality that has the poten-
tial to coordinate and organise its internal and external experiences but it does not yet have
a strong sense of being separate from its external object, the mother. Through the mother’s
provision of a reliable pattern of ordinary, everyday childcare that meets the infant’s need
for food, warmth and comfort, the infant ego is strengthened. Where the continuity of care
is consistent over time, the infant can make the transition from a ‘harmonious mix-up’ with
the mother to develop a sense of separateness. It is only as the infant’s ego develops with
the support of the external object that it becomes able to integrate its bodily sensations and
feelings as personal experiences and to communicate them in a shared symbolic form.
Having moved from a state of ‘at one-ness’ with the mother and accepting her as a separate
object, the infant encounters a third object as it come to terms with the mother’s relation-
ship with father. The infant then enters into relationships with multiple objects such as
siblings, family members and friends and the wider social community. The process of dif-
ferentiation of ego from object is an important part of the infant’s capacity to accept that it
lives in a shared external reality in mutual dependence with others.
The development of the infant ego takes place in relation to areas of experience that are
unconscious to the infant. The unconscious arises from the interplay between bodily sen-
sations and feelings, the experience of its early object relations and fantasies about the
relationships between these experiences. This interplay creates an internal world popu-
lated by internal objects that represent aspects of the self in relation to its external objects.
The internal objects form patterns of interrelationship, which, although remaining uncon-
scious to the infant, nevertheless influence their sense of self in relation to external
objects and to the wider social environment throughout life.
The ego, however, is not yet the self; it is an aspect of the total personality. The subjec-
tive sense of self arises from the interplay between conscious and unconscious processes
arising in relation to the object. Unconscious process can be a rich resource for creative
living with others and it can be a place where unwanted or feared aspects of the self can
be buried, ‘repressed’ and put out of conscious awareness, restricting self-potential and
relationships. The presence throughout life of an unconscious internal world and uncon-
scious processes means that the person never fully knows who they are and who they are
becoming.


The path of healthy development moves through various stages of dependency towards the
recognition of independence and mutual interdependence with others. This ideal is not easily
achieved and the process involves conflicting feelings in relation to the object. Initially the
merger provides an experience of bliss and harmony that helps the ego cope with the conflict-
ing feelings involved in the developmental tasks of integration and separation. The move out
of this harmonious state of merger means experiencing separation anxiety and a fear of loss
of the object leading to anger and frustration at this loss and finally apathy and depression at
the realisation of separation. Although some of these feelings can be distressing and disturb-
ing, they do not represent unhealthy states of mind but rather inevitable and necessary points
on the developmental pathway. For Fairburn, the developmental task in health is for the ego
to be strong enough to integrate these contrasting feelings in relation to the object. For
Winnicott when they can be accepted they become available to the self as part of feeling alive
and real and as a resource for living creatively with others.

Where the mother is not able to provide a reliable pattern of childcare that ensures continu-
ity of being, the feelings aroused by separation become too strong and ego integration fails.
The internal world is dominated by negative representations of self and object, which
becomes the unconscious model for relating to both external object and objects. This can
lead to the use of psychological defences to protect the infant from the feelings aroused by
separation. This, however, is at the expense of limiting the development of self and relation
to the object.

Health depends upon the mother providing a reliable pattern of childcare that meets the
infant’s needs for nurture and dependency. The conscious memory of this care is linked to the
unconscious memory of the mother’s presentation of herself as an object during the harmoni-
ous mix up and period of un-integration.
Rayner describes how for Fairburn in health the contrasting feelings aroused by separa-
tion produce a splitting of the ‘central organising ego’ (1991: 147) into different aspects
representing the self in relation to the object. This process creates an internal world contain-
ing a multiplicity of ego nuclei identified with different kinds of feeling. Where the mother
has been able to provide reliable care these ego nuclei interact to form a dynamic system
held together by the central organising ego giving the infant a sense of being a ‘whole per-
son’ participating in secure relations to external objects.
Balint speculated that the womb was the first environment for the infant and was experi-
enced as a ‘harmonious, interpenetrating mix up’ (1968: 66) of its own and maternal bodily
substances. This harmonious mix up is disrupted by birth, providing a first distinction
between self and object. In health as the infant develops it will move between experiences

which regain the feeling of primary love and oneness with objects in the external environ-
ment and dissatisfaction and frustration as objects present themselves as separate.
Rayner described how for Winnicott the mother’s physical holding of the infant’s body and
holding the infant in mind psychologically helps integrate the ‘psyche-soma’ and the develop-
ment of the true self towards personalisation (1991: 135). At a time when the infant cannot
accept dependency, the mother will present the breast at just the right moment and the infant
enjoys the feeling that when it needed something like the breast, it created what it needed. For
the infant, the space between the turn of the infant’s head and the mother’s body is a ‘potential
space’, a space ‘in-between inner and outer reality’ in which the infant develops the subjective
illusion of having created the breast out of the needs of its true self. Later, the child uses the
transitional object, a favourite toy, a piece of blanket or cloth to stand in for the absent mother,
and helps the infant tolerate the reality of separation (Winnicott, 1971). The transitional object
in this potential space is the forerunner of symbolism and necessary to the development of the
‘ordinary creativity’ and capacity needed to change in response to the environment.
Potential space is developed through play and games with other children. This allows the
relationships between illusion and creative engagement with reality to be held and trans-
formed in networks of object relations beyond the family. In providing cultural and institu-
tional spaces that are able to receive the spontaneous gestures and the unconscious processes
of its participants, culture is necessary to support the lifelong process of personalisation. The
support of society for these activities is necessary to health and quality of life.

The origins of psychological disturbance lie in trauma arising from real loss of intimacy with
external objects, particularly the mother. Rayner summarises Fairburn’s view that if the
mother were absent or unavailable emotionally the infant adopted the schizoid and depressive
positions (1991: 149). In the schizoid position, in the first six months of life, the infant inter-
prets the mother’s absence as a rejection caused by the infant’s own love being destructive of
their mother’s love. In the depressive position, where separation from the object has been
acknowledged, it is hate that is imagined as having destroyed the mother, producing the split-
ting of the ego and the creation of insecure object relations.
For Balint, the ‘Basic Fault’ (1968: 18–23) arises at a stage during the harmonious inter-
penetrating mix up when the self and object are not differentiated and is experienced as the
absence of something that should have been there. He uses the metaphor of the irregular
fault lines that can be found running through the regularity of crystalline and geological
structures, which can break when placed under stress, fragmenting the normal structure. If
the harmonious mix up is too powerfully or repeatedly interrupted then the infant becomes
prematurely aware of its separateness and dependence upon objects. Its capacity to regain
the feeling of being loved and at oneness with objects in the external environment is lost,
leaving a sense of frustration, futility and hopelessness at the possibility of future satisfying

relationships. Where failure occurs after the stage of acceptance of dependency on external
objects has been reached, the normal depression that follows loss of omnipotence becomes
malignant.
Abram describes how failure of the environment at Winnicott’s stage of absolute depend-
ency breaks the infant’s ‘continuity of being’ (1996: 61) causing a rupture in the infant’s
sense of its own coherence. Where the mother’s environmental care is unable to mend breaks
in the continuity of being, the infant can experience states of feeling annihilated and of
‘unthinkable anxieties’ (1996: 161). Because the help that the infant expected and needed has
not been provided the infant suffers a sense of privation, of never having had what it expected
to have. At the stage of dependence, breakdown in environmental cover produces a sense of
deprivation, where the infant is aware of the loss of an object relation that had provided what
it needed. Where repeated attempts to overcome privation and deprivation fail, the symbolic
potential of the potential space between mother and infant is closed down. The sense of living
creatively is inhibited, leading to impoverished and hopeless relationships with the self and
its objects.

Rayner describes Fairburn’s ideas on the splitting process used during the schizoid position
to defend against the reality of the external object and the external world. The central organ-
ising ego is mentally subdivided, ‘split’ into different ego nuclei each representing an aspect
of the self in relation to an object (1991: 147). Splitting can be further exaggerated by the
idealisation or denigration of the relationships between ego nuclei and their objects or
through a disassociation between the different feeling states associated with the different ego
nuclei and its objects. At their most severe the different ego nuclei will be totally denied as
being part of the self and projected into the external environment in the form of hallucina-
tions. Similarly denied, split and dissociated ideas and feelings will form delusional beliefs
that attack and deny the sense of shared reality.
For Winnicott, psychotic defences become organised at the point of privation caused by
environmental failure and are an ‘organization towards invulnerability’ (Rayner, 1991:
136). The defences help deny the unbearable felt reality of ‘unthinkable agonies’ caused by
environmental failure. In response to a failure at the stage of absolute dependency the
infant will develop a false, caretaker self. The infant takes over the function of the failed
environment and begins to look after itself to protect the integrity of the true self.
Feelings of omnipotence and an idealisation of the self and its capacities are used to deny
the need for and dependency upon the object. Reliance upon intellectualisation and ration-
alisation persuades the ego that it can look after its bodily and emotional needs, or deny and
ignore them, breaking the psyche soma integration. Instead of an internal world containing a
multiplicity of possible ego and internal object relations that turn outwards towards the
world, there is a state of internal conflict in which the ego and its objects relate in anxiety,

fear and paranoia. These states of mind in turn generate further cycles of defensive splitting,
denial and projection that lead to a predominance of one person relating and schizoid with-
drawal from relations with the object (Rayner, 1991).
In the depressive position the infant has reached a stage of awareness of the external object
and has begun a process of two-person relating. If ego integration is weak then the manic
defence is used to deny the depressive feelings, which arise in recognition of the fear that the
infant’s hate has damaged the object. There is a return to one person relating and a spitting
of the self and object that fragments the internal world. Having achieved a sense of external
reality, there will now be a tremendous investment of energy on activity in the external world
aimed at denying the limits of the self and dependency in relation to the object. Instead there
is a focus upon the achievements and importance of the ego and self. The fragmented ego and
object relations of the internal world are projected onto the external world and the attempt to
create and control an idealised and grandiose external reality is in fact an attempt to support
and repair the projected internal world.
The same intrapersonal mechanisms are brought into play during the period of three-
person relating, when the young infant encounters difficulty in accepting the mother’s rela-
tion with the father or partner. The child may regress to a two-person relationship with the
mother that denies the reality of the father or more extremely to one-person relating. The
difference here is that because the infant ego has developed enough to experience its own
bodily sensations as part of the self, the pleasurable bodily sensations arising from an
emerging infantile sensuality and sexuality are now brought into relation to the object. Here
the Independents develop the classical Freudian oedipal position to suggest that the splitting
of the self in relation to the object, the needs for dependency, the anger and frustration aris-
ing from the loss of intimacy with the object, become sexualised. Pleasure through sexual
gratification for its own sake is now sought as a way of holding the self together and as an
alternative to the failed provision of intimacy and nurture by the object.

Fairburn used the Kleinian idea of projective identification to describe how feelings that are
unmanageable for the infant are denied and projected into the external object. The object is then
related to as if the feelings belonged to the object itself and the infant attempts to control those
feelings at a distance by controlling the object. Fairburn also described how this process might
be used to create different techniques of relating to the object such as schizoid withdrawal or
playing roles aimed at controlling the relationship with the object (Rayner, 1991: 15).
Balint imaginatively described two different types of personality and techniques of relating
to the object in response to separation anxiety (Rayner, 1991: 119). The Ochnophil enjoyed
the loss of self in merger with the object. In contrast, the Philobat overvalued the self and
enjoyed the distance it created between itself and its objects. Both types were able to create
satisfactory if limited relationships.
For Winnicott the false self is deployed in respond to demands from mother and the envi-
ronment that do not meet the needs of the infant. In complying with those demands the false

self protects the true self at the cost of limited personalisation and withdrawal from the
object. In regression from the oedipal conflict, sexuality will be deployed as a way of holding
together the self and controlling the object as a way of denying the mother’s relationship with
father that threatens the young child’s needs for intimacy and nurture.
At the stage of deprivation instead of false self-compliance, impingements from the
mother are sought. Later, repetitive patterns of destructive behaviour and anti-social acts
such as aggression and stealing are deployed to provoke a response from the family and
social environment.

Fairburn described how individuals might use and shape social institutions in an attempt
to control and perpetuate their own disturbance. He gave the example of politicians who
might use other people as partial objects, and encourage schizoid relations in social
policy to enforce ruthless, ideologically bound and closed political systems (Rayner,
1991: 151).
Winnicott describes anti-social acts as acts of hope that the environment will make good
the ‘deprivations suffered in the relationship with mother’. This behaviour attracts further
impingements of the self in the form of sanctions and punishments from the social environ-
ment. (Abram, 1996: 37).
2.5 Change
The capacity to change depends upon the quality of the object relations enjoyed by the
infant. Patterns of relating are internalised as unconscious templates that become the pattern
for relationships in later life. Where relations with the object are unsatisfactory the infant
builds psychological defences to protect itself from the agonies and anxieties caused by
environmental breakdown. The defences severely limit the potential of the self and when the
object and the environment continue to fail to meet the infant’s needs ongoing development
becomes frozen and stuck. Similarly, the capacity to change is disturbed when the potential
space of the wider culture is not responsive to the needs of the individual. The pattern of
environmental response, either rehabilitative or punitive determines the possibilities of
change.
Environmental breakdown may result in painful symptoms of anxiety, depression,
obsession or psychosis in the individual. When the individual is unhappy with their cir-
cumstances or can see that they have a role to play in the perpetuation of the kind of
relationships that feel to be self-limiting and destructive, the individual is ready for
change. They may initially seek new objects, for example the GP and the offer of medi-
cation, or try new relationships, or they may have already tried these options unsuccess-
fully. At this point the individual may be ready to seek a new kind of object relation in
the therapeutic relationship.

3 PRACTICE

The aim of the therapy is to meet the client’s need to find an object that will help them find
their own personal new beginning. The therapist aims to provide an object relation in
which the client’s unconscious patterns of relating are re-experienced and transformed
through the mobilisation of their personal creativity and the capacity to play, allowing the
developmental and maturational process to unfold.

The offer of psychoanalytic psychotherapy has been described as ‘a very unusual pre-
scription’ as it does not offer a cure in the sense of treating a medical illness, although it
may and often does result in the relief of symptoms (Bruda, 1974: 84). There may be
problems of self in relation to others that are not fully resolvable but for which new ways
of relating that are less destructive or self-limiting may be found. Long-term psycho-
therapy can be a life-changing experience but it is an emotionally and financially demand-
ing process so it is important that people understand what is being offered when the pre-
scription is made.

Physical conditions involving brain damage will not be amenable to change through ver-
bal psychotherapy. Similarly, a long-term history of psychotic breakdown or a long-term
psychiatric history might indicate insufficient ego strength or sense of self to cope with
the emotional demands and the capacity for relationship required in psychotherapy. A
person who is heavily dependent on alcohol or drugs to cope with traumatic and stressful
situations would not be able to allow the engagement with their feelings necessary to
engage in the psychotherapeutic process. A focus on psychological problems having their
origin in somatic symptoms may suggest a tendency to concrete rather than the symbolic
thinking necessary in psychotherapy, although here cultural styles in the expression of
psychological distress need to be taken into account. Finally, psychotherapy is not helpful
where urgent medical or social intervention is needed or there is an immediate risk of
harm to self or others.

Individual therapy can be helpful for a variety of disturbances between the self and object.
For example, where the level of ego strength and self–object differentiation is poor and the
main mode of object relating is ‘one person’; where ego strength and a sense of self and two-
person relating are established but are easily lost under depressive feeling or stress; or at the

moment of three-person relating to resolve oedipal conflicts and restore the possibility of
three- and multi-person relating. Where the client focuses the presenting problem on multi-
person relationships for example, the relationship with their partner, or family members, or
where conflicts with friends and work colleagues seem dominant then a therapeutic focus on
couple, family or group therapy may be indicated.
Wherever they are within this spectrum, the client must be able to identify sufficiently with
the aims and purposes of the therapy to form a therapeutic alliance and agree to work together
with the therapist. The therapeutic alliance requires that the client has the capacity to tolerate
frustration and sustain anxiety without seeking instant relief or gratification of their feelings
and impulses. They need to show some curiosity about themselves and to what degree they
are psychologically minded in the sense that they can make connections between events in
their life and feelings that they have about themselves. Finally it is helpful if there is evidence
of their capacity for ‘ordinary’ creativity in the sense of making even a small change or suc-
cess in their life

Rayner (1991) describes the independent style as requiring a playfulness and creativity that
is linked to an enjoyment of ambiguity, doubt and uncertainty. The therapist needs to be curi-
ous about, and in touch with, their own unconscious process and be open to being changed
themselves by their encounter with the client. They need to be emotionally robust enough to
contain their client’s feelings in all of their ambiguity, uncertainty and rawness without feel-
ing the need to rush to ‘cure’ and manage the client’s life. They need to be open and honest
with themselves about their strengths and limitations and be prepared to acknowledge their
own resistance to recognising their dependence on others for support and insight in their
clinical work.

Perhaps the most important capacity for the therapist is to allow their own unconscious to com-
municate, and be open to the client’s unconscious. However, because of the therapist’s inevita-
ble resistances and unknown effects of the impact of the client’s unconscious, the outcome of
this potentiality is not predictable The therapist needs to develop the capacity to be in a state of
not knowing without the need for preconceived answers and ideas, thus creating the conditions
in which the unconscious might speak. The therapist develops this capacity in relation to their
ability to use the splitting processes of the ego to create an observing ego (Casement, 1985)
which listens closely to the content of the client’s material, monitors the therapist’s feeling
state and bodily sensations and makes theoretical hypotheses in relation to the client’s com-
munication. A further split might involve the therapist consulting their ‘internal supervisor’,
an internal object created from identifications with their external supervisor who enters into

the internal dialogue (Casement, 1985). This process of self-observation requires the thera-
pist to make use of trial identifications with their own and different aspects of the internal
and external objects that the client projects into the relationship and to be able to move fluidly
between these identifications.
In reality the therapist spends a lot of time in a state of ‘not knowing’, allowing their mind
to move back and forth across multiple associations and identifications without trying to
understand too much material prematurely. The practised ability here is that when they are
ready, the therapist will form a hypothesis in their own mind about the key underlying
themes of the client’s communication and share this in a brief and understandable manner
with the client. To decide when best to share this hypothesis with the client involves the
therapist’s development of their sense of tact. This is their ability to offer a link, a reflection
or an interpretation, taking their timing and cue from the client. The decision is based on a
respect and sensitivity to what the client is experiencing and feeling in the session and thus
what they may be ready to hear and receive.

3.4.1 Therapeutic relationship
The therapist encourages freedom of thought in the sessions giving permission to say
whatever is important and comes to mind, receiving this in a non-judgemental manner.
Although the therapist acknowledges the position that they occupy in terms of power in
the therapy, the relationship is conceived as one of reciprocal influence, in which the
therapist is open to being changed as a person or in their ideas and practice through their
encounter with the client.

Using their professional tact they will be courteous, respectful and trustworthy in the estab-
lishment of the therapeutic alliance and therapeutic boundaries. Despite this consistency,
each client makes use of the therapist in a different way and the therapist will allow them-
selves to be re-created anew by each client. The therapist will not volunteer personal informa-
tion, answer direct questions, nor give advice or solutions to any problems that the client may
bring. The therapist will tend to speak sparingly during the sessions, aiming to be an unob-
trusive presence.
Depending upon the particular moment in the development of the relationship and the
personal style of the therapist, humour may alternate with seriousness during the therapeutic
dialogue. As part of the ending process some therapists will answer some questions more
directly with the aim of allowing the client to gain a more realistic sense of them as an object,
helping the client to let go of the therapist as a transference object. Another approach is that
the therapist will continue to work with the questions rather than answering them and con-
tinue to analyse until the very last minute.


3.5.1 Assessment
The aim of the initial assessment is to see if psychoanalytic psychotherapy will be of ben-
efit to the client. It is not the purpose of the session to reach a diagnosis of the client’s
symptoms or to highlight their psychopathology. The therapist will try to make the client
feel comfortable and at ease, introducing themselves, explaining the aims and purposes of
the assessment and indicating how long the session may last. The session may be for the
50-minute therapeutic hour but may be longer, perhaps an hour and a half to allow time for
information-gathering to take place and to leave plenty of time for the client to ask ques-
tions. The therapist gives an idea of the structure of the session, for example that it will start
with a number of questions and that there will be time for any questions from the client.
Towards the end of the session they would both see if a decision about commencing therapy
can be made, if another session is needed or if referral to another therapist or another kind
of therapy might be helpful. At this point the therapist might ask if the there were any ques-
tions so far and if not, go on to the opening question.
Something like ‘Tell me what it is that brings you to psychotherapy now?’ might be a
typical opening question. It is deliberately brief and minimally structured which allows the
client to say why they have come to therapy at this moment in their life and to tell their
story in their own way. As the story unfolds the important relationships in the client’s life
will be revealed, how they get along with others and their relationship to their social envi-
ronment. As the assessment aims to get to know the client well enough to begin to make a
decision about the suitability of psychotherapy, the assessor will ask a number of questions
for information and clarification. If the client does not readily volunteer the information, it
is helpful to ask them to describe their childhood and family history. Here the aim is to get
a sense of past and current family relationships, the age, social class, gender, ethnicity and
race of family members, what kind of person mother and father or the significant caregiv-
ers were. It is important to ask about any siblings, the client’s place in the birth order and
the quality of sibling relationships. In relation to the social environment it is helpful to ask
about the education and employment of family members through questions about school
life, further education and the quality of relationships with friends and teachers. Other
areas to take account of include the employment history of the client, their type of job or
profession and the quality of relationships at work with colleagues and managers. Finally
we would be interested in any emotional and sexual relationships including marriage or
partners throughout their life history.
The therapist may ask the client about any current or past health problems, including any
past psychiatric history, any addictive behaviour including drug, drinking or disturbed eating
patterns, or any physical illnesses or conditions that might impact on their ability to make use
of psychotherapy. It is important to ask if there has been any previous experience of psycho-
therapy, what kind of psychotherapy it was, how they felt about it and whether they felt it
was helpful or not. Finally there would be an opportunity for the client to ask any questions
and to discuss what they hope to gain from psychotherapy.


While listening carefully to the client’s narrative the therapist will have noted the relationship
between the presenting problem brought by the client, the ego strength or sense of self, the
characteristic defences used by the client, the quality of object relating with significant others
in their past, their current life and in their interaction in the session with the therapist. From
this evidence the therapist will make a tentative hypothesis about where in the developmental
process the client may be experiencing problems in relationship.

The main strategy is to provide a setting that aims to provide a new kind of object relation-
ship. To enable this process the therapist provides a boundaried space over an extended
period of time within which the therapist presents themselves as an object through which the
client can experience their disturbed sense of self and patterns of object relating. The open
structure of the sessions allows the interaction between preverbal states of feeling, uncon-
scious processes and logical, rational thought to be experienced. Through providing a thera-
peutic relationship, which is structured around abstinence and neutrality, the relationship
evokes both needs for intimacy and nurture alongside the feelings of anxiety, aggression and
frustration that are part of the developmental process. The absence/presence of the therapist
and the open agenda provide a minimal framework that allows maximum space for the devel-
opment of the client’s unconscious process and personal creativity. By providing an object
relation that can help the client develop a sense of self that can integrate these experiences
the movement toward personalisation and creative living can unfold.

The psychotherapeutic setting is designed to provide an environment that recreates some ele-
ments of early maternal provision. First, is the reliable provision of a consistent room which
is warm and comfortable over a long period of time and the setting of therapeutic boundaries
including appointments at regular times and of regular length. This creates a secure space in
which the client can experience ‘continuity of being’ and feel safe enough to allow new
experiences and feelings. The therapist may ask the client to lie down on a couch while they
sit in a chair to the side of the couch where the client has their head. Lying down on the couch
can encourage a feeling of rest, relaxation and stillness that will support the process of free
association and the therapist sitting just out of sight encourages the client to use the therapist
as the receptacle of projections and fantasies. Where therapy takes once or twice a week then
the client might be invited to sit face to face with the therapist.
The therapist’s professional attitude allows a distance from the client that is neither too
distant nor too close. The therapist will not disclose details or information about their per-
sonal life or express their opinions, preferences and thoughts about subjects that the client

may raise. It is of course impossible for the therapist to not reveal anything of themselves in
the sessions, but in seeking to limit the intrusion of the therapist’s opinions and preferences
they become available to the client to use as a blank canvas that might receive their spontane-
ous gesture and as an object that can be used for projection and fantasy.
The main direction from the therapist is that the client accepts and works within the
boundaries of the session and that they observe the fundamental rule of psychoanalysis:
to speak whatever comes to mind, no matter how illogical, irrelevant, nonsensical, triv-
ial, silly, unpleasant, downright immoral, politically reprehensible or repugnant it may
seem. In creating an atmosphere that allows free expression, the therapist will remain
non-judgemental in their attitude. Beyond this call to free association, the therapist
allows the client to make their own agenda for the session. This way of working creates
‘a space between’ therapist and client in which unconscious process may emerge and into
which feelings may be placed.
The creation of this space is therapeutically crucial as what it allows to emerge are the
phenomena that are the driving force of the therapy, the transference and countertransfer-
ence. Freud had initially described the transference as that moment where the client trans-
fers their feelings about significant others in the past, usually the parents, onto the figure
of the therapist. In this moment, the client began to relate to the therapist as they had
related to those significant others. In response to this transference the therapist might
develop a countertransference, feelings aroused in the therapist by the client that relate to
their own personal history. For Freud this was a manifestation of the therapist’s own
defences which could hinder the professional attitude. The Kleinian development broad-
ened the definition of transference to include the totality of feelings, expressed verbally
and non-verbally by the client in the session. Paula Heimann, then a Kleinian and later an
Independent, developed the idea that countertransference feelings could be a tool through
which to understand the client. When allied to the professional attitude the feelings aroused
in the therapist could be an indicator of the client’s projected feelings and the kind of object
relation that those feelings involved (Heimann, 1950). Through this use of the counter-
transference, the therapist could mobilise the capacity of their own unconscious process to
communicate with the client’s unconscious.
Transference and countertransference processes will manifest differently and can be posi-
tive, negative, psychotic and erotic. They can be used therapeutically in different ways,
depending upon the level of self–object differentiation and kind of object relating available
to the client. Where a client is ‘one-person relating’ then the continuity and comfort of the
therapist’s room, their continuing non-judgemental presence, the tone of their voice as they
make a reflection or holding statement may all address the transference non-verbally. The
therapist will be aware of their countertransference feelings and keep them in mind for use
when the client is more available to verbal and symbolic interaction. Where the client is two-
or three-person relating transference and countertransference can be worked with verbally to
make the links between the client’s current sense of self and object relations and patterns of
relationship established with significant objects in early infancy and childhood, similarly for
the here-and-now interactions with the therapist.

Transference and countertransference were initially seen as a resistance to the process of

change a way of blocking uncomfortable feelings that threatened to fragment the sense of self
and the relation to the object. The resistance to the process of change deploys the intra and
interpersonal processes discussed earlier as defences against the clients needs for intimacy
and nurture, against separation anxiety and the anger and frustration arising in relation to
self–object differentiation. Just as the infant needed to use these processes as defences as part
of their normal development, working with defences involves seeing them as part of the total-
ity of the transference–countertransference situation and freeing them up, allowing the devel-
opmental unfolding to take place.
Working with defences in this way involves the handling of regression, a moment in the
therapy in which the client returns to the feeling state associated with an earlier organisation
of the self and object relating, where their developmental process had become blocked.
Kohon describes two different kinds of regression that the therapist works with in different
ways. Firstly, benign regressions, arising in the context of two-person relationship that aim
for recognition from the object/therapist, will allow the development of self-object differen-
tiation. The second is a malign regression, a retreat from the frustrations of three person,
oedipal relating, which aims at involving the object/therapist in gratifying the frustrated
desires. The recognition and frustration of these regressive desires by the therapist enables
the process of change to resume (Kohon, 1986).
Psychoanalysis is a space where the dream is welcomed as an avenue of approach to the
client and their unconscious and it is an approach frequently travelled by the Independent
tradition. Fairburn understood the totality of the dream content, the setting, the imagery, the
characters and its narratives as reflecting the current organisation of the ego and its external
objects and the internalised unconscious ego and object relations. The narrating of the dream
and its reception without too much verbal interpretation or a verbal interpretation of the
dream linking the different aspects of the ego in relation to its objects makes the dream avail-
able in different ways to the client who is either one-person or two-person relating. Rayner
describes Independents such as Ella Sharpe, Charles Rycroft and Marion Milner who have
helped clients use the relationship between dream imagery, art and creative processes as a
resource for creative living, feeling alive and real.

Providing a setting that feels consistent, reliable and safe, combined with the therapist’s
interest and attempts to understand the client, contribute to a feeling of being contained in
a holding environment. This may provide confidence and some relief from the immediate
symptoms or problems that have brought the client to therapy resulting in an initial shift or
progress in the client’s situation.
As the sessions begins to feel dependable, the original environmental failure situation
becomes unblocked and the client will take the risk of bringing those defences, the frag-
mented sense of self and disordered patterns of object relations into the transference with the

therapist. The transference from the environmental breakdown is felt vividly and experienced
as real in the here and now of the session. This can provoke a recurrence of old symptoms
and defences causing a fragmentation of self in relation to the therapist. Although this can
feel as if the therapy is breaking down, the intensity of the feelings bring conviction to the
process when they are felt to change and result in new possibilities of relationship.
Depending upon the mode of relating possible to the client, the therapist can make dif-
ferent kinds of interventions to effect change. Regression to the early failure, e.g. Balint’s
Basic Fault, provides an opportunity to regress to the harmonious mix up and engage with
the area of creation out of which the infant makes differentiation of self and other. Just as
omnipotence can be used defensively, the experience of omnipotence is necessary for the
development of the early infant ego. Working with defences involves freeing these devel-
opmental processes so that instead of a regression to early infantile omnipotence that
protects a fragile sense of self, the experience of omnipotence and loss of omnipotence in
the holding environment leads to progression and the unfolding of the developmental
process.
Where the client is capable of two- and three-person relating the therapist can use verbal inter-
pretations to allow preverbal and bodily feeling states to be accepted, allowing the beginning of
psyche–soma integration. Links between different kinds of object relation which have been kept
apart using splitting can be integrated and links can be made between patterns of object relating
in the past, in the present and in the here and now of the therapy relationship. These moments
allow an integration of the fragmented ego, allowing new kinds of object relation.
There will be important moments when the therapist will fail their client, allowing the cur-
rent failure to be experienced in relation to earlier environmental failures. Through surviving
this process with the therapist, the client becomes able to tolerate a movement from regres-
sion to dependence to independence. Continuity of therapy over time allows aspects of the
self and relation to the object that have been defended against to be integrated leading to an
increased sense of aliveness and feeling real. The client loses and finds the therapist repeat-
edly in the therapy and as this process is worked through over and over again, there is an
increase in the strength of the self.
The moment when a dream is offered is a sign that the ego or sense of self is ready to
receive the dream as a possible personal communication and a recognition that there is an
external object ready to receive it. Over time, repetitive dreams may change in line with
changes the client is able to make in their relationship to their sense of self, their internal and
external objects and with the therapist. Dreams may also be reported less frequently as their
underlying unconscious content is assimilated and integrated with the client’s conscious ego
and sense of self.
Lack of progress can occur when regression becomes malign rather then benign, i.e. grati-
fications occur at the expense of feelings of dependence and enactment of earlier situations
takes place at the expense of recollection and working through. The therapist may be blocked
in their own countertransference or by adherence too closely to their theoretical beliefs. One
response to blockage in the therapy is for the therapist to exercise the x-phenomenon, the

analysts ‘act of freedom’. The effectiveness of this moment is that it represents a shift in the
therapist, which allows a shift in the client (Kohon, 1986).
There are inevitable moments when the therapy does not seem to progress, despite the
therapist’s best efforts. To recognise and work with these moments the therapist has to culti-
vate their professional attitude, which includes using their clinical supervision with an expe-
rienced supervisor and if necessary a return to their own therapy. These moments of impasse
can result in further progress and change or it may be that the therapist has done as much
work as they can with a particular client and it may be time for the therapy to end or a move
to a different therapist.
The recognition of when it is time to end is something that is negotiated by the therapist
and client. Either party may feel that enough has been done or that further progress is not
possible. The decision to end the therapy can provoke a regression to states of early environ-
mental failure, provoking psychotic or depressive defences, or issues around separation and
loss that have not been adequately worked with to re-appear or new issues may arise. Ending
the therapy involves a giving up of the object in a process resembling mourning and working
toward a realistic evaluation of what has been achieved and what is possible.
4 CASE EXAMPLE
4.1 The client

Angela was an Afro-American woman in her mid-forties. She worked in a scientific
capacity for a large company and her husband, Barry, worked in a similar field. They had
been married for several years, owned their own home and had decided not to have chil-
dren. Angela had limited contact with her family in America but kept regular contact
with American friends. She and Barry enjoyed an active social life and had shared inter-
ests in computers and cycling. Angela enjoyed reading and photography and was an
enthusiastic cook.
4.2 The therapy

There was no couch available in the consulting room so we sat facing each other in chairs.
Angela alternated between a witty and imaginative spontaneity and critical wariness. She was
worried that my comments or my silence indicated disapproval. It became increasingly dif-
ficult for her to tolerate my not directly answering her questions as this created a frustrating
distance between us. Over time, her desire for intimacy was expressed through dreams and
fantasies of wanting to be naked and to merge with me in a ‘harmonious mix-up’ in the room.
She pursued this aim through direct questioning for personal information challenging the
boundaries created by the professional attitude. She sometimes did this playfully and sometimes

the frustration of intimacy was expressed through anger. After eight years of twice a week
therapy with Angela I realised that there was a reality to a particular kind of intimacy that had
developed out of the intense, lived reality of the feelings experienced week after week by us
both in our work together.

Angela was referred from a workplace counselling service after becoming depressed follow-
ing a dispute with her female manager over scientific disagreements. This conflict led Angela
to leave her job to work as a shop assistant in a food store. She had a history of short stays
in hospital for bi-polar episodes. Her symptoms had been in remission for some years and she
was on small doses of anti-anxiety and anti-psychotic medication. Angela was concerned that
she was still depressed and realised that her conflict with the manager was linked to her poor
family relationships. She could be overtly critical and angry with people, particularly Barry.
She was not entirely happy to be working in the shop.
Her parents were separated, her mother had a history of frequent hospitalisation with a
diagnosis of bi-polar disorder and her father was a violent alcoholic. Angela felt her parents
were preoccupied with themselves, critical and unloving. She enjoyed a good relationship
with her grandparents. She was the eldest of two sisters with whom she had difficult relation-
ships. Despite her brief bi-polar episodes Angela had successfully studied science at univer-
sity and had benefited from the support of several older white male mentors. Despite being
generally unconfident and shy in her sexuality, she had several relationships including a brief
marriage. She met Barry over the internet and decided to come to the UK to meet him and to
escape an increasingly critical and hostile family environment.
In the initial meeting Angela acknowledged that she felt nervous and wary but nevertheless
there was an openness and warmth as she told her story. She showed insight and was able to
volunteer her feelings. Picking up on the theme of white mentors, I asked how she felt about
working with a white male therapist and she replied that she was comfortable with this. My
tentative hypothesis at this early stage was that an insecure relationship with a depressed
mother had led to a precarious state of ego integration. At a stage of absolute dependency a
false self-organisation had precociously taken over the function of absent maternal care.
Despite this beginning Angela had reached some capacity for two-person relating and mobi-
lised the manic defence to cope with depressive feelings.

In the last session before the first major break Angela dreamt of a dark laboratory. She was
cutting up a brown laboratory mouse and pulled out the long thread of an organ attached to
which was a string of tiny embryoes, all pulsing with life. Laboratory breeding had geneti-
cally deformed one mouse and she wanted to keep it alive while she went away. She put it in
a covered bowl filled with water in which the mouse swam frantically, being just able to
breathe by keeping the tip of its nose out of the water.

Her association was that as we had been digging around in her past she was afraid that in
the imminent break she would be left with painful feelings. On the return from the break
Angela thought about leaving the therapy. Her association was that, just as her mother did, I
would fail to keep attending appointments I had made with her. She became preoccupied with
the transitions on entering and leaving the session and with the breaks. When Angela began
to trust that unlike her mother I was an object who was not going to abandon her, she began
to feel that the room was her own.
Later she volunteered her unhappiness that in the initial session I asked how she felt
about working with a white male therapist. She thought the question petty and hateful and
suggested that I might have a problem working with her. Having spoken with venom she
then expressed concern for me and apologised. When I tried to acknowledge the way that
my question had made her feel she replied that at that point in the assessment she had felt
that she could work with me and the comment threatened to separate us. Later in the
therapy she questioned whether race is like ‘the grit in oyster, irritating, or are we are
making a pearl?’
Angela kept control in the session by saying that she pretended that I was part of her so
that my interventions were really her talking to herself. She feared that I possessed a
‘heavy seeing’ that revealed things about her of which she was unaware. I asked what she
feared I might see and she talked about her mother always being critical of Angela and
that mother was ‘always right’. Her father was gay, as were several of her married uncles.
As a young girl these loveless marriages gave her a confusing message about the relation-
ships between men and women. We explored this in the transference as her wondering
how I as a man might view her as a woman and she grieved that she did not have a father
who could love her.
We worked towards an ending over a period of a year. During this year her mother became
ill and died before Angela could visit her. Her youngest sister was pregnant, raising issues
about Angela not having her own children because, like the deformed brown mouse, she was
afraid of transmitting a bi-polar genetic disease. She returned to America for the memorial
service and managed to stay out of what she described as her sister’s madness. In the last
weeks she questioned whether the improvements made in therapy would last.

During the therapy Angela successfully returned to scientific work. She and Barry
attended relationship counselling and she became less critical and controlling of their
relationship. She finished with her anti-anxiety medication but decided to stay on a
minimal dose of the anti-psychotic. In the last session she used her mobile phone to show
me a picture of herself in a dress because she had felt too uncomfortable to wear it to the
session.
Angela relinquished her protective false self-organisation and allowed herself to
depend on me in the therapy. Through my maintaining a professional attitude she was
able to let go of the manic defence to regress and creatively experience omnipotence and

the depression following awareness of separateness. My reliable presence over time ena-
bled a continuity of being that strengthened her ego capacity and sense of self. This
allowed her to express concern for me as an object, indicating her awareness of me as a
separate object who had survived her attacks. As she let go of the self-criticism internal-
ised from the parental couple, she became less controlling and critical with others. Her
increased sense of self allowed her to integrate the mutilated and cut body images and to
disentangle herself from the confused parental relationship and sexualities, personalising
her relationship to her femininity. Through no longer using the manic defence, she was
able to mourn the loss of a childhood and the lack of loving relationship with her mother
and father. In hindsight I wondered if in concentrating on dependency and early ego
states I had avoided the oedipal implications of her sexuality. Angela had used the ther-
apy in her own way and the dress seemed to indicate part of her new beginning.
5.1 Developments
5.1.1 Brief therapy
The post Second World War BPS was concerned that providing anything but the five-times-
a-week psychoanalytic model would lead to a dilution of psychoanalysis. In contrast, the
Independents wanted psychoanalysis to be available to the wider community. The impetus
for the broader application of psychoanalysis was linked to the democratic aspirations of the
postwar welfare state.
Balint worked with general practitioners in small `Balint groups' to reflect psychotherapeu-
tically on their relationship with their patients. He extended this work to include marital and
couple therapy. Winnicott similarly worked with social workers bringing psychoanalytic
insights to their casework in childcare and mental health. Rayner (1991) describes how
Independent analysts, such as Rickman and Main, joined Kleinians like Bion and Jacques and
worked in military hospitals and the NHS, developing small and large group work. Pioneering
the establishment of therapeutic communities, they challenged traditional hierarchies
between professionals and professionals and patients. Despite opposition from the BPS,
including some independent thinkers, independent analysts helped found the Cassell
Hospital, the Tavistock Institute and the Tavistock Institute of Human Relations. Working
with professionals from health, the social sciences and industry a psychoanalytic theory and
practice were developed which understood the individual in relation to group dynamics
shaped by the institutional and social context. The enrichment of the welfare state by psycho-
analytic ideas enlarged the sphere of the social potential space.
These socially orientated developments paralleled the evolution of individual theories
of development in the UK and America. Masud Khan (1986) outlined the role of cumula-
tive trauma in the formation of the self in relation to its objects. Harry Guntrip (1968)
explored one, two and three person relating to develop the idea of different levels of
psychotherapy with different kinds of clients Patrick Casement (1985) developed influ-
ential ideas on working with countertransference and its role in the analyst learning from

the patient. In America Otto Kernberg attempted to integrate Freudian theory and object
relations (Kernberg, 1994).
Christopher Bollas developed Winnicott's ideas on the potential space between mother and
infant to propose a specific kind of object relation in which the mother was experienced as a
`transformational object'. The shift from the potential space between mother and infant to the
social potential space represented the search for new transformational objects through educa-
tion, work, art and leisure activities (Bollas, 1987).
The Independents influenced early psychoanalytic debates on the importance of the mother's
role in the development of female sexuality in contrast to the father's priority in Freudian theory.
Influenced by Freud and Lacan, Juliet Mitchell made important contributions to the debates on
female sexuality and on the importance of sibling relationships in psychoanalysis (2000). More
recently Kirshner opened a critical engagement between a Lacanian theory of the subject and
Winnicott's idea of the self (2011). O'Connor and Ryan wrote about the relationship between
the internal and external world through the lens of gay and lesbian sexuality and social class
(O'Connor and Ryan, 1993). Similarly Kareem and Littlewood looked in depth at therapist
blind spots in relation to race and culture (Kareem and Littlewood, 2000).
The Independent emphasis on the role of environmental provision in individual develop-
ment created an object relations theory that potentially unified the fields of the
psychological and the social (Rayner, 1991: 360). Recently, the liberalising tendencies
within psychoanalysis and the contemporary social policy focus on human rights issues
have led analytic institutes to acknowledge contemporary sexual identities and family pat-
terns, while the BPS has formally declared that sexual orientation is not evidence of
psychological or developmental disturbance and that it is the quality of relationships rather
then sexual orientation which is important. How these changes will be reflected in theory
and practice is an ongoing question.
Balint developed a brief, focal therapy based on psychoanalytic principles where he
offered 15–30 sessions and outlined a therapeutic plan from the start (Rayner, 1991: 270–1).
The therapist modified their way of working and had to be active in the dynamic management
of the boundaries, particularly the time boundaries of the therapy. Balint’s work was contin-
ued by his pupil Malan, who demonstrated that successful outcomes depended upon: the
therapist and client agreeing a clear focus for the work; a strong motivation for change from
both therapist and client; and an intense emotional atmosphere. Winnicott developed a
method of brief child consultation that used art and games as a way of engaging the child’s
personal creativity. He also worked with the child’s parents, offering psychoanalytically
informed advice and support (Rayner, 1991: 436).

Working within the UK health system, psychoanalytic theory and practice moved beyond
the consulting room and became available to a wider range of people, enriching the inclu-
sively of psychoanalysis as a potential space. The social struggles following the postwar
boom in the 1960s produced the slogan ‘the personal is political’ as the voices of previously

marginalised social groups challenged hierarchies of social power. These movements also
challenged psychoanalysis as part of an oppressive social consensus and impacted on inde-
pendent thinking.
Juliet Mitchell’s feminist perspective highlighted the particularity of women’s experi-
ence as psychoanalytic practitioners and clients. She drew upon a psychoanalytic tradition
that included Wilhelm Reich’s relationship to working-class struggle, the debates on femi-
nine sexuality and Ronald Laing’s existential psychoanalysis. Kareem and Littlewood
argued that where therapists were unable to work with external world issues they further
exacerbated internalised oppression, contributing to a further fragmentation of both the
therapist and client’s sense of self (Kareem and Littlewood, 2000).

The limitations of the classical psychoanalytic approach in terms of time and money
remain, restricting its application to limited sections of society. The growth of psycho-
analytic psychotherapy trainings outside of the BPS has gone some way to broadening the
demographic of those who practise psychoanalytic psychotherapy and have access to its
services. However, working in the public sector as the answer to the issue of accessibility
may no longer be viable. Critics argue that the long-term erosion and privatisation of
public services combined with the UK Government Health and Social Care Bill (2012)
will result in a psychological and social field that far from being unified, looks schizoid,
fractured and broken.

Within the BPS the middle group were often referred to as ‘the muddled group’ and there is
some justification for this witty epithet. For example, Fairburn stresses the paranoid schizoid
position as part of normal development while for Winnicott it is a sign of a breakdown in
environmental provision. Winnicott also argues the continuity of his ideas with those of clas-
sical psychoanalysis but as Rayner argues, Winnicott seldom makes a systematic comparison
of their theories (Raynor, 1991: 154, 196).
Mitchell argued that the Independents’ heritage of evolutionary and Darwinian thinking
meant they ignored the social construction of gender roles and family organisation.
Winnicott’s idea of the mother and her family context is criticised as a model of a white,
1950s nuclear family that does not reflect the changed employment patterns and organisa-
tion of contemporary families (Mitchell, 2000). Similarly, O’Connor and Ryan argued that
the assignment of fixed qualities to masculine and feminine attributes in object relations
theory reinforces social and gender stereotypes (O’Connor and Ryan, 1993). Kareem and
Littlewood argued that different cultural concepts of the self and family structure are also
ignored. They made the point that concentrating on the infant mother dyad seldom

accounts for the internalisation of individual and institutional racism and its effects on
black and ethnic minority clients (Kareem and Littlewood, 2000). These theoretical
assumptions have lead in the past to actual discrimination against women and sexual
minorities in psychoanalytic training and with clients, contributing to wider social dis-
crimination and oppression (Cunningham, 1991).
5.4 Controversies
The role of sexuality in development has been an underlying issue in controversies between
the Independents. Balint and Winnicott were criticised for not exploring the erotic dimen-
sions of their use of touch during therapeutic regression (Rayner, 1991: 201). More recently
Casement has criticised the use of limited bodily contact such as hand-holding as an avoid-
ance of countertransference issues. André Green has critiqued the absence of the role of
sexuality in object relations theory in general (Green, 2001). Limentani has worked to
develop an object relations theory that does not pathologise gay and lesbian sexualities
(Limentani, 1999) and O’Connor and Ryan outlined similar issues in relation to transgen-
dered identities (O’Connor and Ryan, 1993).
All of the BPS groupings are faced with two major issues posed by current social policy.
Firstly, should psychoanalysis become a state registered profession regulated by the Health
Care Professions Council (HCPC)? Secondly, what attitude should be taken to ‘evidence-
based practice’ and the government’s research agenda in the pubic sector?
6 RESEARCH
For the Independents, every new case was a piece of research, a process of enquiry in which
the therapist’s ways of working and experience met the unique constellation of character and
self in relation to their objects that each client represented. The Independents developed their
theoretical and clinical practice in the context of like-minded professionals who, through
close discussion of casework, clinical supervision, debate and discussion, formed a research
community in which ideas could be developed and tested.
This method of research remained faithful to the interactive style of the Independent
therapeutic encounter and helped develop new insights and ways of working with clients.
However, as we have seen, there is a lack of agreement among the Independents on the defi-
nition and validity of theoretical constructs. There were further difficulties in defining the
differences between different categories such as Fairburn’s Schizoid and Depressive charac-
ters or Balint’s Ochnophils and Philobats, or on agreeing criteria for which categories were
to be preferred. Similarly there was no consensus on what would consist of a successful
outcome for psychoanalysis and it is difficult to make a comparison both between and within
approaches. It is also difficult to compare and generalise across single cases because of the

impact of unforeseen life events, the spontaneous remission of symptoms and the different
impact and influence of different therapists on clients. While the creative interplay of ideas
allowed an engagement with the unique experience of each therapeutic encounter, there
remained an impasse in the evaluation of different elements of psychoanalytic theory and
practice.
Fonagy, a contemporary Freudian, completed an EBP-based systematic review of outcome
studies of psychoanalytic treatment (Fonagy, 2002). These studies suggested that psychoa-
nalysis helped people who were diagnosed as having mildly neurotic problems and in relation
to a cost-benefit analysis for this client group, long-term therapy demonstrated better out-
comes than short-term. Fonagy described the Stockholm Outcome of Psychotherapy and
Psychoanalysis project (Sandell, 1999) that showed an improvement over time for clients
who received 4–5 times a week psychoanalysis compared to psychoanalytic psychotherapy,
with the improvement continuing after analysis was ended. The findings showed that clients
whose therapists adopted a broadly independent style did better than those whose therapists
adhered to a strict therapeutic neutrality and insight-orientated approach. Positive elements
included a good therapeutic alliance, particularly where the therapist worked to engage the
client in therapy as constructive contribution/creative collaboration, a good match of client
to different level of psychotherapy with a ‘skilled’ therapist and a therapeutic focus on the
client’s most important relationships. In terms of the therapy process positive results were
associated with interpretation of the client’s negative feelings in the here and now of the
therapy session (Fonagy, 2002). The empirical evidence provided some support for the
Independent view of the psychoanalytic relationship and for its potential to help certain kinds
of client.
Within the current social policy context Fonagy suggested a research agenda for psychoa-
nalysis practice (Fonagy, 2002). This included reaching a consensus on: diagnostic criteria;
developing a methodology that could measure changes experienced during the process of the
therapy session; and outcome measures which would capture the specific changes brought
about by psychotherapy. The aim of such a methodology would be for psychoanalysis to be
able to offer specific treatments for specific disorders rather then aiming for overall personal-
ity change. Within this empirical framework he argued the importance of the social and
contextual influences on behaviour. His paper ends with a call for psychoanalysts to end their
isolation and to enter into active collaboration with other disciplines.
Fonagy’s proposal addresses the Independent commitment to public-sector work and
collaboration with other professionals. However, as Frosh has argued, the empirical meth-
ods of evidence-based practice are based on the ‘drug dose’ model, where a specific dos-
age of particular ingredients is targeted at a specific disease entity. The model sits uneas-
ily with the psychoanalytic engagement with the particular subjectivities of therapist and
client, the process of meaning making within therapy and the non-utilitarian definition of
psychoanalytic outcomes do not lend themselves to quantitative analysis (Frosh, 1997).
The danger is that in the increasingly privatised environment of the pubic sector the
therapeutic encounter and relationship will be replaced by an increased focus on a behav-
ioural and medical diagnosis identifying discrete treatments requiring the application of

particular ‘skills’ and ‘techniques’. Instead of the invitation to psychoanalysis being an

‘unusual prescription’ the client is positioned as a consumer with a problem requiring
treatment and to whom therapists sell their technical skills as commodities in the glo-
balised market place.
Frosh recommends that the empirical model should not be the sole model for evaluating
the worth of psychoanalytic practice. In relation to how the Independents might address these
research dilemmas, the last word goes to Winnicott, whose idiosyncratic practice represents
a kind of evidence based anathema:
You may cure your patient and not know what it is that makes him or her go on living … the absence of
psychoneurotic illness may be health but it is not life (Winnicott, 1971: 100).
7 FURTHER READING
Campbell, J. (2000) Arguing with the Phallus: Feminist, Queer and Post Colonial Theory: A Psychoanalytic
Contribution. London: Zed Books.
Coltart, N. (1992) Slouching toward Bethlehem. London: Free Association.
Flanders, S. (ed.) (1993) The Dream Discourse Today. London: Routledge.
Mitchell, J. (2003) Siblings: Sex and Violence. Cambridge: Polity Press.
Sandler, J., Sandler, A-M., Davies, R., Green, A. (eds) (2001) Clinical and Observational Psychoanalytic Research:
Roots of a Controversy. Madison CT: International Universities Press.
8 REFERENCES
Abram, J. (1996) The Language of Winnicott. London: Karnac.

Balint, M. (1968) The Basic Fault: Therapeutic Aspects of Regression. London: Tavistock.
Bollas, C. (1987) The Shadow of the Object: Psychoanalysis of the Unthought Known. New York: Colombia Press.
Bruda, H. (1974) When Strangers Meet. New York: Harvard Press.
Casement, P. (1985) On Learning from the Patient. London. Routledge.
Cunningham, R. (1991) When is a pervert not a pervert? British Journal of Psychotherapy 8(1): 48–70.
Fonagy, P. (2002) The outcome for psychoanalysis: the hope for the future. In S. Priebe and M. Slade, Evidence in
Mental Health Care. East Sussex: Brunner-Routledge.
Frosh, S. (1997) For and Against Psychoanalysis. London: Routledge.
Green, A. (2001) The Chains of Eros. London: Karnac.
Guntrip, H. (1968) Schizoid Phenomena, Object Relations and the Self. London: Karnac.
Heimann, P. (1950) On counter transference. International Journal of Psychoanalysis 31: 81–4.
House of Commons (2011) HM Government Health and Social Care Act accessed 26. 03. 2013. www.publications.
parliament.uk/pa/cm201011/cmbills/132/11132.i-v.html
Kareem, J. and Littlewood, R. (eds) (2000) Intercultural Therapy. London: Blackwell Science.
Kernberg, O. (1994) Internal World and External Reality: Object Relations Theory. London: Aronson.
Khan, M. (1986) The concept of cumulative trauma. In G. Kohon (ed.), The British School of Psychoanalysis.
London: Free Association.

Kirshner, L.A. (2011) Between Winnicott and Lacan: A Clinical Engagement. New York: Taylor & Francis.
Kohon, G. (ed.) (1986) The British School of Psychoanalysis. London: Free Association.
Limentani, A. (1999) Between Freud and Klein: The Psychoanalytic Quest for Knowledge and Truth. London:
Karnac.
Mitchell, J. (2000) Psychoanalysis and Feminism: A Radical Reassessment of Freudian Psychoanalysis. New York:
Basic Books.
O’Connor, N. and Ryan, J. (1993) Wild Desires and Mistaken Identities: Lesbianism and Psychoanalysis. London:
Virago.
Rayner, E. (1991) The Independent Mind in British Psychoanalysis. London: Free Association.
Sandell, R. (1999) Long term findings of the Stokchol Outcome of Psychotherapy and Psychoanalysis Project
(STOPPP). Paper presented at the Psychoanalytic Long Term Treatment Conference. A Challenger for Clinical and
Empirical Research in Psychoanalysis. Hamburg, Germany. In S. Priebe and M. Slade (2002) Evidence in Mental
Health Care. East Sussex: Brunner-Routledge.
Winnicott, D.W. (1971) Playing and Reality. London: Routledge.

4
Jungian and Post-Jungian
Approaches
Ann Casement
Analytical psychology is the name given to the depth psychology founded by the Swiss
psychiatrist, Carl Gustav Jung (1875–1961). This title differentiated it from psychoanalysis
following his acrimonious parting with Freud in 1913, though Jung’s preferred designation
for his approach was complex psychology. His writings have been disseminated universally
through twenty volumes of the Collected Works; his ‘autobiography’ Memories, Dreams,
Reflections; and his correspondence in The Freud-Jung Letters, and the C.G. Jung Letters.
Jung’s major theoretical formulations were influenced by earlier thinkers from various disci-
plines. His favourite philosopher was the pre-Socratic, Heraclitus, whose concept of enantia-
dromia, a psychological law denoting the ‘running contrariwise’ hypothesis that everything
eventually turns into its opposite, was an influence on Jung’s theory of opposites. Heraclitus
also posited that all things are in a state of flux, which links to the concept of process.
Plato’s theory of Ideal Forms is the forerunner of Jung’s a priori theory of archetypes,
conceptualised as inherited patterns in the collective unconscious. The latter also owes some-
thing to the nineteenth- to twentieth-century French sociologist, Émile Durkheim’s collective
representations, which denote the beliefs and assumptions collectively held that individuals
in a society unconsciously accept. The twentieth-century French anthropologists, Henri

Hubert and Marcel Mauss’s thinking on categories of the imagination was also an influence.
From Aristotle, Plato’s student, Jung derived the concept of teleology (where the focus is on
the purposeful rather than the causal), which contributed to Jung’s development of the indi-
viduation process (becoming wholly, indivisibly oneself).
German Idealist philosophy was an important influence, Jung’s other favourite philosopher
being Kant, whose epistemological theory figured in Jung’s theory of archetypes (inherited pat-
terns in the collective unconscious). German Idealism was influential on Jung’s development of
the transcendent function (which mediates between opposites), and on alchemy (introduced to
him by the sinologist, Richard Wilhelm) as a psychological process, whose focus is the transfor-
mation of personality. The later German philosophers, Schopenhauer and Nietzsche, with their
ideas respectively of the Will and the Übermensch, contributed to Jung’s development of the
concepts of unconsciousness and the Self. Jung worked with the Nobel Laureate quantum
physicist, Wolfgang Pauli, on his theory of psychoid archetypes (psycho-physical patterns that
are completely inaccessible to consciousness); and on synchronicity (phenomena that are not
subject to the laws of time, space and causality).
A summary of influences on Jung from the medical and psychology worlds includes Wilhelm
Wundt (word-association experiments), William James (psychology of religion, collective
unconscious, typology), Pierre Janet (the autonomy of unconscious contents), Théodore Flournoy
(non-pathological and creative components of the subconscious), Sigmund Freud (unconscious,
libido – the latter reconfigured by Jung as psychic energy), Eugen Bleuler (schizophrenia).
Spirituality is the leitmotif running through Jung’s writings, and his quest for the dark or
shadow side of the Godhead led him to study Eastern and Western religions and to esoteria,
such as Gnosticism, Kaballa and Manichaeism.

The writer of this chapter conducted an interview with the Jung scholar, Sonu Shamdasani, com-
missioned by The Journal of Analytical Psychology (Casement, 2010). This followed closely on
the publication in 2009 of Jung’s Liber Nous (the ‘Red Book’), one of the most significant events
in Jungian history. The book contains Jung’s confrontation with ‘the unconscious’, starting in
1913, where the fantasies, later to be known as active imaginations that were recorded in the
so-called Black Books, began to be transcribed through the medium of artwork and calligraphy
into Liber Novus. This may be thought of as Jung’s spiritual biography, on which he continued
to work until 1930. In 1959, Jung added a brief Epilogue to the work in which he acknowledged
that his acquaintance with alchemy in 1928 took him away from Liber Novus.
At the front of the book is an important statement in which Jung states these years
were the most important time of his life when the ‘numinous beginning, which contained
everything, was then’ (Jung, 2009). The term numinous (awesome, mysterious events not
subject to the individual’s control) is key to Jung’s approach to the person and human

JUNGIAN AND POST-JUNGIAN APPROACHES 77
nature, which he derived from the German theologian, Rudolf Otto, who applied it to
fleeting experiences that are awesome, mysterious or tremendous.
By 1914, Jung had already formulated what may be thought of as his structural theory. This
included the following concepts: emotionally stressed complexes (autonomous sub-personal-
ities); the unconscious (inaccessible to the ego); the psychological types (different types of
consciousness) of the introvert (greater value placed on the inner world) and the extravert
(greater value placed on the external world); the psychological mechanisms of introversion
(inward-looking) and extraversion (outward-looking); and the non-sexual libido (reconfig-
ured by Jung as psychic energy – a neutral form of life energy). He was also developing a
phylogenetic or evolutionary notion of the unconscious, later termed the collective uncon-
scious, and the notion that dreams were not wish-fulfilment but, instead, had a compensatory
function in relation to consciousness. In the course of working on Liber Novus, Jung devel-
oped the notions of individuation (becoming wholly, indivisibly oneself), and of the Self (the
agent of wholeness), and the subject images of the persona (the front presented to the outer
world), shadow (the unwanted side of personality), anima/animus (the internal feminine and
masculine principles), and the mana personality (supraordinate power).

Complexes play a key role in Jung’s conceptualisation of psychological disturbance. He
states that ‘the phenomenology of the psyche brings into view those psychic processes in the
background which underlie the clinical symptoms’ (Jung, 1931/1971: 528). Complexes are
the emotionally toned contents in the dark recesses of the psyche, which are autonomous in
that they come and go as they please and have the power to resist conscious intentions. To be
in the grip of a complex is to be in a state of possession, whereby a complex ‘forms some-
thing like a shadow-government of the ego’ (Jung, 1954a: 87).
The term ‘complex’ did not originate with Jung but was widely used in nineteenth-century
French neurology and psychiatry by Jean-Martin Charcot and Pierre Janet, and by Josef Breuer,
Freud’s accomplice in the founding years of psychoanalysis. The central myth of psychoanalysis,
the Oedipus complex, was discovered by Freud, and the inferiority complex by Alfred Adler.
Jung conducted experimental research into complexes applying the word-association tests
during his time working in psychiatry from 1900 to 1909 at the Burghölzli Hospital in Zürich.
Complexes are characterised by conflict, which frequently come back to mind unbidden and
constantly interfere with conscious life in a disturbing and harmful way.

Though complexes represent discordant and antagonistic elements in the psyche, they also
have the potential to contribute to psychological health if they are brought to consciousness
thereby depriving them of their autonomous power. In this way, they are valuable symptoms
without which psychic activity would come to a fatal standstill and are ‘focal or nodal points

of psychic life which we would not wish to do without’ (Jung, 1954a: 529). Jung conducted
a self-analysis in his early work entitled Symbols of Transformation first published in 1912.
The material he was looking at in this work was from a young woman, who was the ostensi-
ble patient, but the actual patient was Jung himself. He used various myths, including that of
Siegfried from Wagner’s Ring, wherein Fafner, the dragon who guards the ‘treasure hard to
attain’, stands for the mother who psychologically possesses the son/daughter’s libido. If the
son/daughter remains unconscious of this, he/she is in the grip of a mother complex so that
slaying the dragon, the fantasy that appears so often in myths and fairy tales, represents the
son/daughter’s liberation from the autonomous grip of the mother complex.
One of the main aims of Jungian analysis is the regulation of affect in a patient. The
autonomy of a complex forces itself tyrannically upon the conscious mind and the resultant
‘explosion of affect is a complete invasion of the individual, it pounces upon him like an
enemy or a wild animal’ (Jung, 1954a: 132). This traumatic affect may be represented in
dreams as a wild and dangerous animal – a testament to the autonomous nature of a complex
when split off from consciousness. Psychological health is the result of a patient becoming
increasingly aware of this danger and gaining more conscious control over the autonomous
contents that lurk in the unconscious.

Analytical psychology views the acquisition of psychological disturbance in individuals as stem-
ming from too great a separation between consciousness and the realm of unconsciousness. Jung
divided the latter into two parts: the personal unconscious and the collective unconscious. The
former, according to Jung, is the realm of complexes, the latter that of archetypal contents.
When an individual lives only the conscious side of their personality, the less conscious
side will fall into shadow and, as a result, become increasingly powerful in the process. For
instance, a negative mother complex that is the result of the experience of neglectful or bad
mothering in childhood will lead to experiencing all women in a negative light. Complexes
are akin to sub-personalities that are autonomous so that any encounter with a woman can
activate negative feelings.
If the experience of mothering has been particularly brutal in the early years of existence,
this can lead to an individual being at the mercy of an intra-psychic archetypal force, such as
a witch. This has serious consequences for an individual in cutting them off from any life-
giving potential in the psyche and subject to death-dealing ones instead such as pathological
envy or hatred of anything that leads to new life.

An individual who is cut off from the potential that lies in the conscious is liable to be at the
mercy of uncontrollable affect or to fall into depression. That is the result of psychic energy

being withdrawn from the conscious realm into unconsciousness where it leads an autono-
mous life. This represents a form of regression in a consciousness that has hurried forward
too quickly and lost touch with the unconscious background to which it should be connected.
When the tempo of the development of consciousness is too rapid, leaving behind the realm
of unconsciousness, the complexes and archetypal contents that reside in the latter start to
take on a life of their own and become destructive of ego consciousness.

Chronic depression can arise when change is being signalled, for instance, at the time of a
major life event when the status quo has to be abandoned in favour of new life. This can arise
when a young person should leave the parental home to take up the challenge of a life of their
own but is unable to do so as the result of a pathological mother or father complex. Depression
can become chronic for an individual who is still internally tied emotionally to an over-pos-
sessive mother, or who is under the control of a domineering father. Chronic depression can
also be the result of an individual failing to deal with relationship problems, for instance, an
unhappily married person who remains passively in a marriage.
Jung’s tenure at the Burghölzli Hospital in Zürich from 1900 to 1909 showed him to be a
gifted psychiatrist in his treatment of dementia praecox (schizophrenia). In order to do this,
he used the word-association test, which had originally been used unsuccessfully as an intel-
ligence test. The timing of patient’s responses to word stimuli were recorded, as well as the
rate of heartbeat and respiration. In the course of these experiments the graph of the word-
association test showed a correspondence between verbal responses and the respirational
rate. This, in turn, demonstrated that the mind and body work in unison and were similarly
affected by the influence of emotion largely due to interpersonal interactions.
One case illustrating the use of the word-association test that was published by Jung related
to a female in-patient suffering from paranoid dementia. She was an unmarried dressmaker
who heard voices slandering her and told her, amongst other things, that she was a doubtful
character. The patient became so disturbed by these voices that she often thought of drowning
herself. As an in-patient she had delusions that she had a fortune worth millions or that her
bed was full of needles, which gradually became more grandiose when she claimed to be
Noah’s Ark or the Empress Alexandra.
Over two years, Jung did simple word-association tests on this patient in which each
stimulus word was followed by a long silence. To the word ‘love’ she responded ‘great
abuses’; to ‘ring’ she responded ‘bond’, ‘alliance’, or ‘betrothal’. Jung attributed the long
time in responding to word stimuli to the continual interference of the complexes, which in
the case of this woman patient, he finally diagnosed as the complexes of injury and of eroti-
cism. Jung saw the senseless and confused fantasies the patient had constructed in her psy-
chosis as bearing a similarity to dream-thoughts. These became more understandable once
the patient’s life-history of interpersonal disappointments were taken into account and could
be seen as compensatory for a wretched life. For Jung, the psyche works in a compensatory
way to balance the interpersonal outer world.


The analytical psychologist and psychiatrist, Michael Fordham, revised Jungian classical
theory and practice, the latter being the approach that remained close to Jung’s original
formulations. An important contribution of Fordham’s to this revision was his theory of
deintegration and reintegration, which built on the concept of complexes as unconscious
structures with innate mental contents. Fordham’s revision proposed that there was a
primary self that was an integrate ‘a psychosomatic potential waiting to unfold in interac-
tion with the environment’ (Astor, 1995: 53). The primary self is featureless and acquires
characteristics when parts of it begin to relate to the environment. Deintegration was the
term Fordham used for energy going out to objects in the environment, for example, ‘a
self-representation here is a product of the deintegrating self combining with the environ-
ment, for instance the breast’ (ibid.: 58). Reintegration was the term Fordham used for
energy returning to the self. In this Jungian model, the continual interaction with the envi-
ronment leads to the structuring of the mind and to the infant self-creating the environ-
ment in which it will develop. ‘The most significant deintegrate of the self is the ego’
(ibid.: 70).
The following summary of an infant observation offered by Fordham illustrates how
environmental factors contribute to perpetuating psychological disturbance. A newly born
baby persistently whined and grizzled, although his over-all relation to his mother seemed
good. Feeding and nappy changes were negotiated satisfactorily but the mother never talked
to the baby. One day she handed him to the infant observer while the infant was whining
and grizzling. This ceased when the observer started to talk to him. As Fordham put it, the
mother was as a rule an observant and sensitive woman and she noted what had happened
with the infant observer. From then on, she started talking to the baby and the whining and
grizzling ceased, even though the baby could not understand what she was saying. This
interaction with the environment is an important step in engaging the infant in adult patients,
which Fordham incorporated into his practice with sullenly silent patients.
The Jungian analyst and psychiatrist, Jean Knox, explored the treatment of trauma due to
stressful situations in the environment that have occurred in the past. Psychodynamic
defences get put into place each time a flashback to the initial trauma is experienced in the
environment, for instance, in the case of a war veteran when a loud noise is heard. These
defences are initially conscious but become involuntary and unconscious over time. Knox
instances the case of an adult patient who experienced a sudden and traumatic separation
from his parents at the age of five, when he was rushed into an isolation hospital suffering
from scarlet fever. His parents were only allowed to see him from behind a glass screen and
the nurses in the hospital were harsh in their treatment of him, smacking him each time he
stirred jam into his rice pudding.
At the same age, the patient had just learnt to read and, in the course of analysis, he
remembered he had used reading at the age of five as an escape from the harsh environment
he found himself in at the hospital. He continued to use reading as an unconscious defence
whenever he found himself in stressful situations, particularly those involving separation.

2.5 Change
Jung’s approach to the analytic process ‘consisted essentially in a dialogue and a mutuality
requiring the emotional involvement of the analyst for change to occur’ (Casement, 2001:
79). The whole being of the analyst as well as the analysand plays its part in the movement
from psychological disturbance to psychological health. It is not only the analyst who influ-
ences the analysand in the course of Jungian analysis, but there is a reciprocal influence on
the analyst by the analysand. Mutual transformation is a key to this approach as the analyst
is as much in the analytic process as the analysand.
The analyst must change if he/she is to become capable of bringing about change in the
analysand, the key to this being the human quality the analyst brings to the work. The
Jungian analyst, Joe Cambray, has explored the analyst’s subjectivity in relation to the real-
ity of an other in the interactive field that exists between the two, which is not entirely the
analyst’s nor entirely the analysand’s. Exploration through amplification of the myths
embedded in both the analysand’s, as well as the analyst’s psyche, emanates from the ana-
lytic third that is constellated between the two. It is important to stay in the analytic third,
which may be caught in the complexed interactive field, and not try to shift an analysand’s
anger and despair too quickly to the symbolic field. In this way the analyst is able to empa-
thise with the analysand’s emotional suffering. This can result in a more secure alliance
thus enabling a deeper exploration of the schizoid defences of both analyst and analysand.
The awareness of mutuality is all important in rescuing the analyst from the need to ‘know’
what is right for the analysand or to inappropriately direct the latter in any way.
3 PRACTICE

For Jung, individuation was the central goal of a long analysis, in the course of which the
analysand aspires to achieving wholeness or becoming a complete personality. The concept
of teleology, or the doctrine of final causes, is important here as it underlines the view that
the self, which is the totality of the psyche, is functioning to push an individual towards the
fulfilment of their destiny. The individual’s ego may not concur with this, particularly at the
time of what Jung called the second half of life. In this model, the first half of life is gov-
erned by the maturational process, which is largely directed to the goals of outer life
governed by the ego, such as academic and work achievements, accompanied by separating
out from the natal family in order to lead a life of one’s own.
The second half of life entails a gradual shift from the concerns of the ego to a greater
awareness of the self and the inner world of the psyche. Jung regarded this period as the
time when an individual’s ‘myth’ challenges them to begin to separate from a collective
worldly stance to follow the quest for their own identity. The thirties are the age that rep-
resents a time of greater introspection that can lead to individuals seeking the help of

therapy. If, on the other hand, an individual represses this urge and tries to continue to live
only on an outer level, a neurosis will probably be the end-result. The Jungian therapeutic
method in working with neurosis entails a symbolic approach, which allows for a sponta-
neous relationship between consciousness and unconsciousness. Symbolisation is the best
possible formulation of new realisations emerging from the realm of unconsciousness.
Jungian therapy supports a turning away from the demands of ego and a conscious return-
ing to unconsciousness.
Traditionally, Jungian therapy had focused on working with analysands in the second half
of life, in particular, those judged to be embarking on the goal of individuation. The analytical
psychologist, Michael Fordham, challenged this view by stating that individuation as a goal of
Jungian therapy was not confined to the second half of life. Through his work, he discovered
that children were also on the path to achieving consciousness through differentiation of sub-
ject from object, for instance, in the child’s gradual separation from the mother during the first
two years of life. This opened the way for Jungian therapists to work with children and ado-
lescents, in other words, those who were still very much in the first half of life. The goal of
therapy with young people is the increased mastery of bodily functions, the beginnings of a
conscience and consciousness, and the development of a capacity for concern through the
synthesising of opposites such as good and bad. All these, combined with the start of the pro-
cess of symbolisation, are prerequisites of the goal of individuation in Jungian therapy.
The Jungian analyst, Rosemary Gordon, wrote of a two-fold goal in Jungian therapy: the
first is that of cure, which is related to the expansion of the ego through the assimilation of
contents from the personal and the collective unconscious. This can lead to a greater balance
of the two realms and a spontaneous flow of psychic energy between them. The other goal is
that of healing, which is involved in the individuating process and the work towards a more
complex wholeness of the individual.

There are no criteria in analytical psychology for the assessment of the unsuitability of
patients/analysands to be treated by this approach. It may be successfully applied to adults of
any age suffering across a range of disorders. However, this writer’s experience of many
years working as a therapist in a psychiatric hospital would lead her to advise that seriously
disorganised patients should be seen in a setting that provides secure containment for them
as well as for the therapist such as a psychiatric unit.
Jungian therapy is also effective in the treatment of children and adolescents as case
vignettes in this chapter will exemplify. An illustration of this is the following summary of a
case written up by Elizabeth Uban, a Jungian adult analyst and specialist child psychothera-
pist, in the UK’s National Health Service (NHS).
The work with this young patient focused on the lack of emergence of the ‘central arche-
type’, that is the archetype of the self as the central, organising principle in the mind. The

patient was a 14-month-old boy, Vejayan, treated by Urban at a mother-baby in-patient NHS
unit. His mother had been in a clinical depression since his birth and Urban witnessed a sense
of deadness in her expression with no truly shared play between mother and infant son. The
exchanges between the two did not get below the surface and Vejayan appeared frustrated by
the sense that there was a mind behind his mother’s face that was not available to him. The
concern was that he ‘functioned primarily in a two-dimensional way, and it was unclear
whether he had the capacity for shared play, three dimensionality and mind-to-mind relation-
ships’ (Urban, 2008: 339).
Through Urban engaging in play with Vejayan, he eventually came to infer what was in the
therapist’s mind and to have a new thought, which he grasped as his own. Fused as it is with
self feeling, this new thought can be seen as ego development resulting from the integrative
activities, according to Michael Fordham’s model detailed above, resulting from the central
archetype.

There are no criteria employed in analytical psychology for deciding whether or not patients/
analysands would benefit at the outset from couples, family and group therapy. In the assess-
ment sessions it may become clear that another approach might be more suitable if there is a
specific problem that needs addressing, for instance alcohol addiction, which may entail
referring the patient to Alcoholics Anonymous (AA). This does not exclude seeing the person
for Jungian therapy at the same time as he or she is going through the programme at AA.
Similarly, individuals may be being seen by a general practitioner or psychiatrist for treat-
ment for clinical depression and be prescribed anti-depressants. This, again, would not pro-
hibit them from having Jungian therapy alongside the medical treatment.
The analytical psychologist, Luigi Zoja, has worked intensively with drug addiction and
came to see the underlining motivation amongst young addicts was the need for the kind of
initiation rituals that are lacking in Western society. Jungian therapy can help with identifying
the psychological needs that are expressed by addiction.
When a severe problem is identified in a patient at the beginning of or during the course
of Jungian analysis related to family or relationship problems, it is usual for the practitioner
to refer the patient for family or couples therapy. As a significant number of Jungian analysts
are trained couples and family psychotherapists, it is a simple matter to refer individuals
needing that kind of treatment to such colleagues.

The psychoanalytic psychotherapist, Nina Farhi, told this writer that she had heard the psy-
choanalyst, Donald Winnicott, say there were three things an analyst must do: stay well, stay
awake and stay alive. Another quality needed by practising analysts/therapists is to have

attained sufficient self-awareness of their own psychological wounds before embarking on

treating patients/analysands. They also need to have faced up to and, as far as possible, suf-
ficiently resolved their own narcissistic tendencies, which give rise to feelings of grandios-
ity, in order to be able fully to empathise with patients’ sufferings. This entails becoming
grounded in their common humanity so that they do not have contempt for themselves in
order to reach a point where they can accept the humanity of others. Humility is another
important personal characteristic in effective therapists, whereby they are aware that they do
not know what is right for patients in order not to manipulate patients into acting or thinking
in certain ways. Moral courage is another necessary prerequisite so that a therapist is not
afraid to reflect difficult matters back to a patient. What Jung refers to as shadow needs to
be worked on in therapy and often entails having to withstand a negative transference onto
the therapist by a patient. Therapists also need intelligence and, above all, common sense so
that they do not have unrealistic expectations of what may be achieved in analysis or
psychotherapy.

A vignette of case material that illustrates the empathy and humanity needed to be an effec-
tive therapist is well documented in the following case material written up by the Jungian
analyst and psychiatrist, Richard Carvalho. This details a psychotherapy done with a woman
who had passed into ‘later life’, i.e. the inevitable decline into dying and death. Carvalho,
using Fordham’s model, states that these are deintegrates of the self. Death is part of the
individuation process; the latter defined by Carvalho as the easy straightforward interchange
between conscious and unconscious processes ‘via the demand for the somatic and emotional
to be translated into mind’ (Carvalho, 2008: 3). He makes a much needed revision to Jung’s
original definition of the archetype as a psychic structure with an ‘instinctual’ and a ‘spiritual’
pole to ‘emotion’ and ‘thought’ (reason, insight, moral judgment). The term ‘spiritual’ has
been debased through over-usage in Jungian circles and is in need of the kind of reformulat-
ing to be found in the work of writers such as Carvalho and the Jungian analyst, Wolfgang
Giegerich.
Psychotherapy with a dying patient is different in many ways to that with patients at earlier
stages of life in that the ‘last deintegrate’ does not allow for hope that things might get better
or be cured. This particular patient’s initial insistence that this might be the case had involved
her in a depressive split ‘in which her “stupidity”/body-self had been at the mercy of her
contempt/mind-ego, or her suffering mind at the mercy of her cruel body’ (ibid.: 15). This
resulted in her feeling fretful, persecuted, lonely and isolated, which shifted in the course of
therapy over her last few months to the possibility of mourning wherein she felt less isolated
and lonely and ‘perhaps, she was able to meet the very last part of her final challenge, death’
(ibid.: 15) that allowed her, body and mind, to decide to die as self. As Carvalho reveals,
previous to the work with this patient, he had had to experience his mother’s decline into
mindlessness in which she became obsessively preoccupied with the distance between her
and her commode.


The prototype of the therapeutic relationship in this approach was set by Jung’s seminal 1946
paper, The Psychology of the Transference (in The Practice of Psychotherapy (1954b). From
the late 1920s, alchemy became the focus of his psychological work so that in this lengthy
paper he incorporated ten woodcut prints from a medieval alchemical text Rosarium
Philosophorum that illustrate the history of an incestuous couple. Jung used these as a projec-
tion of what unfolds in the course of a long analysis between the unconscious of the analy-
sand and the analyst. This is played out symbolically in the paper as the combination of two
alchemical substances, in the course of which both are altered. This echoes what was said
earlier in this chapter about the importance of mutuality between analyst and analysand in
Jungian psychotherapy.
The brief outline below of the various stages involved in the alchemical process depicts an
interchange between king and queen, bridge and groom, masculine and feminine, or animus/
anima (the active and passive principles in the mind that when brought into relationship
culminate in the syzygy, the yoking that results from conscious interchange between the two).
According to Jung, the incestuous nature of the transference/countertransference that arises
in the course of a lengthy analysis may be concretised in an actual sexual relationship
between the two participants. He proposed that this unconscious way of relating is depicted
in the earlier pictures of the Rosarium in the left-handed contact between king and queen. The
pictures also depict the couple falling into depression, which is the point at which the analy-
sand experiences the analyst in a negative light that can lead to the breakdown of the analysis.
If these dangers can be navigated and worked through in the alchemical container, the analy-
sis can move to a more symbolic plane culminating in an experience of a higher union that
gives birth to new life or greater consciousness on the part of both participants. This stage
symbolises the withdrawing of the libido from the alluring fascination of the eroticised trans-
ference/countertransference. Alchemy viewed psychologically is a dialectic in the work of
distilling material from unconsciousness as a recursive process. For the Jungian analyst,
Wolfgang Giegerich, alchemy is a work against nature in displacing human existence from
the biological sphere to the slow path to mindedness.

The following extracts from a long-term analysis will be used to illustrate some of the
features that characterise the therapeutic style of a Jungian practitioner. These include
interpretation in the transference/countertransference based on the alchemical process that
would feature prominently in a classical Jungian analysis. These extracts are taken from
the Jungian analyst, Gerhard Adler’s book devoted to an in-depth study of the first year
of a five-year analysis with a 48-year-old woman (Adler, 1961). This will serve to illus-
trate the interactive style of the analyst conducting a Jungian analysis along classical lines
which is also informed by the more psychoanalytical approach rooted in transference/
countertransference.

The analysand’s presenting symptom was severe claustrophobia, which she had experi-
enced occasionally in her mid-thirties but which had become increasingly intrusive in recent
years. This culminated in an attack while she was staying at a hotel in Switzerland when she
awakened in a state of acute distress and had to leave the room, spending the rest of the night
sitting outside on the hotel steps. After this episode, the attacks recurred with increasing
frequency.
The analysand’s ambivalent attitude to finding herself in analysis is expressed in the first
dream that went as follows:
I set out to begin a journey, abroad I think. I drive up to some little station in an open car, full of parcels.
I have to cross the line in the car to catch the train, and just as I am about to do so, after having lost some
time talking to a friend, I see that the train is coming in and I cannot cross: the stationmaster, on the other
side, holds up his hand and won’t let me pass. Friends who are present say, ‘He might just as well have
let you pass’ (Adler, 1961: 70).
Adler interpreted the dream to the analysand as follows. Her unconscious resistance is repre-
sented by the various objects that serve to hold her up from embarking on the journey in the
dream, which was reflected back to the analysand as embarking on the journey of analysis to
a foreign land. The latter represents the unknown realm which will be ventured into during
the course of the work and which arouses unconscious fearful feelings in this analysand, who
is about to undertake it. The stationmaster who will not let her pass stands for the analysand’s
transference onto the analyst, who may, after all, not be helpful and sympathetic but could be
as critical and lacking in understanding as the world around her. In fact, he appears as a for-
bidding parental figure who has the power to incapacitate her.
In Jungian analysis, it is important to bring a patient/analysand’s unconscious ambivalence
into the sessions as soon as possible so it can be made more consciously known, which is
what Adler does early in the work with this analysand through his interpretation of the first
dream. As the analysis progressed towards the middle of the first year of work, Adler became
aware of the constellation of the transference/countertransference, which finds its expression
in alchemical language. This is the quaternity made up of the analysand’s feminine ego being
projected into the male analyst’s animus, that is to the unconscious masculine side. At the
same time, the analyst’s masculine ego becomes projected into the analysand’s anima, the
unconscious feminine side.
Adler talks about this stage as the one where the incestuous tendency that is present in the
alchemical process, as the withdrawal of libido from the concrete persons of analyst and
analysand to the experience for the latter of the inner masculine creativity, and for the analyst
of the inner feminine counterpart in the objective psyche. This incestuous tendency seen
analytically is ‘trying to unite the different components of the personality, that is conscious
and unconscious, ego and non-ego’ (Adler, 1961: 216).
The analyst is now able to let go of actively trying to pursue his own theories or values
and, instead, to be receptive to the analytical processes that are being activated in the
unconscious projections of the two participants. This illustrates the all-important notion of

mutuality in Jungian analysis between analyst and analysand. Nevertheless, it is at those

moments, where deep unconscious processes have enveloped both, that the image of the
symbolic alchemical container in the analyst’s mind acts to ensure there is no destructive
acting-out on the part of the analyst.
Towards the end of this first year of analysis, the analysand brought a dream that she had
had before the session in question but had ‘forgotten’.
I have had an interview with Dr Adler, but instead of going away when it is over, I remain sitting there in
a sort of dream. It is growing dusk. Then Dr Adler comes down the path from the gate with several men,
friends of his, and I suddenly realise that I have no business to be where I am; I ought to have gone (ibid.:
332).
Adler took the objective aspect of the dream to refer to his own attitude, that is, a criticism
of his own too masculine attitude. This shows in the analysand feeling she has no business to
be in the company of Adler and his men friends. Adler explored the significance of the repres-
sion of the dream with the analysand, which she had kept back from reporting as she felt it
might interfere with his acceptance of her and of what he could take. He, in turn, realised that
he had been afraid of his countertransference of becoming too fascinated by and interested in
her unconscious material. This is the situation being tested out in the dream. Adler disclosed
to the analysand his reaction, which had a considerable effect on her and which enabled dis-
cussion in the session of the inevitability of mutuality between analyst and analysand. ‘This …
positive interaction gave her, as she said, a feeling of new dignity, and helped her cope better
with … the desire to impress me (which contained a genuine need for acceptance on a deep
level’ (ibid.: 334).
It was agreed between them that this ‘need’ was connected with the claustrophobia, which
released a considerable amount of libido that had been invested in the symptom. By the end
of the first year of analysis, the work could have been terminated but continued for four more
years as the analysand was finding the encounter with archetypal material so creative.

3.5.1 Assessment
The following case material written up by Alessandra Cavalli, the Jungian child and adult
analyst, is with a three-and-a-half-year-old child, Gigi. The assessment process was carried
out over the first two sessions after he was referred to the analyst with a diagnosis of autistic
features. The symptoms included speech delay and difficulty in relating to peers. The ana-
lyst’s assessment notes state that she felt she was in the presence of a deaf child, who had
learnt to pronounce sounds with extreme difficulty. His speech was undecipherable to human
ears, including those of his mother.
The analyst goes on to report that Gigi’s voice had a strange sound as if it were coming
from an enclosed space and re-echoed, and his words held no meaning whatsoever to the

extent that the analyst could make out no sound that sounded familiar to her. There was
nothing of particular significance in Gigi’s history, apart from the fact that he was abruptly
weaned at seven months when the family changed houses and mother was preoccupied with
the move and burdened with emotional and physical stress from this.
After the initial assessment, the analyst had the following considerations to make with
regard to Gigi’s condition. He appeared to have lost mother’s attention when he was
weaned and this loss coincided with the loss of mother’s capacity to be mindful of him ‘so
that his hypothetical depressive and aggressive feelings could not be metabolised once his
breast feeding mother “disappeared”’ (Cavalli, 2011: 6). At times in the sessions, Gigi had
expressed these feelings concretely by biting the analyst’s arm.

The analyst’s formulation of Gigi’s case was that his incapacity to manage the internal pres-
sure of an archetypal primitive need to bite was linked to the external reality of the loss of
his mother’s capacity to be in tune with him. This experience left him feeling as if she was
mentally dead, leading to his perception that mother was unable to contain these primitive
needs and leaving him without a psychological skin so that he had no choice but to hide
within himself. This led to his adopting some autistic defences as a way of stopping his
development, which must have felt dangerous to him.
During his analysis, Gigi could find a space where he recreated and lived out his ‘lost’
experience, which enabled him to find a mind that was in tune with him with which he
could deintegrate, and which was receptive to his inarticulate experiences. The resultant
transformation of the non-symbolic act of biting into a symbolic thought, whereby emo-
tional data can become mind, followed on from Gigi being able to gain some knowledge
about it and to integrate his experience into his self. In this way, ‘the analyst-patient couple
becomes a creative couple: each participates in the realisation of an innate archetypal
unformed vision’ (ibid.: 11).

Its founder, C.G. Jung, is often depicted as a religious thinker, which does not mean that his
psychotherapeutic aim was advocating a return to organised religions such as Judaism,
Christianity or Islam. For Jung, the most important experiences in life were encounters with
what he called the numinous, which may be experienced in analysis as fleeting moments of
awe, mystery, reverence, terror or joy. It is these archetypal experiences, filled as they are
with affect akin to religious experiences, which can lead to revelation, thus provoking funda-
mental shifts in both analysand and analyst. Jung warns that numinous experiences are
ambiguous in that they can be either creative or destructive; in the latter context they can
result in feelings of grandiosity in one or both participants in analysis. The numinosity of

incest that Jung explored in alchemy is an example of this if it is concretised in sexual acting-
out rather than being lived on a symbolic level.
Another goal of Jungian therapy is not narcissistic self-absorption but the continuing
investment in relationship with the other(s): ‘The unrelated human being lacks wholeness, for
he can achieve wholeness only through the soul, and the soul cannot exist without its other
side, which is always found in a “You”’ (Jung, 1954a: 244).
Psychic wholeness is the long-term aim of Jungian therapy with the self-conceived of as
the totality of conscious and unconscious ‘because it does in fact represent something like a
goal of psychic development’ (Jung, 1958: 582). As Jung says elsewhere, ‘The goal of the
procedure is the unio mentalis, the attainment of full knowledge of the heights and depths of
one’s own character’ (Jung, 1963: 474).

Jungian psychotherapy sessions are usually timed to last fifty minutes, the early ones of
which will be used for assessment and setting the contract of the procedure in terms of fre-
quency of sessions per week and financial arrangements. The latter would not apply, of
course, where the psychotherapy is being conducted in a state-funded setting.
Some Jungian therapists use a combination of chair and couch for analysands/patients,
whereas those at the more classical end of the spectrum would favour the chair only. This is
deemed more suitable to the classical Jungian approach, which is based on a dialogue between
analysand and analyst. Other analysts may mainly use the couch, which is seen as more condu-
cive to regressing the patient to early life stages and to the lifting of defence mechanisms.
The use of transference/countertransference techniques is ubiquitous, although the
view of these varies according to the analyst’s orientation and is usually accompanied by
interpretation. Work with dream material is also widely utilised, an important component
of Jungian dream interpretation being the notion of compensation. In this approach, dream
contents are viewed as compensating for the conscious attitude of the analysand, for
instance, a self-righteous woman may dream she is a whore; or a man suffering from
megalomania may dream of a large tree trunk being felled. An important point relating to
dream analysis is the emphasis on their manifest as opposed to latent contents.
Amplification and active imagination are used by analysts with a classical orientation, the
former technique aspiring to connect the content from a dream or fantasy with universal
imagery by way of mythical, historical or cultural analogies; the latter refers to the collabora-
tion of consciousness with unconsciousness in order to facilitate the emergence of those
contents that lie just below the threshold of consciousness.

The change process in Jungian therapy will be illustrated by work with couples via the
writing of the Jungian analyst and psychoanalytic couple therapist, Judith Pickering. In

1931, Jung wrote about marriage as a psychological relationship using the metaphor of
‘container-contained’, which has become a central concept for therapists working with
couples. Briefly, this argued that in any union, one partner will feel herself to be the con-
tainer, the other the contained. The former will feel confined by the union and will ‘spy out
the window’ (‘Marriage as a psychological relationship’ in Jung, 1925: 195), while the
latter experiences the container as complex and undependable. From what one has learnt
of the Jungs’ marriage, this dichotomy seems to stem from that union as Jung did have
extra-marital affairs.
The simpler nature will seem like a room that is too small, with too little space. The complicated nature
will give the simpler one too many rooms, too much space so that he/she will never know where they
belong. Thus the more complex will contain the simpler … without itself being contained. Yet the more
complicated has a greater need of being contained, and will feel themselves [to be] outside out of the
relationship (ibid.: 196).
Jung attempted to counteract the idea that all love relations are incestuous and only based
on parental substitutes by developing his linked concept of anima/animus. The develop-
mental function of these archetypal structures is to lure individuals out of the warm
embrace of familial relations to outer life through projection of idealised anima/animus
fantasies into others. There are, however, dangers inherent in the projection of these
idealised fantasies as the real beloved can be turned into a two-dimensional image of an
internal structure.
This is some of the theoretical foundation of Pickering’s work with couples. The strategy
outlined by Pickering for effective change in work with couples is outlined in Box 4.1:
Box 4.1 Couple therapy
•• Therapy/therapist as container for container/contained dynamics between the couple, as a safe space,
a transitional environment.
• Therapy/therapist as container for container/contained dynamics between the couple.
• Therapist and therapist as representing thirdness.
• Tensions between individual transferences and the transference/countertransference of the marriage in
therapy.
• Marital therapy as an arena where patterns of relating are identified, and may be replayed, but in a
different and mutative dynamic.
• Relationship between object-choice and couple as object-maker: how they make the therapist/therapy
a particular object.
This strategy mirrors the overlapping areas of couple relationships and couple therapy. The
following vignette from Pickering, who practises psychotherapy in Sydney, Australia, will
illustrate some of the dynamics at work in it.

Box 4.2 Mimi
Mimi, a 35-year-old Chinese woman whose family had emigrated to Australia from Singapore when she
was a child, dragged her rather reluctant suitor, Steven, to psychotherapy saying that she needed to
know what his intentions were as ‘I don’t want to waste any more time flogging a dead horse’
(Pickering, 2008: 136).
Mimi declared if Steven did not propose to her by the end of the hour, it would confirm
her worst fears. In an attempt to get out from under the fairy godmother/matchmaker
projection onto her, the therapist suggested they might all three need more time to find
out what was going on behind the scenes.
In the course of on-going therapy, it emerged that Mimi had a demanding mother and
absent father, who, when he did arrive back from frequent trips abroad, used to shout at
Mimi whenever she dressed up to impress him. Steven was the youngest of three children
of a Lithuanian family, who had suffered with psoriasis as a child. His father could not stand
any sign of weakness and would demand that Steven ‘Get on with it!’ ‘Be a man!’
Mimi experienced Steven’s reluctance to propose as the deflating father she had had.
Steven, for his part, experienced her as the demanding father telling him to ‘Get on with it!’
Neither analysand was aware that they were in the grip of complexes that were being
relived in the ‘here and now’ until these dynamics were lived out in the therapy sessions.
Over time, Mimi and Steven were enabled by the therapist to reflect on complex patterns
of behaviour developed in childhood that had led them to select each other as possible
partners.
4 CASE EXAMPLE
4.1 The analysand

A 59-year-old professional man, whom I shall call John, came into therapy as a result of the
recent complete breakdown of his marriage to a woman, whom I shall call Evelyn. She was
his second wife and younger by 19 years. Both had successful careers in their chosen fields
and they had decided to marry, fairly quickly after their first meeting, because of their strong
feelings for each other and because neither wanted children. John had been previously mar-
ried and had children from that marriage; Evelyn had always wanted a career without the
burden of children so that the marriage had been contracted on that basis.
At their first meeting 15 years before, John and Evelyn fell passionately in love, which
surprised them both as, up to that time, they had each thought of themselves as rational people
who were not ruled by their passions. John was delighted with this new experience and
thought himself fortunate in having at last found his ideal woman – one who not only shared
his intellectual pursuits but who also enjoyed cycling and walking in the countryside. They
bought a weekend cottage where they could indulge these pursuits, which were followed by
interesting conversations over home-cooked meals by John, who was a good cook.

This idyll lasted for several years and came to an abrupt end with the approach of
Evelyn’s fortieth year, when she became aware of an overwhelming urge to have a baby.
John was devastated by this news and ‘tried to reason with her’ but she became increas-
ingly adamant, and he eventually realised she was determined to fulfil her newly awak-
ened maternal desire. He was equally determined not to embark on fatherhood again, and
they eventually reached an impasse that resulted in his moving out of the marital home.
In the months that followed, he began to experience headaches and to have sleepless
nights. When he consulted his general practitioner about these, he was advised to seek
therapy.
By his own account, John’s childhood had been reasonably contented with parents who
cared for him and his younger brother, although there did not seem to be a great deal of
warmth or physical affection between the parents or between them and their children. He
went to boarding school at 13 and then to university where he did well. His first rather hazy
memory was between three and four years old when he was lost by his mother on a shopping
expedition to the town near where they lived. He was taken to the police station from where
he was eventually collected by mother, who did not seem particularly concerned about hav-
ing lost him.
4.2 The therapy

Following the assessment process, John and I agreed on twice-weekly sessions of therapy. He
did not display any visible emotion about starting therapy and seemed, instead, to accept that
he might need it in a rather lukewarm way. Beneath this surface acceptance, I was aware that
there were hostile feelings, which were confirmed by a short dream he brought in the third
session.
I hail a taxi and tell the driver to take me to Halcyon Road. After a bumpy ride, we arrive at a rather
ramshackle house in the middle of nowhere, which the driver tells me is the end of the road. I get out
reluctantly as I am not sure I want to be there but the driver insists she is right and tries to overcharge
me. We have an argument but I am obliged to pay the fare, at which point the driver leaves.
He described the atmosphere in the dream as grey and chilly and he felt lost at the end
with no idea of where he was or why he was there. I reflected back to him that the dream
was an expression of his affective state, which included depression and his negative feel-
ings about therapy, expressed in the dream as being taken for a ride, at the end of which
he was overcharged. This unpromising beginning established the negative feeling tone of
the therapy.
4.2.1 Assessment and formulation of the analysand’s problems

John’s inner emotional life is ‘chilly and grey’, which goes back to the lack of warmth and
affection in childhood, followed by a first marriage which he felt obliged to undertake as
the woman was pregnant. He had been a dutiful, if not loving, husband and father, and the

marriage had eventually unravelled from which he had little in the way of emotional fall-
out. The only time he had come truly alive emotionally was after the meeting with Evelyn
and in their subsequent marriage. This had come to a traumatic end with what he called her
‘betrayal’ of their vow to live only for each other.
The dream expresses his ambivalent view of therapy which, on the one hand, he hopes is
going to return him to the ‘halcyon days’ shared with Evelyn. Instead, he fears he is going to
be let down again and that his investment in therapy will result in his being ‘left in the middle
of nowhere’ at the end of it. I reflected this back to John, which he received in a resigned way
as possibly expressing his feelings combined with the fact that he felt he had no other option
but to continue in it. At the same time, divorce proceedings between him and Evelyn had been
instigated, which were being conducted entirely through their lawyers as John was deter-
mined never to have anything further to do with her.
This bleak situation both within the therapy and in his outer life continued for several
months and was akin to the nigredo stage in the psychological alchemical process. This is the
dark night of the soul when there is no psychic energy available to lift the therapy out of
depression and the analysand may give up and leave. Through the sessions that followed,
John seemed poised to do that as he said there seemed little purpose in remaining in this
deathly state. My only recourse was to be there as a container for his despair, and the undi-
gested rage and resentment that underlay his schizoid depression.

In the course of working with John, I consulted two pieces of writing from other Jungian
analysts. The first was the seminal article on betrayal by the archetypal psychologist, James
Hillman. In this piece, he states there are several sterile choices open to a person who has felt
betrayed. These are revenge (‘an eye for an eye’) (Hillman, 1975: 71); denial (of that person’s
former worth); cynicism (a betrayal of one’s own ideals); self-betrayal (where the alchemical
process is reversed and gold is turned into faeces); paranoia (the paranoid distortion of
human affairs).
All these reactions were part of the transference directed at the therapist by John at differ-
ent times in the therapy, which became nothing but prostitution, i.e. being overcharged for
being left barren and forsaken. In his relationship with Evelyn, John believed he had found
perfection in ‘another who can never let one down’ (ibid.: 65). His bitterness is the result of
being expelled from paradise into the ‘real’ world of human consciousness and responsibility.
For John, this experience, if he does not remain in the sterile choices in which he is currently
caught, has the potential to lead him from being an ‘eternal youth’ to becoming an individual.
One suspects that for Evelyn, it is the opening of the path to adult maturity and womanhood.
For both, the salt of bitterness needs to be transformed to the salt of wisdom personified by
Sophia, the alchemical feminine.

The early stages of working with John led me to the initial incorrect diagnosis of narcis-
sistic personality disorder. At the same time, I became aware that he did not evoke the split

countertransference feelings that are associated with pathological narcissism, for instance, a
desperate reaching out for help on the part of the patient which, if responded to by the
therapist, is immediately followed by a grandiose defence of needing no-one. Nevertheless,
I was convinced I was dealing with a form of narcissism and found enlightenment in the
writing of the Jungian analyst, Edward Edinger.
Edinger views the myth of Narcissus as representing an alienated ego that cannot love
because it is not yet related to itself. ‘Narcissus yearns to unite with himself because he is alien-
ated from his own being’ (Edinger, 1972: 161). The psychological meaning of Narcissus’s fall-
ing in love with his own image is a frustrated state of yearning for a self-possession that does
not yet exist. It is through a descent into the realm of unconsciousness, which entails a symbolic
death that a union of ego with self can occur. As a result of this change of focus in the therapy,
John was made more cognitively aware so that he was able to think more effectively about what
had happened and was enabled to start on the path to self-reflection, which began to open the
way to the flow of psychic energy and a gradual lifting of the former deathly state.
5.1 Developments
5.1.1 Brief therapy
The Jungian approach adapts well to brief psychotherapy as evidenced in an article by Anna
Bravesmith, a Jungian analyst and brief therapist in the NHS. In that, she describes her work
within a GP practice in London over ten sessions with a woman patient called ‘A’, with a
co-morbid presentation of generalised anxiety, panic disorder and depression. Bravesmith
asserts that ‘the unconscious engagement of both patient and therapist needs to be recognized
and utilized in brief therapy’ (Bravesmith, 2010: 277).
The 32-year-old patient had to flee her native Eritrea at the age of 13, which had engendered
such pain and suffering that the patient was afraid to make links from her current symptoms to
these experiences as they could be a threat to her sense of self. The assessment of the patient
and an agreed focus of the work was done in the first two sessions, which was the containment
of current troubling issues as well as the underlying issues relating to the presenting problems.
As the sessions progressed, ‘A’ began to be more open and was able to tell the therapist in
the fifth session about a clitoridectomy and infibulation that had been done on her at the age
of six. ‘A’ was still a virgin as she was afraid to have sex but she had been assured by one of
the doctors at the GP practice that this could be corrected by a further operation. An important
feature identified by the therapist about brief therapy is that it should not be used to strengthen
defences, which might provide temporary relief but would obstruct any possible future long-
term therapy.

Psychoanalysts and psychotherapists functioning within a Jungian orientation are to be found
worldwide, as exemplified by some of the case material already presented in this chapter, and

work with a diverse range of patients and analysands. This section will include material from
an analytical psychologist in Cape Town, as well as one working with sexual diversity in the
United States.
Astrid Berg is a Jungian analyst and child and adolescent psychiatrist at the Red Cross
Children’s Hospital in Cape Town. She has applied Jung’s hero myth, born out of the human
need to become an individual by separating from the parents, in particular the mother, to an
African context. In this way, Jungian theory is taken out of the confines of the consulting
room and related to a cultural complex enacted in the ritual of adolescent males into manhood
that is still widespread in South Africa. Jung’s notion of sacrifice says as follows: ‘The
essence and motive force of the sacrificial drama consists in an unconscious transformation
of energy’ (Jung, 1967: 669).
African mothers are able to give themselves over to the primal union with their child
knowing that, consciously or unconsciously, when the time is right their sons will be sepa-
rated from them and the incest taboo respected. In initiation rites, the sacrifice involves both
mother and son, as she fears for his safety and because it is a separation from physical close-
ness for both. The son has to live out the myth of the hero in sacrificing his foreskin and
exposing himself to danger either of death or permanent injury. The death or morbidity rate
can be high in these initiation rituals and tragedy ensues when it leads to hospitalisation of
the initiate. If all goes well, the son ‘dies’ symbolically and returns to his home transformed
into a man, henceforth to be treated by his mother with the respect due to his new status.
Barry Miller is a Jungian analyst in Los Angeles, who is interested in issues related to the
psychology of desire. ‘The subject of homosexuality often becomes a scapegoat for all our fears
and prejudices, as well as our grandiosities in how we face the very nature of the human psyche’
(Miller, 2010: 114). This is explored in an account of his analysis of a homosexual man whose
compulsive, anonymous sexual rituals overtook his life and filled him with self-loathing. His
previous therapist had advised him to come out as a ‘gay man’ and leave his wife of twenty
years. This was followed by an increase of sexual addiction and the intensification of suffering.
Miller’s view is that analysis should provide a safe place to explore the personal relevance
of sexual behaviour for the individual. In the course of analysis, this patient came to see that
his feelings of loneliness went deeper than any that could be assuaged by love for his wife or
innumerable male lovers. ‘My interpretation is that it is loneliness for his own self, that he is
not alive to himself and desperately seeks a self-re-union’ (ibid.: 119). Unconsciously, the
patient had been trying to fill this loneliness through encounters with an actual penis, instead
of being related to the symbolic phallus that would enable him to grow psychologically and
emotionally. Miller states it is essential for the therapist to ‘hear the story of sexuality … as
if for the first time’ (ibid.: 122) echoing James Hillman’s writing as follows: ‘My interest in
story is as … a way in which the soul finds itself in life’ (Hillman, 1975: 4).

The Jungian analyst and psychiatrist, Jean Knox, has turned to attachment theory and
neuroscience to add more flexibility to the classical Jungian archetypal model in her

development of the concept of individuation. For instance, an attachment-orientated ana-

lyst will accompany the patient on a developmental journey that allows for new experi-
ences to emerge in the analytic relationship. This can be ‘sometimes an attuned affective
response or a countertransference feeling from which an interpretation will be made’
(Knox, 2009: 9).
From neuroscience, Knox has turned to research carried out by the neuroscientist, Allan
Shore, which shows that change in therapy is crucially dependent on the affect regulation that
gradually develops from relational interaction. This ‘creates the conditions necessary for the
neural development in the orbitofrontal cortex and other areas, on which affect regulation
depends’ (ibid.: 10).

A long-standing criticism of Jung’s and Jungian contributions to psychoanalysis and psycho-
therapy is the one made by Donald Winnicott, a member of the British Psycho-Analytical
Society. This was encapsulated in Winnicott’s 1964 critique of Jung’s so-called autobiogra-
phy, Memories, Dreams, Reflections, in which the former asserted that Jung appeared to have
no contact with his own primitive destructive impulses. Winnicott postulated that this led to
the fact that ‘his necessarily aggressive assertion remained unassimilated and concretely
enacted’ (Meredith-Owen, 2011: 39). Winnicott diagnosed Jung’s lifelong obsession with
‘containment’ and, ‘wholeness’ as a flight from destructiveness, chaos, disintegration, and the
other madnesses.
The Jungian analyst, William Meredith-Owen’s elegant response to this criticism is to
agree, in part, with Winnicott. For example, Jung’s ‘attack on the edifice of Freud’s work,
which, of course, he had a significant hand in constructing’ (ibid.: 69). Further, ‘the Jungian
tendency to immersion in the subjective world … may be a defence against psychotic fears’
(ibid.: 69). However, he attributes some of Winnicott’s critique to not recognising that Jung
was his shadow and the fact that they shared much in common. Part of Winnicott’s dismissal
of Jung may also have been due to political pressure at the British Society where he was a
somewhat marginalised figure. ‘Too overt a rapprochement with Jung would have risked
even further isolation’ (ibid.: 71).
5.4. Controversies
The most thought-provoking controversies currently in circulation about Jung’s contribution
to psychology are those made by the Jungian analyst, Wolfgang Giegerich. Whilst remaining
true to many of Jung’s ideas, Giegerich started to emerge from an unconscious identification
with Jung in 1984. From that time, he has looked at Jung’s contributions with a more critical
eye and makes the following points. Jung hypostasised ‘the unconscious’, treating uncon-
sciousness as a positive fact as if it were some kind of author of dreams, visions, myths, ideas.

In the same manner, Jung reified ‘the archetypes’. Furthermore, Jung saw neurosis ultimately
as ‘a sacred disease or religious quest so that psychic illnesses are seen as basically valuable,
noble, even “sacred”’ (Casement, 2011: 541). In addition, Jung insisted that the salvation of
the world consisted in the salvation of the individual soul. As Giegerich states, a psychology
that deserves its name cannot take any positive reality, either the individual or society, as
fundamental.
Giegerich holds Jung responsible for the condition of today’s Jungianism, which he views
‘as the prevailing subjective, fundamentally amateurish, and popular character of the typical
Jungian publication’ (ibid.: 542). He claims they are written in an inflated, phoney spirit in
which use is made of ‘symbols’ and ‘myths’ as well as of words such as ‘the sacred’ and ‘the
numinous’. Giegerich is highly critical of Jung’s recently published Red Book on the follow-
ing grounds: it is Jung’s ‘Answer to Nietzsche’; it is not a great work of art comparable to
Dante’s Divine Comedy or Nietzsche’s Zarathustra; it is the ‘new bible’.
Other controversies that are directed at what may be called Jung’s innatism, in particu-
lar with regard to his theorising about archetypes, appear in the writings of the Jungian
analysts Joe Cambray, Warren Colman, George Hogenson, Jean Knox, and Margaret
Wilkinson.
6 RESEARCH
Research has played an important role in the Jungian approach from the time of Jung’s
research project with the Word Association Test (WAT) in the course of his psychiatric work
at the Burghölzli Hospital in Zürich in the early nineteenth century from 1900 to 1909. Two
recent research projects that have been carried out by Korean and Japanese analytical psy-
chologists are presented below.
The first is a research study done on the influence of complexes on implicit learning.
This was based on Jung’s theory that complexes are the living units in the unconscious
composing the via regia to unconsciousness. This study used a protocol approved by the
Research Ethics Committee of the College of Medicine at Ulsan University, Seoul, and
was carried out by a team of Jungian analysts who were also neuropsychiatrists. The 28
subjects who were to be studied were undergraduates at the Ulsan Medical School. These
subjects had been tested to eliminate any history of traumatic brain injury, epilepsy, alco-
hol or substance abuse, or any neurological problems; 14 of these subjects were randomly
allocated to the complex word group, while the other 14 subjects were allocated to the
non-complex word group.
A Korean version of the Word Association Test, for which the original one hundred test
words were translated into Korean equivalents, were used in the research project. The test
method used in this project included failures of association for a given word such as delays
in reaction time, the repetition or the misunderstanding of stimulus words, laughter and other
emotional responses, and reproductions that were given correctly or distorted. Each of these

reactions were treated as signs of a complex at work. When these reactions occurred, they
counted as one point for that word and the words with the highest number of points were
chosen as ‘complex words’.
The results that were produced by this method showed that implicit learning occurred only
if the stimulus contained a complex word, but it was noted that this did not occur if the stimu-
lus contained a non-complex word. The results of these tests were taken to demonstrate that
this heightened attention and enhanced implicit learning were due to the presence of complex
words. These words were chosen for their disturbing rather than facilitating influence on con-
scious processes. The conclusion was that whenever a complex pulls at a subject’s attention,
the amount of available mental energy for the use of conscious thought diminishes. This men-
tal energy then becomes available for the process of implicit learning in the unconscious.
The conclusion of the study was that the activation of complexes enhanced the attention of
the subjects and made implicit learning possible under poor learning conditions. ‘That com-
plexes known to disturb conscious cognitive processing enhance unconscious processing
suggests that complexes are not just abstractions but real things having an influence on both
consciousness and the unconscious’ (Yong-Wook Shin et al., 2005: 187).
The second piece of research presented here is that of a research team composed of
Japanese Jungian analysts, who studied the efficacy of Jungian psychotherapy in the treat-
ment of pervasive developmental disorders (PDD) and attention deficit hyperactivity disorder
(ADHD). The research team felt it was important that they shared the same Jungian based
attitudes and approaches to treatment of disorder, but a more generalisable approach was
achieved through the inclusion of psychotherapists from other disciplines. The research
methodology focused on psychological phenomena and not on case studies as the aim was to
move from the study of narrative in order to deepen the understanding of a psychological
phenomena towards a conceptual level viz. that of union and separation.
The findings of the research team were that the main common characteristic in PDD and
ADHD seems to be the lack of a subject ‘which manifests itself as the absence of awareness
of otherness and difficulties with boundaries and language’ (Kawai, 2009: 659). A normal
psychotherapy is ineffective in the treatment of severe cases as it presupposes an established
subject. Instead, the members of the team practised a psychotherapeutic approach where the
process of union and separation was enacted either in the therapeutic relationship or in sym-
bolic play. This gradually led to the birth of a subject.
In milder cases, such as ADHD, moments of separation and confrontation with the thera-
pist were sufficiently effective in establishing a subject. In working with these disorders, it
was found that the term ‘subject’ is more appropriate than the terms ‘ego’ or ‘self’ in the
effective treatment of autistic disorders as it is not substantial but relational to the other and
lives in language. Without object and other there is no subject and without language there is
no subject. This means there is no capacity for symbolisation or metaphorical thinking, which
is why an autistic child cannot play with dolls or assign roles to them as dolls cannot sym-
bolise something other.
Even in less serious cases, despite the surface adjustment, the subject is not present and
such patients give the impression of having neurotic symptoms. If the treatment focuses on

those, they turn out to be fake symptoms as the subject is not clearly established and there is
no differentiation from the other. What then occurs is that the patient will follow the therapist
and adjust to his/her attitude and diagnosis.
The theoretical model focused on by the team was that of the later Jung’s study of the
dialectic of separation and union in alchemy. The Jungian analyst, Wolfgang Giegerich, has
pointed out that Jung’s later work began to move away from the substantiating of psychic
phenomena such as ego, often portrayed by a hero figure. The subject cannot be substantiated
in this way and only emerges as a dialectical movement of union and separation. The research
team’s findings were that the therapy used in the treatment of PDD and ADHD compels
therapists to go beyond a developmental point of view and a substantiating view of image
toward a dialectical understanding of image as sublated in union and separation that appears
in Jung’s alchemical work.
7 FURTHER READING
Casement, A. (ed.) (2007) Who Owns Jung? London: Karnac Books Ltd.
Giegerich, W. (2010) The Soul Always Thinks. New Orleans: Spring Journal Books.
Jung, C.G. (2009) The Red Book: Liber Novus. Shamdasani, S. (ed.) New York: W.W. Norton in the Philemon Series
of the Philemon Foundation.
Singer, T. (ed.) (2010) Psyche and the City. New Orleans: Spring Journal Books.
Stein, M. (ed.) (2010) Jungian Psychoanalysis: Working in the Spirit of C.G. Jung. Chicago: Open Court.
8 REFERENCES
Adler, G. (1961) The Living Symbol: A Case Study in the Process of Individuation. New York: Bollingen Foundation.
Astor, J. (1995) Michael Fordham: Innovations in Analytical Psychology. London and New York: Routledge.
Bravesmith, A. (2010) Can we be brief? British Journal of Psychotherapy 26(3): 274–90.
Carvalho, R. (2008) The final challenge: ageing, dying, individuation. Journal of Analytical Psychology 53(1): 1–18.
Casement, A. (2001) Carl Gustav Jung. London: Sage Publications Ltd.
Casement, A. (2010) Interview with Sonu Shamdasani (February 2010). Journal of Analytical Psychology 55(1): 35–49.
Casement, A. (2011) The interiorizing movement of logical life: reflections on Wolfgang Giegerich. Journal of
Analytical Psychology 56(4): 532–49.
Cavalli, A. (2011) On receiving what has gone astray, on finding what has got lost. Journal of Analytical Psychology
56(1): 1–13.
Edinger, E. (1972) Ego and Archetype. Boston and London: Shambala.
Hillman, J. (1975) Betrayal. In Loose Ends. Dallas: Spring Publications Inc.
Jung, C.G. (1925) Marriage as a psychological relationship. In C.G. Jung (1954) The Development of Personality.
Vol. 17. London: Routlege & Kegan Paul.
Jung, C.G. (1954a) The Development of Personality. Vol. 17. London: Routledge & Kegan Paul.
Jung, C.G. (1954b) The Practice of Psychotherapy. Vol. 16. London: Routledge & Kegan Paul.
Jung, C.G. (1958) Psychology and Religion: West and East. London: Routledge & Kegan Paul.

Jung, C.G. (1963) Mysterium Coniunctionis. London: Routledge & Kegan Paul.
Jung, C.G. (1967) Symbols of Transformation. Princeton: Princeton University Press; London: Routledge &
Kegan Paul.
Jung, C.G. (1971) Psychological Types. London: Routledge & Kegan Paul Ltd.
Jung, C.G. (2009) The Red Book: Liber Novus. Shamdasani, S. (ed.) New York: W.W. Norton in the Philemon Series
of the Philemon Foundation.
Kawai, T. (2009) Union and separation in the therapy of pervasive developmental disorders and ADHD. Journal of
Analytical Psychology 54(5): 659–75.
Knox, J. (2009) The analytic relationship: integrating Jungian, attachment theory and developmental perspectives.
British Journal of Psychotherapy 25(1): 5–23.
Meredith-Owen, W. (2011) Winnicott on Jung: destruction, creativity and the unrepressed unconscious. Journal
of Analytical Psychology 56(1): 56–75.
Miller, B. (2010) Expressions of homosexuality and the perspective of analytical psychology. Journal of Analytical
Psychology 55(1): 112–24.
Pickering, J. (2008) Being in Love. East Sussex: Routledge.
Urban, E. (2008) The ‘self’ in analytical psychology: the function of the ‘central archetype’ within Fordham model.
Journal of Analytical Psychology 53(3): 329–50.
Winnicott, D.W. (1964) Memories, Dreams, Reflections by C.G. Jung. International Journal of Psycho-Analysis 45:
450–5.
Yong-Wook S. et al. (2005) The influence of complexes on implicit learning. Journal of Analytical Psychology 50(2):
175–90.

5
Psychodynamic Therapy: The
Kleinian Approach
Julia Segal
Psychoanalysis has provided the basic concepts and understanding underlying psychodynamic
(or psychoanalytical) psychotherapy and counselling. Melanie Klein, a psychoanalyst who
came to London in 1926 from Vienna via Berlin, contributed new, potent insights to the work
begun by Freud. Unlike many others, she never broke with Freud and always maintained that
her work was a development of his. Hugely controversial at first, her ideas have gradually
become more accepted, with Kleinian analysts achieving world recognition. Some conflicts
remain, however, between Kleinians and other psychoanalytical psychotherapists. In this
chapter I use ‘therapist’ to include counsellors and psychoanalysts, except where the distinc-
tion is relevant.
Klein’s ideas were originally developed and described by a group of analysts who gath-
ered around her in London, including Susan Isaacs, Paula Heimann, and Hanna Segal,
Wilfred Bion, Herbert Rosenfeld, Betty Joseph and (later) Elizabeth Spillius; Winnicott was
also influenced by her. Klein’s experience as a mother contributed to her sympathetic insight
into the complexities of relationships between children and their mothers. Encouraged by
her analysts, Ferenczi and Abraham, she was one of the first to take Freud’s work on dream
interpretation and apply it to the play, first, of her son, and then, as she built up a practice
in Berlin, of child patients. Later she used her insights with adult patients too and

encouraged her students to use her techniques successfully with severely disturbed patients.
She and her followers are responsible for the concept of ‘projective identification’, which is
now widely used.
Klein developed a new language with which to talk about ways we think, feel and behave
and about ideas, assumptions and beliefs people hold about themselves and others. Her
work convinced her that, from an early age, small children are active participants in rela-
tionships with their mothers and others around them, having both feelings and awareness;
this challenged beliefs current at the time but has been confirmed since by the work of
neuropsychologists.
Following Freud’s idea that significant feelings can be evoked in a patient by the relation-
ship with the analyst, Kleinians pay great attention to unconscious (as well as conscious)
aspects of this relationship. They are careful to keep the setting – place, time, person and
attitude of the therapist – as firm and unchanging as possible, in order to understand better
the ways patients respond to unavoidable changes and loss. Present-day Kleinians also pay
very close attention to the feelings evoked in the analyst or therapist by the patient/client,
which may sometimes be understood as a form of non-verbal communication (‘projective
identification’: explained in J.C. Segal (1992) and many other Kleinian texts) from the client
to the therapist. It is by understanding the relationship between patient/client and analyst/
therapist in the room (particularly signs of difficulty in the relationship) that the most sig-
nificant changes can be brought about. Clearly, the therapists’ insight into their own function-
ing is of great importance, and all Kleinian trainings insist on therapists having their own
analysis. Kleinian ideas can seem strange to begin with, but bring new possibilities for
understanding and new relief from anxieties.

Klein thought relationships were crucial to development. She found that relations with the
world in general, including not only family and other people but also institutions and the land-
scape, are based on perceptions and understanding developed in relationships with the earliest
caregivers. Understanding develops as the child develops, modified by experience of the self
and the world, but always based on what went before.
The capacity to ‘take in’ new ideas, for example, is based on the experience of ‘taking in’
food, which involves also ‘taking in’ something derived from the emotional states of both the
baby being fed and the person feeding the baby. A baby or child who felt that they always
had something forced into them will have a different view of the world and a different capac-
ity to learn from one who has been expected to take something only if they can swallow and
digest it easily.
As children, we cannot survive without others upon whom we can depend, not only for food
and shelter, but also for the capacity to think and to modify our beliefs to fit our surroundings.

THE KLEINIAN APPROACH 103
Children learn to see themselves as good or bad, dangerous or creative, able to rely on others
to take care of them or afraid to trust themselves or others, depending on their experience of
others and their relationship to themselves. It is important to remember that a child’s experi-
ence is made up not only of actual external events, but also of what the child made of those
events. Klein found, for example, that a disturbed child believed that her mother deliberately
starved her and fed her bad food, although later, under the influence of more secure and loving
feelings, the same child knew that the mother did not do this at all. She also found that children
are basically concerned to keep their parents well and happy.
Crucially, there are ways of relating to the world that include a capacity to recognise real-
ity and ways that attempt to prevent recognition of reality. When reality appears too painful,
there are many ways of obliterating the perception of it. Some of these actually change real-
ity; some disrupt the capacity to see anything; others only change the direction of attention,
for example, by splitting what the person sees. If it is too painful to see the mother paying
attention to a new baby, a child may scream, attracting her attention and so changing reality.
If the pain of seeing is too agonisingly unbearable, the child might actually go temporarily
blind or deaf. A more normal response might be for the child to allow their attention to be
distracted, so they did not have to see the mother’s behaviour, although with another part of
their mind they would know about it. In their mind they might split their mother into a ‘bad
mummy’ who feeds the baby, and a ‘good mummy’ who plays with them; one consequence
of this is that the child also splits him or herself into a ‘good child’ (who loves the good
mother) and ‘bad child’ (who hates the bad mother).
Clearly, which of these responses the child ‘chooses’ (and they may or may not feel they
have a choice) will depend on a multitude of factors. Each will have different consequences
for the present and for the future. The child’s capacity to tolerate certain levels of pain or their
determination to maintain a particular fiction will play a part. A sympathetic adult may help:
‘You eat this now and later the baby will sleep and I can read to you.…’ A mother influenced
by Kleinian ideas might include a sentence acknowledging the child’s feelings (and so help-
ing the ‘good child’ to know about the ‘bad’ one): ‘I know you don’t like me feeding the baby,
but…’ Often adults find children’s grief unbearable and rather than acknowledge it may
ignore it or become angry. The child can then feel ‘alone with their badness’, abandoned or
punished by their parent ‘because they are bad’. In such ways adult methods of constructing
a view of the world can be ‘passed on’ from adults to children.

Psychological health and disturbance are governed by the multitude of daily choices we
make, in how we perceive our own (internal) reality and the world around us.

Kleinians do not think so much in terms of ‘psychological health’ and ‘disturbance’ as in
terms of states of mind, which can come and go. What at one point might be disturbing, at

another time could save a life: ignoring some aspect of reality may help to make a decision;
in the long term, ignoring the same aspect may cause serious relationship problems. Some
psychological disturbance is normal; healthy people can often behave and feel in ‘dis-
turbed’ ways.

At certain times, when afraid for our own life, we see things in a black and white, split
way; we cast blame; guilt can be unbearable; the sense of time disappears in a frantic
‘NOW’. We can feel controlled by events or impulses over which we have no control, and
try desperately to control others. When anxieties are less high, we have more of a sense
of time passing; we are more concerned to save the lives of those we love (including sav-
ing them from our own attacks on them), and we see things in a more nuanced way. Klein
distinguished the ‘paranoid-schizoid position’ and the ‘depressive position’ (see e.g.
Segal, 1973) as different responses to different levels of anxiety. Each has its place in
psychic development and in the maintenance of health or the causation of ill-health. We
need to distinguish good from bad, and splitting helps us do this. We need also to bring
things together at a time when we are calmer – and to bear the pain of our guilt about our
past mistakes.
Kleinians use the concept of unconscious phantasy to talk about the ways people think. It
arose when Freud noticed that the analyst was experienced as behaving as if they were a
figure from the patient’s past. Klein and her colleagues saw it more generally: we take things
in in a way influenced by our own state of mind and then work on them in our minds, asleep
and awake. (A child, angry with a parent who leaves them, may believe the parent was or is
angry with them.) Our perceptions form stories about ourselves and others, both consciously
and unconsciously (angry monsters may appear in dreams). These fantasies (or ‘phantasies’)
then organise our perceptions; what we see and feel as reality (teachers may be seen as angry
monsters – and provoked; Spillius (2001) describes this in more detail (see also J.C. Segal,
1985, 1992).
Our phantasies may be more or less realistic; more or less matching what is truly ‘out
there’, depending on our age when we created them and on our state of mind at the time. We
change them when forced to: when our picture of reality no longer ‘works’. However,
Kleinians think people recognise realistic beliefs and phantasies as being safer and more
comfortable to live with (e.g. in the long-term it is preferable to know you can be ‘bad’, and
have some idea of where this begins and ends, rather than trying to maintain a fiction that
you are always ‘good’). Defences are set up against unrealistic phantasies (e.g. that your
badness means you are a monster) rather than against reality (your badness is sadly ordi-
nary). Unfortunately, very frightening (‘persecutory’) beliefs (you are afraid you are a mon-
ster) can have dangerous, unhealthy consequences for you and those around you.
There are many reasons a child may be angry with their mother: when she says ‘no!’, or
when she pays attention to someone else, making the child feel left out or jealous. In phan-
tasy, the child may attack the mother: either ‘blanking out’ the ‘mother in their head’, per-
haps, or actually running away from or hitting the mother ‘out there’. Whatever the child

does, the phantasy of the mother is affected; the actual mother may or may not be. For a while
the child may feel the mother as vengefully wanting to attack back. Later, when the child no
longer feels so angry, they may suppress all memory of wanting to hurt their mother and only
remember their ‘good mummy’ and good self. They might, however, want to make sure that
their ‘good mummy’ is all right; children (and adults) are not always sure if they have actu-
ally succeeded in hurting people they attacked in their minds.
Anxieties about having damaged a ‘good mummy’ are seen by Kleinians as the basis for
creativity. Early on, the mother makes up most of the baby’s world: ‘mother’ phantasies
might be closer to later perceptions of comfortable (or scary) furniture (a bed, or a large
wardrobe) or soft singing in a cosy room, a ‘vanished world’, than a person who comes and
goes. Anxiety-provoking phantasies can be represented in the external world through sym-
bolism, which can then be ‘reality-tested’ (bouncing on the bed does not destroy the world).
The reassurance may be only temporary and have to be repeated.
The child’s future capacity for work and creativity, for healthy life choices, good relation-
ships, happiness or unhappiness depend on whether the child can hold onto, or regain after
losing, a good relationship with their ‘internal’ or phantasy mother in the face of their own
angry or aggressive or otherwise distressing phantasies. This will depend on many factors:
the child’s situation; their own constitution; their environment; the capacities and support
available to the adults around the child.
Anxiety-provoking phantasies involving parents (e.g. about being loved and cared for, and
being capable of loving and caring) affect choice of lovers, friends and partners, in subtle
ways, affecting what people expect and notice, what they are drawn to, what they instinc-
tively avoid. These relationships can then confirm or change these anxieties. Some anxieties
are too powerful to be changed by ordinary relationships, but may be changed by psycho-
analytical psychotherapy: others may never be reached.
We have some choices about which phantasies we draw upon. For example, we may try to
keep in mind only good-self phantasies, but the ‘bad’ ones may lurk at the back of our minds,
making us unsure of ourselves. Being caught out too often by our own bad behaviour we may
decide that accepting awareness of our badness is a better strategy, even though it brings
guilt. We need to feel safe enough and sufficiently hopeful to do this, and this will depend on
our situation and the reliability of other people around us. On the other hand, if we can
‘mend’ some of the splits in our minds we feel less insecure, we respond differently to those
around, and they respond differently to us.
There are many states of mind that can sometimes be experienced as bearable and some-
times as simply too threatening or ‘persecutory’. For example, a little guilt allows an apol-
ogy; too much may provoke an attack: ‘What do you mean, my fault?!’ A little anxiety may
be a spur to development, too much force a retreat. Anger is a less damaging form of a more
persecutory hatred or fury.
If a mother becomes ill, stirring the child’s fears that their phantasies about damaging her
are true, the child may guiltily try to be ‘very good’, hoping to make her better. However, if
this does not work, and their guilt becomes too persecutory, they may despair and behave
badly, as a way of getting their bad feelings into the outside world. Punishment may then feel
‘right’ to the child, but not address the problem. On the other hand, reducing the child’s guilt

(‘it’s not your fault mummy’s ill; aunty is coming to help’) may enable the child to feel more
hopeful, able to apologise or to actually help – although jealousy of ‘aunty’ may have its own
repercussions.
Kleinians are careful to acknowledge non-persecutory forms of emotions. For example,
although there are paranoid forms of jealousy, jealousy itself is a normal response to a
threat of losing someone you love. Kleinians distinguish both jealousy and admiration
from envy, which is used by Klein (1957) to refer to destructive phantasies directed
towards something because it is perceived as good (normal current usage does not make
these distinctions).
Emotional and mental health then, depends on the level of anxiety we have to cope with,
and how we cope with it. Change happens as a result of changes to our capacity to use our
minds.

We do not know what causes one person to completely obliterate their capacity to see or
think or hear or feel something realistically, while another only modifies or redirects this
capacity. It is fairly clear the level of felt threat will have an influence. Being afraid that
a parent is about to kill you or to die themselves will evoke a different response from
being afraid that they will have another baby. A sense of the capacity to control events, to
make things better, probably plays a part. The presence and/or attention of someone else
(and their state of mind) make a difference. The relationship with parents in the mind at
the time is important. Where significant aspects of the self are ‘cut off’ from awareness
early in life, the effects will be greater than if this happens later, or in a way which is
easier to reverse. And then there is luck; the way things just happen, which a baby or child
or adult then interprets as confirming or disproving their predictions, their worst or their
best phantasies.
Because it is the person’s interpretation of what they perceive that counts, it can be impos-
sible to know what caused what. Is (or was) a threat real? Was there a source of support that
was rejected, or was it not there in the first place? Dreams and events leave very similar
traces in our minds.

As well as anxiety-inducing events, pressures from our culture, from family and from our
own world-view encourage or allow awareness of certain aspects of reality, and discourage
or prevent others in the long term. Many people function with very unrealistic views of the
world; whether or not these disturb anyone, themselves included, will depend on their cir-
cumstances (there are many different, contradictory, religious beliefs, all of which must
‘work’ in some sense most of the time).


The level of sensitivity to pain, both physical and mental, plays a large part in maintaining
any particular world-view, since changing any view of the world may involve some kind of
emotional pain.
The role of ‘internal objects’ – ‘parents in the head’ – is also important; parents (and other
significant people) long dead but alive in the imagination, can affect the choices people make.
‘Parents-in-the-head’ are made up not only of actual, historical parents, but also include ele-
ments from other parental figures and also, importantly, aspects of the self attributed to them
(see J.C. Segal, 1992: 40–4).

Other people play an important part in perpetuating or challenging our way of being. Both as
historical figures from our past and active figures in the present, they can help us to bear our
anxieties, to recognise them and bring reality to bear in a way which reduces them. However,
other people can also add to pressures to reject awareness of our own internal (and external)
reality. They can also contribute their own difficulties. People who see the world in very
disturbing or disruptive ways (badly-behaved children at school; murderers) can have a pow-
erful effect on the minds of others.

Societies, like individuals, can encourage or discourage certain ways of seeing the world.
Under war conditions people tend to think and behave quite differently from the ways
they react in peacetime. If there is a ‘blame culture’ at work, people are more likely to
feel they have to watch their backs. However, individual ‘internal worlds’, built up
through a lifetime of relating to others, provide resources to deal with these pressures in
different ways.
2.5 Change
In general, in order to escape phantasies that are damaging our lives we need to find a new
way of looking at the world. Recognising that going on as we are is not an option can result
from a change in the external world or the internal one. This often requires the capacity to
bear thoughts that have been unthinkable. If the pain is too agonising, even more damaging
methods may be used to get rid of it.
Many life changes can evoke old anxieties and old phantasies as well as new ones. Over a
period of time – at least two years for many significant losses – these can be worked through,
producing a new set of ‘normal’ phantasies fit the changed situation. It is by working through
such anxieties that new possibilities for living can be created.
The mental companionship of the right person can make the difference between whether
a phantasy and its associated anxiety can be thought about, dreamt about and modified, or

only re-experienced or recreated in someone else (see H. Segal, 1981, 1986: Chapter 7). Left
to ourselves we do not find it easy to challenge unrealistic states of mind, however much
trouble they are causing. The capacity to accept help from another person can enable us to
make a change that makes life better, rather than worse.
3 PRACTICE

The aim of psychoanalytical therapies is to help clients develop a greater capacity to
think, to bear anxiety and psychic pain, particularly the pain of loss. This enables anxie-
ties to be brought into consciousness, tested against reality and, as a result, reduced; at the
same time the way the client sees themselves and those around them changes. In particu-
lar, patients may be expected to become better able to hold onto goodness, observed in the
self or in others.
Psychoanalytical psychotherapists in general resist symptom-based ‘goals’, which can
interfere with the work of understanding. Instead, they offer to explore, bit by bit, the
concerns both conscious and unconscious, brought to them by the client. The therapist
tries to discover and understand the way the client sees the world, the ways they distort
or confuse their perception: their anxieties, their hopes, their fears; the ways they make
their own lives more difficult; how they seek and find pleasure; and the ways they relate
to others – any of which may be far from obvious at first. If specific goals had to be
defined, these might have to be changed on a day-to-day basis as more unconscious mate-
rial is brought to light. It may be only after a long time in therapy that very significant
issues are revealed. Goals set at the beginning may at this point be seen to be unrealistic,
the client feel cheated and the therapist guilty. Some problems are only revealed after they
have gone (e.g. a client once told me that our work had enabled her to stop smoking before
she told me she smoked).
Often people arrive in therapy with many ideas about why they are coming. They may
have had an unsatisfying work history or a series of unsatisfactory relationships (or none at
all). They may have illnesses that doctors cannot diagnose, or which are thought to be
affected by psychological factors. They may suffer from states of mind and/or behaviour
that they do not understand but feel taken over by and compelled to repeat. They may have
had some kind of collapse: a depressive or manic breakdown. Sometimes the overt goal is
simply to ‘have therapy’ so that they can become better therapists or counsellors themselves.
A child may be sent to therapy because their parents are worried about them: the child may
or may not be troubled about themselves. A client’s goals may change as the therapy pro-
gresses and both client and therapist develop a greater understanding of the potential and
limits of their work together.
People sometimes choose psychoanalysis or psychoanalytic therapy if they have a sense
that they do not feel ‘right’ without being able to pin this down; or if they just want to

understand themselves (and others) in more depth. Unconscious goals also play a signifi-
cant part for clients. It may only be in therapy, with a growing awareness that something
can be done about it, that someone who came into therapy ‘for their work’ can admit that
some aspect of their lives could actually be changed for the better.
Psychoanalytical therapists know from experience that some clients come not only wanting
to be helped, but at the same time, perhaps quite unconsciously, finding it difficult to tolerate
being helped and even wanting to ‘prove’ that they cannot be helped. Touching painful areas
is difficult, however much improvement is hoped for. There are many reasons why someone
might, consciously or unconsciously, refuse a therapist’s offer of exploration. Because of this,
the contract with a therapist cannot include an obligation to make an improvement that a cli-
ent could prevent. There is also a strong belief that the client has the responsibility for the
work as much as the therapist; that if a therapist takes too much responsibility, the client may
simply ‘hand over’, making the task impossible.
Psychoanalytic therapy aims to open up the mind where previously it was closed down: to
reduce the number of ‘no-go’ areas by reducing the fears about what might be lurking in the
hidden recesses of the psyche. Generally, psychodynamic therapies work to modify the uncon-
scious beliefs and anxieties that prevent people from using their minds and their resources and
from living their lives in the best way available to them. By offering understanding, psycho-
analytic psychotherapists aim to increase a more long-term sense of being ‘contained’ or held
securely. This helps people to allow themselves to become more realistic; more in touch with
the reality of their own impulses and conflicts, and more aware of others too.

A client’s capacity for and interest in engaging with the therapist is the most important selec-
tion criterion: the therapist too has to feel they can work with this particular client. There
needs to be some curiosity about the self and a desire and capacity to tolerate some of the
painful feelings that may emerge.

Very few people would be considered unsuitable for all Kleinian therapists, but many thera-
pists choose to work with a particular subset of the population. I work as a counsellor with
people who have functioned well previously but are concerned about a physical illness.
Others specialise in work with people who have serious personality problems, are ‘border-
line’ or depressed. The setting is important. For example, someone who has a history of
violence would not be a suitable client for a therapist working alone at home.

In a consultation the therapist would explore with the client why they have come and what
they want from the work. During this process the therapist would normally make some

kind of intervention of the kind they make in their work. How the client responds to this
intervention would give the therapist information about the possibility of working
together.
If work with a couple was on offer, therapist and client would decide together early on
whether the client was best seen on their own or with a partner. Different issues can be dealt
with in each setting, and some judgement would be made about which were most pressing.
If a partner is to be invited in, the therapist would take into account the potential for the
complex feelings which arise in three-way relationships.

Effective Kleinian therapists have the capacity to make clients feel understood and more
secure, though there may be periods when it seems as if client and therapist have very
different views about what is going on. A sense of warmth and wisdom can be combined
with a certain kind of formality: Kleinian therapists are engaged in a serious piece of
work; they are not friends and do not pretend to be. However, some are more informal
than others.
There may be periods when the client is angry with their therapist, or when the therapist is
angry with the client, or has other powerful feelings towards them, or ‘goes blank’: these may
be a sign of the client’s problems or the therapist’s. The therapist should have the capacity to
become consciously aware of his or her own reactions and of pressures to act in ways famil-
iar to the client. Therapists have to make complex decisions about how to handle their own
emotional reactions in order to help the client to understand something important about
themselves.
Therapists working with clients who have difficult mental health issues have to be able to
tolerate a high level of attacks on themselves as well as on their work. They must not retaliate
and must retain, or better, be able to regain afterwards, the capacity to observe, notice and
think creatively about their own functioning – including their mistakes – as well as their
clients’.
A therapist has to work through his or her own feelings and phantasies about the issues
clients bring them. Experiencing a similar problem may or may not be helpful; the therapist
has to recognise that their own experience is likely to be similar in some ways but very dif-
ferent in others from that of their clients.
If a client functions in a way that happens to resonate with the therapist’s vulnerabilities,
the therapist’s own issues can be evoked. The therapist needs to be in a position (and of a
mindset) that enables them to take this to their supervisor or their personal therapist. There is
always a risk that the therapist will not notice they are either being drawn into a client’s illu-
sory world, or are being unduly influenced by something from their own past. This is why
Kleinian psychoanalytic trainings ask for a personal analysis with a training analyst and
ongoing supervision.


Skill is involved in understanding the unconscious communication contained in speech and
behaviour in the consulting room. A good awareness of what is going on for the client and
what they are ready to understand is necessary to enable clients to feel their anxieties are
‘contained’. There is also skill in judging what level of formality or informality is appropriate
for each particular client and how firmly different boundaries have to be held.

The relationship sought is one of collaboration in a joint endeavour with the client as the
focus. Some aspects of therapeutic style depend on the individual therapist and individual
client, others less so. Since clients relate to the place and to time as well as to the therapist,
the setting is a vital part of this relationship.
The aim is to provide the client a reliable, trustworthy experience with a therapist who
gives them mental and emotional space. This may be quite different from other relation-
ships they have had in the past, and it can be transforming. Firm boundaries help client
and therapist feel safe and allow more powerful anxieties to surface. For example, a cli-
ent may choose to bring up an important, disturbing issue just before they leave.
Knowing the therapist will not extend the session can allow the client to trust that they
can ‘drop it and run’.
Everything a client brings can be understood by the therapist as part of the client’s contri-
bution to the joint work. What the client wears, how they walk into the room, where and how
they choose to sit or lie, as well as their choice of topics and the words they use are all con-
sidered part of the information about the client and their internal world which the therapist is
being invited to understand. The therapist expects to share their understanding with the client,
and by the client’s response, to modify or to clarify it and develop further, deeper, under-
standing. In line with a general avoidance of self-disclosure, Kleinians do not generally tell
a client how the client makes them feel.
Kleinian boundary settings matter most where the therapist works with clients who have
serious mental health problems and are therefore most likely to misunderstand and distort the
intentions of the therapist. However, deep disturbances are not always evident at first, and
people in the most disturbed states of mind may appear the most ‘healthy’ or seductive as
they apply the greatest pressure to break the therapist’s boundaries.

Kleinians place emphasis on the setting in which therapy takes place and on the meaning
every aspect of the setting has for the patient or client. The furniture and decorations of
the room, kept constant if possible, should not get in the way of the client thinking about
themselves and freely associating. The therapist’s appearance and manner should be

consistent and unobtrusive. Times and dates of sessions are clear and held in the thera-
pist’s mind, so that breaks are foreseen and discussed in advance. Appointments can be
changed, but the therapist thinks about the unconscious meaning of such changes (as
well as the conscious ones) and may discuss this within the therapy. Signs of the thera-
pist’s life outside the session are kept to a minimum, leaving the client’s imagination as
much freedom as possible.
Psychodynamic psychotherapists sometimes use the couch. Some clients find lying
down too threatening; some may be unable even to sit until their anxieties settle. A couch
allows client and therapist to keep their faces from one another, which has several advan-
tages. For example, the client may bring something which actually arouses disgust in the
therapist, or which is very seductive or horrifying. It is hard to avoid betraying certain
feelings; it is also hard to convince a client that they have not seen a certain expression on
the therapist’s face, even if the therapist is quite sure it cannot have been there.
Some therapists use humour with some clients; others less so. Some are more formal; oth-
ers less. Therapeutic style also depends on the client’s mode of relating, for example, whether
the therapist thinks humour would be likely to be misunderstood. Because Kleinians are
highly aware of unconscious phantasies and of the importance of symbolism, they never
touch clients, except (perhaps) to shake hands. Experience suggests that some clients can
misinterpret the intentions of any physical contact and may (secretly) see it as an invitation
to a sexual relationship. Strangely, in spite of the relative formality of analysts and psycho-
therapists, at its best the psychoanalytic and psychodynamic psychotherapy relationship has
the capacity to touch some of the client’s deepest anxieties and to evoke deep gratitude and
lasting comfort. Someone who replaces shifting sands with bedrock can gain a particular
place in a client’s heart.
Similarly, Kleinian settings are generally kept clear of anything that might show the client
something about the therapist’s personal or family life. If clients ask about it, the therapist
would generally explore the anxieties behind the question, rather than reply in a ‘social’
fashion. Clients can find this annoying, but answers can block the client’s imagination, as
well as lead to further questions and a shift of focus from client to therapist.

3.5.1 Assessment
Assessment of the client’s issues, concerns and difficulties is carried out during assessment
of the appropriateness of the therapy for the client. The client is invited to talk about them-
selves and what has brought them to therapy, and the therapist listens to what they choose to
say. The general invitation, to ‘tell me why you are here’, allows the client the greatest free-
dom to select from their lives the issues they think concern them the most. Looking back
many months later, the therapist may realise the client brought very significant information,
which neither understood at the time.
In some settings the therapist directs the consultation more. For example, a client attending
a specialist counselling service for people with their illness, who speaks only of problems

with their husband, presents their therapist with a dilemma. Is the client in the right place, or
do they need to be referred to an organisation that focuses on marital relationships? The
therapist would have to point the client’s attention towards the illness – and its exclusion so
far from the conversation – in order to find out.
People can feel invaded and imposed upon by questions, while an observation may give
them more space to open up at their own pace. However, in some assessments, questions are
unavoidable. The therapist will be looking at ways the client responds to being offered a
thought or an idea: at how suspicious the client is, or how open they appear; how much they
seem to be hiding, how much anxiety is present and, particularly, how much interest in work-
ing with the therapist in this particular way.
Assessment will usually include some exploration of the client’s past experiences: those
that have brought the client to the therapist. Family background often comes to the fore.
Obvious omissions may also be noted and discussed. However, the amount of attention paid
to family background will depend on the kind of problem the client brings. Some organisa-
tions expect clients to provide a lot of information in written form before attending their first
session, and clients may find the exercise itself helpful.

Whether a formal assessment and case formulation is carried out will depend, again, on the
setting. In a forensic setting a formal assessment will ensure that significant and potentially
dangerous aspects of the case are not overlooked. In all settings the therapist may begin to
make some hypotheses about the client and their problems, which will develop over time.
Typically, a case formulation will include the client’s presenting concerns and the thera-
pist’s first estimate of sources of difficulty. Signs of responsiveness to, or rejection of, what
the therapist offers would be noted, as will signs of possible future difficulties, such as sug-
gestions that a client might blank out certain areas of concern (by going to sleep, or becoming
confused). Attendance, in particular arriving early or late or missing sessions would normally
be considered significant information about the client’s attitude towards therapy, to be
explored with the client and probably included in the case formulation.

Klein described spending weeks trying to engage the attention of a very anxious child ‘Ruth’,
who refused to stay in the room without her sister (Klein, 1932: 26). Eventually, in despera-
tion, she began using the toys in the room to show how she understood Ruth’s anxiety. The
child responded for the first time, and the analysis was able to begin. As a result, Klein’s
followers avoid ‘small talk’, getting down to work from the beginning. Although this can be
a bit disconcerting at first for clients, it has the advantage of establishing a setting that permits
disclosure of feelings and thoughts unmentionable in normal social situations. It also makes
maximum use of the time available.

Kleinians try to keep their observations as close as possible to the client’s anxieties, in the
room, at the time, while linking them with current or past external concerns. They watch for
disguised communication and pay attention to the reasons for the disguise, as well as to what
is being disguised and how aware the client is of the client’s own state of mind.
Interpreting the transference is central to the work of Kleinian psychoanalytic psycho-
therapists (who normally use the word ‘patient’ rather than ‘client’). By sharing their under-
standing of how the patient is relating to the therapist (at unconscious levels rather than just
consciously), the therapist tries to bring to the patient’s consciousness important anxieties
and unconscious phantasies which govern the patient’s relations with themselves, with other
people and with the world in general. Once conscious, these can be tested against reality and
can change.
Kleinians are particularly watchful for negative feelings the client may be experiencing,
perhaps unconsciously, towards the therapist (‘negative transference’), not only because
these bring vital information about areas of significant difficulty, but also because they can
threaten the continuation of the therapy. Positive transference can sometimes also be a prob-
lem, for example, if it involves idealisation. Klein showed that idealisation is a defence
against persecutory anxieties, not reality, so if therapists feel they are being idealised by a
client they might look for signs of more hidden persecutory anxieties. A certain amount of
positive transference facilitates the work; too much may hinder exploration of less positive
aspects of the patient’s life and feelings.
Counsellors influenced by Klein may use transference interpretations more seldom, work-
ing more directly with the client’s conscious concerns. Working with couples, however,
where a relationship is the focus, feelings and thoughts evoked in the therapist are a particu-
larly potent source of information about possible feelings and thoughts evoked in partners by
each other.
Kleinians have always been amongst the most strict practitioners in terms of insisting that
any information passed to the therapist by other professionals or by relatives would normally
be shared with the client, and nothing goes on behind their back.

The most central therapeutic technique amongst Kleinian therapists is the use of free asso-
ciation. Freud discovered that the quickest way to uncover significant conflicts or anxieties
in clients was to let them talk, unfettered: just to ‘say what is in your mind’. Encouragement
or praise, advice or instructions, or any other kind of help or service can all interfere with or
block a client’s free association (e.g. to contrary feelings).
Many people find it hard to be on the receiving end of assistance: they may be angry with
those who give them what they want, including understanding; they can easily interpret their
therapist’s observations as put-downs, as a triumph of the ‘knowing therapist’ over the ‘igno-
rant client’. There is considerable skill involved in dealing with these issues when or if they
arise. Klein was said to have a ‘gift for equality’; her patients did not feel she was superior
to them, but felt that she shared their distress acutely without being incapacitated by it.
Kleinian therapists have to help clients to see things that upset them, or which cause them

shame or guilt: a kind of clear-eyed empathy can be vitally important in making the process
bearable. In a similar way, Klein’s theories about development do not generally make moth-
ers feel blamed, or that they cannot possibly live up to an ideal. Kleinians are always aware
of the fact that we make choices, but also that we can be struggling against enormously
powerful forces, which push us in directions we would rather avoid.
Since partings, loss and abandonment are often significant issues for clients, endings as
well as breaks in a series of appointments tend to have greater meaning at an unconscious
level than clients are at first aware. Although it may take a long time for a client to admit that
they have feelings about the therapist being away or about stopping therapy, Kleinians bring
this to their attention and help them think about it.

As a client begins to feel understood, some of their unconscious phantasies change. Feeling
sufficiently safe with their therapist they can explore thoughts and feelings that previously
they had to keep hidden from themselves, from lovers or friends. As these are explored, they
are compared with reality. Clients may find themselves laughing (or crying) at unrealistic
thoughts they realise they had carried around with them for a long time. Phantasies about
strength and weakness, about what parents did or did not do, about what the self has or has
not done; all may gradually emerge into the open. In therapy something is examined and then
put away again, changed. Aspects of the self, which previously had to be kept hidden, can
now be brought into play and become a source of support in themselves. For example, where
previously all anger or all jealousy had to be kept out of awareness for fear of a terrifyingly
earth-shattering reaction, a more normal anger or jealousy may become available for use in
appropriate circumstances.
In psychoanalytical psychotherapy in particular, the relationship with the therapist becomes
a focus. For example, gradually patients become aware of the significance of the therapy to
them, and the ways they react to the therapist’s absence. As the anxieties that held them in
place are reduced by the therapist’s understanding, these reactions can change.
Gradually the client becomes more able to tolerate knowing about parts of themselves
which previously they did not want to know, or which they split off and saw (or evoked) in
others instead. Gradually the therapist helps the client to become more confident in allowing
themselves to feel all their feelings, not just certain ‘permissible’ ones, to think all their
thoughts, not have to shut their minds to some of them. With their new understanding, the
client finds new ways of handling difficult situations, which do not involve ‘shutting their
eyes and hoping for the best’.
As the client’s view of themselves and the world changes, their relationships change.
Friends, relatives or colleagues who previously were not allowed to contribute much,
perhaps were crushed or ignored, may begin to contribute more to the client’s well-being.
As the client feels less persecuted by people or things in their inner world they behave and
feel more kindly in the external world, and this brings rewards. Their internal world
gradually changes and becomes more robust. Feelings about parents become more whole,

less split, with less anxiety, less idealisation and a more realistic estimate of guilt and
responsibility. Klein found that sometimes a client could not bear the therapist to have the
satisfaction of helping. Envy of the therapist’s good work turned it bad in their minds
(Klein, 1957). Therapists today would be quicker to notice this if it was a problem, and to
work with it. Rosenfeld (1987) described the opposite problem: therapists insufficiently
aware of their own failures of understanding who attributed their client’s (justified and
realistic) objections to envy.
Lack of progress may reflect an ongoing enormously high level of anxiety, which cannot
be addressed within the resources available: with this therapist, or within their way of work-
ing. A client who is too afraid of breaking down or becoming violent, for example, may
prefer to stop attending therapy, or may feel it is safe to see the therapist just enough to allow
themselves to maintain their current mode of operation. Offering more appointments in the
week may help, so that the client is not left to hold their anxieties for so long between ses-
sions. The role of the supervisor of the therapist is important, particularly if there is a lack of
progress in the therapy.
4 CASE EXAMPLE
The following case study is written by a Kleinian psychoanalytical psychotherapist. For con-
fidentiality reasons she remains anonymous and some details of the client have been changed.
4.1 The client

Mrs V was a 57-year-old Asian woman living on her own who had become depressed, unable
to work, and stuck in a very negative state of mind. She could not understand why she was
unable to manage the demands of working life and saw the worst in everything. She had had
a hard life, with her marriage breaking down and her grown up children failing to settle sat-
isfactorily into their lives as adults. However, she had also worked hard and had some success
professionally. Short and overweight, she looked impoverished and invited pity but, as she
talked, she revealed a more articulate competency.
4.2 The therapy

In her initial assessment Mrs V became very distressed when thinking of her mother’s
untimely death 30 years ago when she, Mrs V, was pregnant with her first child. On the sur-
face, it looked as if a failure to mourn the loss of her mother was crippling Mrs V’s current
life. However, this very ‘alive’ expression of grief was understood as also reflecting her cur-
rent predicament. Mrs V did not feel she had the inner resources to manage something
unbearable, which was swamping her from within. Mrs V said she did not want long-term

therapy as she had a trip to her country of origin booked which would take her away for an
extended period of time. She was offered weekly sessions for six months.

In our sessions I could see Mrs V behaving in ways that contradicted her conscious inten-
tion. She was very grateful for the therapy, she said, and did not ever disagree with anything
I said, yet she often came a bit late or talked in a way that seemed to create a distance
between us. She was outwardly ‘going along with me’ whilst I felt she was also fairly con-
sistently opposed to any forward movement or development in the therapy. The initial com-
munication of having poor resources seemed connected to a way she saw me as the one who
possessed all the good things. I thought she was projecting this better-resourced aspect of
herself onto me.
I started to notice more hidden and deeply felt anxiety that Mrs V brought to her sessions
indirectly. Mrs V said she was pleased, even relieved, to be in therapy for so short a period.
But as she became less frightened of therapy with me, she expressed her distress about having
to end the therapy much too soon. What had at first looked like great relief had become,
‘What is the point in opening myself to someone who is going to desert me before I have had
enough time?’
As the therapy progressed this linked with Mrs V’s early life. Not only had she lost her
mother just when she needed her, but in childhood she had suffered several other trau-
matic events, including the death of a little sister, for which she felt blamed. Some years
later her parents left her in her country of birth with an unfamiliar aunt and uncle while
they came to the UK. Though she had never thought of it like this, with my input, she
realised that she had crippling feelings of guilt about both these events and had actually
become depressed as a small child. She realised that she grew up into someone who never
really found a voice of her own. She said she was always the one in the family who
remained quietly in corners, not saying much, let alone rebelling or demanding much for
herself. She barely even had a thought of her own in those times, yet she was quite bright
and capable at school.
She did remember though, feeling determined to choose her own husband. Unfortunately,
in contrast to the Asian movies she passionately watched and believed in throughout her
adolescence, her own love-match had no fairy-tale ending but led instead to an unhappy
marriage. She now felt her one attempt to speak up for herself had left her simply carrying
a further burden of guilt and shame: ‘Look what happens when you take charge of your
own life!’ Though she had children and had been fairly successful at work, she did not
really find these aspects of her life meaningful or satisfying enough to compensate for a
deep sense of inner guilt and failure. There were many reasons why she could rationally
continue to see herself as a failure, and thereby justify her misery and dissatisfaction with
life. For example, her eldest son had left home and invested in a business that failed. He
had also accrued large gambling debts. She felt she had no choice but to give him a large
amount of her money to bail him out of trouble, even though she also suspected that this
was not really helping him. It seemed almost as if she welcomed this depleting situation

as if to satisfy a deep underlying feeling that she should be punished all her life for some-
thing that she felt was her fault.
Additionally, everyone around her (including me, in her view) seemed to have so much
more than she did. Although she meant financially, she came to recognise a way she felt
emotionally bankrupt. Why couldn’t she really enjoy life? Why could she not go out with
her friends and ‘let go’ once in a while? I could see very real ways Mrs V was struggling to
come to terms with herself and the demands of life. Mrs V began to seem almost envious of
herself for having access to therapy which seemed to be helping her come alive again. At
the same time some underlying envy and jealousy of her therapist being in a position to
understand her, made her pull away from help. Such feelings made her feel even more guilty
about herself, less deserving; and the vicious cycle of depleting inner resources took hold
ever more virulently.
The collapse that had brought her to therapy was starting to seem now like an important
means of finally getting the help she needed. She felt like a little girl who had been aban-
doned to her own extremely limited resources, without any parent to look out for her and
notice how her struggles were in vain. She felt ashamed that she needed help at her age. At
a deeper level she felt very angry with her parents. This underlying rage and lack of forgive-
ness towards them first became clear to her as she realised she was locked into a similar kind
of battle with her therapist. The crime they/I committed was ‘abandoning her before she was
ready to let go’.
This insight, meaningful and liberating for Mrs V, came about not as an intellectual exer-
cise, but as something played out in the relationship between her and her therapist. After she
recognised this, Mrs V was able to reach a different perspective on herself and others and to
feel more forgiving towards herself and her parents. She also became less addicted to the
fairy-tale version of how life should go, which had always made the more ordinary realities
of everyday life and ageing seem inadequate and unbearably disappointing.
It transpired that she had felt very guilty towards her eldest son. She had found it dif-
ficult to mourn the loss of her mother when her son was born, mainly because she had felt
she lost her much earlier, when, first, her mother cut off from her as a result of the death
of her sister, then, secondly, her mother left for the UK, and thirdly, Mrs V herself cut off
from her mother when she became depressed as a child. All of this left her with many
complicated feelings which made her feel she had not been able to care adequately for her
son emotionally when he was an infant. Shame and guilt about this made her feel she had
to give everything away to him and keep nothing for herself. Therapy enabled her to stand
up to something destructive in her son whilst continuing to love and support him in more
productive ways.

Regular weekly appointments in a constant, reliable setting built up a therapeutic alliance. I
focused on the client and her concerns and encouraged her to ‘free associate’: to say whatever
was in her mind. From what she had said (or not said) I focused on the anxieties which

seemed uppermost in her mind and any issues about our relationship which seemed impor-
tant, as played out in the transference. What she did was as important as what she said,
because it was through her actions that she showed us aspects of herself that she could not
voice.
From an initial sense that she had no voice, through free associating to an actively listening
therapist, Mrs V became gradually more aware of what she wanted to say, first to me, then to
her parents, about abandoning her before she was ready to be left. Being able to rely on
someone who accepted her feelings and was not too disturbed or frightened by them, she
became more able to accept them herself and to recognise aspects of herself (desires, anxie-
ties, feelings) that had previously been hidden.

At the end of six months therapy Mrs V showed considerable changes. In relation to her
therapist she was able to be more direct. She started to come to all her sessions on time,
as if she felt less under the sway of an underlying grievance about not needing, getting or
wanting enough. She could acknowledge that six months’ therapy was far from enough
and that she needed to earn some money to pay for more. Feeling less ashamed of needing
help she was also able to enlist the support of her ex-husband to confront the gambling
problem of her son.
Something came alive inside her that seemed connected to her needs and longings as a
sexual woman. She started to pay more attention to her physical appearance. She began to
want more in her life for herself: female friends, and a romantic involvement with a male
friend. She lost weight, looking more attractive and healthier, and spent a bit of money on her
hair and clothes. She retrained in an area that built on skills she already had and found a job
as a support worker for young people. At the time of follow-up, three months after her ther-
apy ended, she felt that although she had to struggle with low days, she did not feel so immo-
bilised by depression. She was also earning money again and recognised the very real option
to seek further therapy privately.
5.1 Developments
Over the past sixty years a group of Kleinian analysts have been developing Kleinian theory
and practice. Working together they have deepened understanding of various complex topics.
Hanna Segal developed ideas about symbolic equations versus symbolic representations.
Herbert Rosenfeld wrote particularly about psychotic states. Ronald Britton, John Steiner and
others took further ideas about the Oedipus complex, the ‘death drive’ and aggression, includ-
ing examining the role of the ‘third position’: the onlooker; ‘analyst-centred’ versus ‘patient-
centred’ interpretations, about ‘psychic retreats’; grievance and shame. These writings and

others about technique are mainly addressed to psychoanalysts and psychotherapists and deal
with topics of interest to colleagues rather than the general public.
Kleinians have also always written for a more general audience (for example, Klein, 1959;
J.C. Segal (1985); Waddell (1998); and the Tavistock series on Understanding Your Child).
Another strand of development has been the work of analysts opposed to war (H. Segal,
1997) and engaging with climate change (Weintrobe, 2012).
5.1.1 Brief therapy

When Klein died in 1960 few analysts practised weekly or brief psychotherapy. Kleinians
remained the most insistent on the value of a strict setting and frequent sessions for dealing
with the most difficult anxieties, perhaps because they were working with very disturbed
clients. By the beginning of the millennium, however, many psychoanalytical psychothera-
pists and psychoanalysts, including Kleinians both in the UK and elsewhere, saw clients
once, twice or three times a week. In some countries this was called psychoanalysis, although
not in the UK. There were also many counsellors who acknowledged and used the ideas of
Melanie Klein.
For some clients, significant changes can take place in a few sessions. However, it takes
time to really understand a client’s inner world, particularly the most disturbing aspects. Brief
therapy usually means weekly therapy sessions; which means that the client has to carry
therapy-related anxieties over six days rather than a maximum of two or three. The therapist
has to bear this in mind when responding to what the client brings: the client may also be
reluctant to raise some very distressing issues. Awareness of the time available and the mean-
ing of this for the client and the therapy are incorporated into the work from the beginning.
Ending a relationship in a sense always involves a recapitulation of previous endings, which
may have been painful or troublesome, leaving persecutory anxieties. However, by working
with the ending from the beginning, the therapist may have an opportunity to reduce some of
these anxieties.
Long-term psychoanalysis and psychodynamic psychotherapy may still bring the most
benefits: not only to clients, but also to their families and to those around them.

Kleinians work with people of all ages, (including elderly people: see Terry, 2008), from all
over the world, from all kinds of cultural backgrounds, all kinds of sexual and religious ori-
entation and all kinds of mental condition.
Undertaking therapy with people who have certain problems, such as physical illnesses
or disabilities, cognitive problems or speech difficulties, a therapist will often come under
pressure to ‘do things’ for a client, (such as contacting a social worker, or helping them with
their coat). Even in these situations, Kleinians do their best to maintain the setting: trying to
understand and to convey and share their understanding, and to resist attempts to make them
do other things instead. Modifications to the setting or therapy may be necessary, but there
is an added reason for resisting, in that disabilities and illnesses often mean a painful loss of

‘normality’ even where it is not necessary, perhaps because an onlooker cannot bear some
discomfort. Where I have found myself doing something for a client because of their disa-
bilities, the fact that I have ‘broken a rule’ has alerted me to an issue that, on close consid-
eration, was significant in understanding the clients’ real problems. It would probably have
been better to have felt the pressure to act and to have engaged with the client about this
instead of, or before, doing so.

Kleinian psychodynamic work involves a considerable investment of time and resources, by
both therapist and client. Few other professionals offer 50-minute sessions as standard. There
have been many creative attempts to use the insights of Klein in other settings to overcome
some of the limitations this causes. Relationship therapy uses Kleinian understanding with a
focus on the couple relationship. Consultation and staff groups within medical settings and
prisons enable psychoanalytical ideas to benefit staff and those they work with (see Menzies-
Lyth, 1988 and Obholzer and Zagier Roberts, 1994). My book, Phantasy in Everyday Life
(J.C. Segal, 1985) was an attempt to bring Kleinian understanding to a wider audience.

In the 1940s a series of discussions in the London Institute of Psychoanalysis (King and
Steiner, 1992) brought out some criticisms of Klein and her followers by Anna Freud and
hers, in particular that Klein’s view of the child’s mind was far too complex; that a small
child could not feel guilt. This was partly because of the difficulties of talking about an
infant’s state of mind using words that belong to a later stage of development. A beautiful
description by Hanna Segal in Segal (1981, 1986: 34–5), demonstrates the difficulty. She
summarised a child analysis session in technical terms during supervision with Klein, who
blanched and said ‘I do not see how you managed to interpret all that to a child under four.’
Segal then described the session, using the child’s language, and showed just how much
sense it made – to the child as well as to the analyst. Anna Freud later observed guilt in small
children herself.
Some people take exception to the Kleinian idea that all relationships and all interactions
are based on unconscious phantasies. They think that some relationships are entirely reality-
based. However, the concepts of unconscious perceptions, motivations and decision-making,
all influenced by emotions, are now in mainstream neuropsychology. The idea that percep-
tions have to be organised and then worked on in the mind unconsciously is also becoming
acceptable amongst those who study the workings of the brain.
Some psychotherapists think Kleinians place too much emphasis on aggressive and
destructive aspects of the self. From a Kleinian perspective, both loving and hateful feel-
ings are part of psychic reality and both need to be acknowledged. Others also think that
certain defensive strategies should be left alone and not addressed by therapists. Kleinians

agree that defences perform a vital function of protecting the mind from unbearable
thoughts, and that there is an important place for defences, but they place more weight on
the costs involved. They are very aware of the energy required, and the drain on resources
involved in keeping unrealistic fears at bay, and that persecutory fears have far-reaching,
damaging consequences.
If someone comes to me specifically for therapy about an illness, while appearing to deny
some aspect of it, I do not just join in their denial, but cautiously begin to explore ‘what
exactly are they denying?’ They might be trying to maintain (for example): ‘I am not like my
aunt who got worse because she always told people she was ill…’ Taking the denial as a sign
of a hidden (unrealistic) fear allows it to be uncovered and tested against reality. Telling
people you are ill does not really make you worse, though it might have other consequences;
denying you are ill has consequences too.
Cognitive-behavioural therapy (CBT) practitioners sometimes criticise psychody-
namic approaches because they ‘focus on the past’ and insufficiently on the future. Today
Kleinians focus much less on the past. If it does arise it is more likely to be clients who
bring it up, not the therapist. If it comes into the therapy it is doing so for a particular
reason – sometimes, actually, to avoid thinking about more pressing and painful current
issues.
5.4 Controversies
Currently there seem to be few significant controversies amongst Kleinians. In recent years
there have been changes in the way homosexuality has been seen amongst psychoanalysts in
general; Kleinians have been included in this. For a long time homosexuality was seen as a
perversion and an exclusion criteria for becoming an analyst. There are now openly gay ana-
lysts and attempts to discuss sexuality in less derogatory ways.
Kleinian psychoanalysts include some who focus almost exclusively on the moment-
by-moment transference relationship, and others who do this less; this is more a difference
of emphasis than a controversy. The role of the patient’s past history is also a matter of
discussion and difference, with some emphasising distracting and defensive uses of the
past in the session, and others asserting that links with the past can be helpful in various
ways. One of the advantages of the case study method of discussion is that people can
focus on ‘this patient, in this session, this is what I think happened’; and generalisation is
left to the audience.
6 RESEARCH
To practitioners, the work of psychoanalysis, psychotherapy and counselling is research in

itself. Studying the workings of the mind: the ways individuals construct reality, think,
feel, react, make decisions, behave and relate to others has always been one of the primary

concerns of psychoanalysis. Kleinian papers use case material to convey and explore new,
complex and subtle ideas. At their best, these papers are stimulating, inspiring and practical
in day-to-day work with clients. Not a book of rules, a case study is most useful for those
who have the capacity to use others’ insights to enhance their own.
My own work as a counsellor for people who had severe cognitive problems was also
‘research’, testing whether it could be helpful. Results were good, both for the people con-
cerned and their relatives. David Tuckett, a psychoanalyst at the University College London
Psychoanalysis Unit, has recently begun a different kind of research project, using Kleinian
concepts to study the role of emotions in financial decision-making.
Kleinian analysts and psychotherapists have been amongst the most critical of the use
of outcome measures in psychotherapy and psychoanalysis on the grounds, for example,
that outcomes are impossible to quantify and are a result of highly complex factors,
which may or may not have to do with the quality of the therapy. Some psychodynamic
therapists have overcome their objections. Malan (1963, 1975) was one of the first. In a
group of patients selected for brief insight therapy offered by a team of psychoanalyti-
cally trained analysts and psychotherapists, Malan found that effective outcomes correlated
with transference interpretations. He concluded that prognosis was best when enthusiasm
for treatment in both patient and therapist is high; when transference arises early and
becomes a major feature of therapy; and when grief and anger at termination are impor-
tant issues (1963, 1975: 274). Interestingly, the experience of the therapist seemed to
count less.
Attempts to measure both the outcomes and the aims of psychoanalytically inclined
therapists are now ongoing, although specifically Kleinian researchers are still scarce.
Gerber et al. (2011) for the American Psychiatric Association found 94 randomised con-
trolled trials of psychodynamic psychotherapy published between 1974 and 2010: qual-
ity of the later trials was better than that of the earlier ones. Trowell et al.’s outcome
study (2007) examining the role of psychotherapy for childhood depression and Smith’s
(2010) meta-analysis of studies on panic disorder and generalised anxiety both provide
supportive research evidence. Richardson, Renlund and Kachele (2004) gathered an
interesting collection of papers addressing the difficult technical and theoretical difficul-
ties involved. It has been possible to demonstrate that psychodynamic therapy does
produce both symptom and personality change for a significant proportion of clients.
Improvement can be shown to continue after the end of therapy with long-term results,
which are better than comparison groups such as ‘treatment as usual’ (e.g. Leichsenring
2005; who also found that psychoanalysis is more effective than shorter forms of psy-
chodynamic therapy).
More evidence is being gathered and it is on the whole supportive for those whose experi-
ence or understanding points in the direction of Kleinian ideas. Perhaps of note, however, is
that one (so far unconfirmed) research project from Stockholm reported in Richardson et al.
(2004) found that strict psychoanalytical beliefs of therapists, while predicting effectiveness
in five-times-a-week analysis seemed less effective than a more relaxed attitude on the part
of the therapist within once-a-week psychodynamic psychotherapy.

Jonathon Shedler (2010: 98), looking at a large number of meta-studies concluded that:
Empirical evidence supports the efficacy of psychodynamic therapy. Effect sizes for psychodynamic therapy
are as large as those reported for other therapies that have been actively promoted as ‘empirically sup-
ported’ and ‘evidence based.’ In addition, patients who receive psychodynamic therapy maintain therapeu-
tic gains and appear to continue to improve after treatment ends. Finally, non-psychodynamic therapies may
be effective in part because the more skilled practitioners utilize techniques that have long been central to
psychodynamic theory and practice. The perception that psychodynamic approaches lack empirical support
does not accord with available scientific evidence and may reflect selective dissemination of research.
Neuroscience has been another source of research evidence that supports many Kleinian
ideas, including the idea that emotions are important in change; that attachment to caregivers
and early relationships are highly significant for later life; that babies actively relate to their
environment and are aware of and care about the people around them. Kleinian ideas about
unconscious phantasy fit well with neuroscientists’ discoveries (Gerhardt, 2004; Ledoux,
1998) about the ways we learn and experience the world.
Finally, Towergate, an insurance broker, examined legal actions initiated by clients against
their counsellors and therapists. Not only any form of touch other than a formal handshake, but
also personal pictures or any mention of personal matters, of holidays or family; any change in
or carelessness about the therapists’ clothing or appearance or arrangement of the room; any
statement or behaviour which could be classed as outside the professional frame; even changes
of time or place have all been read by certain clients as provocative invitations to a personal,
often sexual, relationship, with threat of litigious consequences. Towergate’s list of ‘risky’ behav-
iours confirms Kleinian sensitivities about the significance of boundaries for patients.
7 FURTHER READING
Bronstein, C. (ed.) (2001) Kleinian Theory. A Contemporary Perspective. London: Whurr.

Segal, H. (1973) Introduction to the Work of Melanie Klein. London: Hogarth Press and Institute of Psychoanalysis.
Segal, J.C. (1985) Phantasy in Everyday Life. London: Penguin Books. Later editions: Aronson, USA; London:
Karnac Books.
Segal, J.C. (1992) Melanie Klein: Key Figures in Counselling and Psychotherapy. London: Sage Publications.
Spillius, E. Bott (ed.) (1988) Melanie Klein Today. 2 vols; Vol. I, Mainly Theory and Vol. II, Mainly Practice. London:
Routledge.
8 REFERENCES
Gerber, A.J. et al. (2011) A quality-based review of randomized controlled trials of psychodynamic psychotherapy.
Am J Psychiatry 168: 19–28.
Gerhardt, S. (2004) Why Love Matters: How Affection Shapes a Baby’s Brain. London: Routledge.
King, P. and Steiner, R. (eds) (1992) The Freud/Klein Controversies 1941–45. New Library of Psychoanalysis.
London: Routledge.

Klein, M. (1932) The Psychoanalysis of Children. Reprinted in The Writings of Melanie Klein, Vol. II. London,
Hogarth Press and Institute of Psychoanalysis, 1975.
Klein, M. (1957) Envy and Gratitude. Reprinted in Envy and Gratitude and other Works, 1946–63. The Writings
of Melanie Klein, Vol. III. Hogarth Press and Institute of Psychoanalysis, 1975.
Klein, M. (1959) Our Adult World and its Roots in Infancy. Reprinted in Envy and Gratitude and other Works,
1946–63. London, Hogarth Press and Institute of Psychoanalysis, 1975.
Ledoux, J. (1998) The Emotional Brain: The Mysterious Underpinnings of Emotional Life. London: Orion.
Leichsenring, F. (2005) Are psychodynamic and psychoanalytic therapies effective?: A review of empirical data.
International Journal of Psychoanalysis 86(3): 841–68.
Malan, D.H. (1963, 1975) A Study of Brief Psychotherapy. London, NY: Plenum Publishing.
Menzies-Lyth, I. (1988) Containing Anxieties in Institutions. London, Free Association.
Obholzer, A. and Zagier Roberts, V. (1994) The Unconscious at Work. Individual and Organisational Stress in the
Human Services. London and New York: Routledge.
Richardson, P., Renlund, C., Kachele, H. (2004) Research on Psychoanalytic Psychotherapy with Adults. EFPP
Monograph Series. London: Karnac Books.
Rosenfeld, H.A. (1987) Impasse and Interpretation: Therapeutic and Anti-Therapeutic Factors in the Psychoanalytic
Treatment of Psychotic, Borderline, and Neurotic Patients. New Library of Psychoanalysis. London: Routledge.
Segal, H. (1981, 1986) The Work of Hanna Segal: A Kleinian Approach to Clinical Practice. Delusion and Artistic
Creativity and other Psychoanalytic Essays. Jason Aronson, USA. Republished: London, Free Association Books.
Segal, H. (1973) Introduction to the Work of Melanie Klein. London: Hogarth Press and Institute of Psychoanalysis.
Segal, H. (1997) Psychoanalysis, Literature and War. Papers 1972–1995. London and New York: Institute of
Psychoanalysis and Routledge.
Segal, J.C. (1985) Phantasy in Everyday Life. London: Penguin Books. Later editions: Aronson, USA; London:
Karnac Books.
Segal, J.C. (1992) Melanie Klein: Key Figures in Counselling and Psychotherapy. London, Sage Publications; 2nd
edn, 2004.
Shedler, J. (2010 )The efficacy of psychodynamic psychotherapy. American Psychologist 65(2): 98–109.
Smith, J.D. (2010) Panic stations: Brief dynamic therapy for panic disorder and generalised anxiety. Psychodynamic
Practice 16(1): 25–44.
Spillius, E. (2001) Freud and Klein on the concept of phantasy. In C. Bronstein (ed.), Kleinian Theory. A
Contemporary Perspective. London: Whurr, pp. 17–31.
Tavistock Clinic Understanding Your Child series. London and Philadelphia: Jessica Kingsley.
Terry, P. (2008) Counselling and Psychotherapy with Older People: A Psychodynamic Approach, 2nd rev. edn.
London: Karnac Books.
Trowell, J., Joffe, I., Campbell, J., Clemente, C., Almqvist, F., Soininen, M., Koskenranta-Aalto, U., Weintraub, S.,
Kolaitis, G., Tomaras, V., Anastasopoulos, D., Grayson, K., Barnes, J., Tsiantis, J. (2007) Childhood depression:
a place for psychotherapy. An outcome study comparing individual psychodynamic psychotherapy and family
therapy. European Child and Adolescent Psychiatry 16(3): 157–67.
Waddell, M. (1998) Inside Lives: Psychoanalysis and the Growth of Personality. London: Duckworth.
Website for Melanie Klein Trust www.melanie-klein-trust.org.uk
Weintrobe, S. (ed.) (2012) Engaging With Climate Change: Psychoanalytic and Interdisciplinary Perspectives.
London: New Library of Psychoanalysis: Beyond the Couch.

PART II
The Humanistic-Existential
Tradition

6
Person-Centred Therapy
Mike Worrall
The client-centred approach to counselling and psychotherapy took a while to find its name. Carl
Rogers (1902–87) developed the ideas that underpin the approach, and he wrote at various times
about relationship therapy, reflective therapy and non-directive therapy. As he and others began
to think about the emerging principles of the approach in other contexts, such as education,
politics, gender studies and conflict resolution, the term person-centred came to signify these
broader applications of the approach. To mark the distinction between the application of its prin-
ciples in different contexts, it’s helpful to talk about client-centred therapy when we’re referring
to clinical work, and the person-centred approach when we’re referring to broader areas of work.
As its name suggests, client-centred therapy is an approach to therapy that puts the client
at the centre of the work. In this way Rogers distinguishes his approach from the prevailing
modalities of his time, which were medical, analytic or behavioural. In his view, these
approaches saw the person as a set of symptoms or behaviours to be treated, modified, or
cured, or as a problem to be solved. A client-centred approach is by definition not theory-
centred, symptom-centred, treatment-centred or problem-centred. The name of the approach
enshrines the central significance Rogers accords the client in the process of therapy.
Rogers was influenced by a number of significant figures. He was introduced in his twen-
ties to John Dewey’s work in progressive education and functional philosophy. He read Jessie
Taft’s ideas about therapeutic social work with children, and through her imbibed some of the
ideas of Otto Rank. Slightly later, he read Andras Angyal’s work on personality theory and
organismic psychology. We can read the influence of these figures in Rogers’s thinking,
which was from the beginning pragmatic, holistic, humanistic and organismic.

130 PART II: THE HUMANISTIC-EXISTENTIAL TRADITION
Rogers was developing his ideas as Franklin D. Roosevelt came to power in America
in 1933. Roosevelt promised a ‘new deal’ for the American people. His commitment to a
progressive and liberal democracy and his reforming aspirations define the spirit of the
age in which client-centred therapy was born, and inform Rogers’s own ideas. Perhaps
because he was a European in America, Angyal (1941: 190) described that spirit with
particular clarity:
If, for instance, one had to point out some of the leading principles of American culture one would have
to consider such points as: a philosophy of self-help, the ideal of the self-made man – an ideal which
historically is probably a derivation of the pioneer attitude. As further characteristics one could mention
an essentially optimistic attitude toward life (‘prosperity is just around the corner’) and a strong faith in
progress; an over-valuation of visible greatness, which is expressed not only in such objects as the sky-
scrapers of New York but also, for instance, in the Rotarian slogan of ‘bigger and better things’; a high
valuation of achievement mainly in terms of practical, visible results. The American attitude toward life
can be characterized, at least roughly, by these and some other points.
Rogers was also, and also from the beginning, a research scientist. He moved with his parents to
a farm when he was 13, and he watched and studied the world around him: moths and birds at
first, and then, influenced by his father’s desire to run the farm in the most modern and efficient
ways possible, agricultural practices. He learnt to observe, record, and experiment, to steep him-
self in the raw data of his experience, and to learn what he could from that experience. Client-
centred therapy has, as a result of this, a long-established tradition of research studies.

Client-centred theory begins with the human organism and its nature. Drawing on Angyal,
who argued (1941: 20) that ‘organism’ and ‘life’ were ‘identical concepts’, Rogers assumes
the existence and central significance of the organism, and derives his theory from this
assumption. Rogers uses the term organism to refer to the visceral, material and unself-conscious
aspects of our being. He uses the terms self and self-concept to refer to the more reflected,
reflective and self-conscious aspects,. This distinction between organism and self is signifi-
cant for the development of client-centred theory and practice.
Rogers then makes a number of assumptions about the nature of the organism, the first of
which is that the organism tends to actualise. Taft (1933: 13) provides Rogers with the basis
for his thinking in this area:
As living beings we are geared to movement and growth, to achieving something new, leaving the out-
worn behind and going on to a next stage.
By this Taft means that it is in our nature to make real or actual all that is potential in us, to
engage with our environment and to become all that we can become. Rogers agrees. He often

PERSON-CENTRED THERAPY 131
used metaphors from nature to illustrate his thinking. He describes (1977: 237–8) watching
seaweed on a Pacific beach, bearing the incessant torrent of the waves day and night:
Here in this palmlike seaweed was the tenacity of life, the forward thrust of life, the ability to push into
an incredibly hostile environment and not only to hold its own but to adapt, develop, become itself.
A second assumption is that that tendency to actualise is both trustworthy and constructive.
Rogers writes (1961: 92) that ‘the inner core of man’s personality is the organism itself,
which is essentially both self-preserving and social’. Rogers’s definition of ‘self-preserving
and social’ in this context includes movement:
• away from facades and oughts;

• away from meeting expectations and pleasing others;
• toward trust of self and self-direction;
• toward process and complexity;
• toward openness to experience and acceptance of others.
Elsewhere he describes this actualisation as a movement away from fixity and towards
fluidity.
In more precise and specific terms, Rogers (1951: 491) proposes that behaviour is always the
‘goal-directed attempt of the organism to satisfy its needs as experienced, in the field as per-
ceived’. This formulation allows us to assume that however bizarre or self-defeating someone’s
behaviour is or seems to be, it is still purposive and positive. This proposition provides client-
centred therapists with theoretical justification to approach a client’s behaviour with compassion
and acceptance, and with a willingness to understand its origins, meaning and purpose.
A slightly hidden assumption is that our tendency to actualise is facilitated, compromised
or thwarted by our environment. Although we are always tending to actualise our potential,
that process happens in relationship with our environment, and is therefore affected by the
nature of our environment. Reflecting further on the Pacific seaweed, Rogers writes (1977:
239): ‘whether the environment is favourable or unfavourable, the behaviours of an organism
can be counted on to be in the direction of maintaining, enhancing, and reproducing itself.
This is the very nature of the process we call life.’ This has particular implications for the role
and practice of client-centred therapists, who for the duration of the relationship become one
perhaps significant element in a client’s relational environment.

Three concepts describe client-centred thinking about psychological disturbance:
• conditions of worth;
• incongruence;
• locus of evaluation.

A condition of worth is a condition we believe we have to meet in order to deserve or receive

love and respect. Rogers (1959: 209) writes:
A condition of worth arises when the positive regard of a significant other is conditional, when the indi-
vidual feels that in some respects he is prized and in others not.
Living to meet the perceived expectations of others is seen as a major source of psychologi-
cal disturbance.
Conditions of worth lead to an initially simple confusion between what I might want or
need for myself, and what I believe others need from or expect of me. This is not as simple
as it may seem, because along with whatever else I may need for myself and in my own right,
I also need to be in relationship with those around me. Angyal (1941) recognises that our
need to be independent and autonomous is as strong as our need to belong to a community
larger than ourselves. Angyal calls this need to belong homonomy, and sees life as a continu-
ous process of balancing our need for autonomy with our need for homonomy, in a world that
is inescapably heteronomous, or other. Some compromise, therefore, between what I want for
myself, and what I have to do in order to belong in the world of others, is inevitable, and not
necessarily evidence of psychological disturbance. However, Rogers sees that when we look
primarily to others for our values and direction, and when we allow the views and judgements
of others to carry more weight in our lives than our own views and judgements, then we are
at risk of disturbance. Rogers uses the term locus of evaluation in this context, and defines it
(1959: 210) as ‘the source of evidence as to values’. Our locus of evaluation is internal if we
are central to our own valuing process, and external if we make others central to it.
Incongruence is an umbrella term for the psychological disturbance that results from punitive
conditions of worth and a largely external locus of evaluation. Rogers defines it (1959: 203) as
‘a discrepancy … between the self as perceived, and the actual experience of the organism’.

Rogers views psychological health as the disappearance of incongruence or a return to con-
gruence, and to the original integrity and wisdom of the organism.
Congruence is a central idea in client-centred theory and a defining characteristic of psy-
chological health. Taken from geometry, congruence signifies the precise matching of forms
or shapes. Triangles that are the same shape and size as one another are said to be congruent
triangles. Rogers uses the word congruence to refer to a similar and precise matching of three
elements: experiencing, awareness and communication. If I am accurately aware of what I
am experiencing within the envelope of my own being I am internally or intrapersonally
congruent. If I communicate accurately my awareness of my experiencing, I am externally
and interpersonally congruent. We are born congruent and psychological health begins with
a return to congruence.
Rogers (1959) writes about the fully functioning person as an ideal of psychological health.
He describes the characteristics of a fully functioning person as process characteristics, by
which he means that a fully functioning person is ‘a person-in-process, a person continually

changing’. These changes are in the direction of congruence, fluidity, openness to experience,
and a creative and responsive adaptability to new situations.

Client-centred theory suggests that we are born congruent or integrated. If we are experi-
encing physiological signs of hunger or tiredness, for instance, we communicate hunger or
tiredness. As we grow, and as we make sense of others’ responses to us, we come to believe
that we are accepted, or more accepted, if we meet certain conditions. We may never hear
the words, and yet we construe our experience of others as they relate to us to support our
growing belief that we are more acceptable if, for example, we stay quiet and less if we
make a fuss; more acceptable if we eat whatever we’re given without complaining, and less
if we’re picky or choosy about what we eat; more acceptable if we put others first, and less
if we make demands of others. Over time we introject or internalise these conditions of
worth, and weave them into the fabric of what we believe to be true about the world and
about ourselves.
This process leads to the development of a self-concept, or a picture of who I am. This
opens us to the possibility of what Rogers calls a basic estrangement or incongruence in
our experiencing of ourselves. He describes this incongruence (1957: 96) as ‘a discrep-
ancy between the actual experience of the organism and the self picture of the individual
insofar as it represents that experience’. I may, for instance, experience organismic or
physiological signs of fear or vulnerability. As a result of internalised conditions of worth,
however, I believe about myself that I am strong and I do not allow myself to be or even
to feel weak or vulnerable. Writing with Ruth Sanford (Rogers and Sanford, 1989: 1492),
Rogers writes even more clearly: ‘Incongruence is the discrepancy that can arise between
the experiencing of the organism and the concept of self. It is most clearly evident in
therapy when it disappears.’

If we see incongruence as another word for psychological disturbance, we perpetuate that
disturbance by maintaining the discrepancy between our organismic experience and our pic-
tures of or beliefs about who we are. This involves a number of mechanisms by which we
mitigate the effect or the learning potential of new experience, and keep our self-concept
stable and consistent. Rogers suggests two significant responses to experience: denial and
distortion. Both of these mechanisms act as a filter through which we make sense of what we
experience, and by which we keep our experience consistent with what we believe to be true
about ourselves and the world.
Denial signifies a process by which we deny the existence or significance of some aspect of our experience.
Distortion signifies a process by which we ascribe to our experience an inaccurate or incomplete meaning.

These processes operate intrapersonally and interpersonally. In other words I can deny or
distort experience whether it emerges from within my own being, or from my dealings with
others or the world.

Examples of intrapersonal denial and distortion might be as follows:
• Intrapersonal denial: I am so out of touch with my own body that I don’t even notice the signs that tell
me I haven’t eaten for a day and a half.
• Intrapersonal distortion: to preserve my sense of who I am I may say to myself and others that I am tired
rather than admit that I’m angry, or I may blame my parents, bad luck or a lack of opportunity for my
own laziness or lack of ambition.

Examples of interpersonal denial and distortion might be as follows:
• Interpersonal denial: I may refuse to hear feedback that I am angry or bad-tempered, or I may simply fail
to recognise someone else’s description of my behaviour.
• Interpersonal distortion: I may be so threatened by my feelings of love and affection for others that I treat
them badly for evoking such feelings in me.

The environment also helps perpetuate psychological distress in that it provides the condi-
tions in which and against which the organism thrives or wilts. Angyal (1965: 6) sees that
‘the organism lives in a world independent of itself’ and that therefore ‘its autonomy is only
partial and must be asserted against the heteronomous surroundings’. He continues: ‘Thus
every single organismic process, and also the life process as a whole, is always a resultant of
two components, autonomy and heteronomy – self-government and government from out-
side.’ For the purposes of client-centred therapy, the environment includes the therapist and
whatever qualities of relationship therapist and client co-create.
2.5 Change
Change happens in relationship, and through communication. In a relationship characterised
by defined conditions, within therapy or outside of it, client-centred theory suggests that
people move in general terms away from fixity and towards fluidity.
Rogers (1957: 95–6) hypothesised that any relationship that was therapeutic would be
characterised by six conditions, and suggested that these conditions were both necessary and
sufficient for therapeutic change. Although he uses the language of therapist and client here,
he is clear elsewhere that therapy is simply a particular context in which these conditions
might be found. Change that we might call therapeutic happens in the ordinary relationships
of life as well as in the particular relationship that we call therapy.

For constructive personality change to occur, it is necessary that these conditions exist and
continue over a period of time:
• Two persons are in psychological contact.

• The first, whom we shall term the client, is in a state of incongruence, being vulnerable or anxious.
• The second person, whom we shall term the therapist, is congruent or integrated in the relationship.
• The therapist experiences unconditional positive regard for the client.
• The therapist experiences an empathic understanding of the client’s internal frame of reference and
endeavours to communicate this experience to the client.
• The communication to the client of the therapist’s empathic understanding and unconditional positive
regard is to a minimal degree achieved.
Rogers suggested that no other conditions were necessary, and that their presence would
necessarily facilitate constructive personality change.
This is a bold hypothesis, and it forms the basis of client-centred thinking about change.
Conditions 2, 3 and 4 in particular specify the attitudes that are assumed to be therapeutic.
In a helpful reformulation of the relationship between these attitudes Bozarth (1996b) sug-
gests that change results primarily from one person’s experience of another’s unconditional
acceptance. We’ve seen that psychological disturbance is thought to arise from perceived
conditions of worth, which in effect lay down rules as to how we must live if we are to be
acceptable in the world. One person’s attitude of unconditional positive regard towards
another subverts those conditions of worth, and says: you don’t have to meet any condi-
tions in order to be acceptable here. Bozarth suggests that the function of empathic under-
standing is to communicate unconditional positive regard, and that congruence is the
preparation which best allows one person to experience unconditional positive regard and
empathy for another.
Rogers sums up this constellation of attitudes in the word received: Writing about the pro-
cess of change he notes (1961: 130) the importance of a person feeling fully received:
By this I mean that whatever his feelings – fear, despair, insecurity, anger, whatever his mode of expression –
silence, gestures, tears, or words; whatever he finds himself being in this moment, he senses that he is
psychologically received, just as he is, by the therapist. There is implied in this term the concept of being
understood empathically, and the concept of acceptance.
Assuming this condition, Rogers suggests (ibid.: 131) that people move ‘not from a fixity or
homeostasis through change to a new fixity, though such a process is indeed possible’, but
rather ‘from fixity to changingness, from rigid structure to flow, from stasis to process’.
This articulates Rogers’s commitment to the idea of process as a major indicator of organ-
ismic health and vitality. We might define good or optimal health as a process and not a fixed
state, as a life of continuous change in response to an environment which is continuously
changing. To be fixed or rigid is to deny or distort the fluid nature of the world around us and
within us.
Client-centred theory is an holistic theory, and the changes that Rogers hypothesises
manifest in every aspect of being. We may notice the movement from fixity towards fluidity

in the way people speak and in the language they use, in the way they think, in their bodies,
in their willingness to show their anger or sadness or joy, and in the way they relate to one
another.
3 PRACTICE

For two reasons in particular, client-centred theory does not specify precise goals for clients.
The first is that Rogers articulates his theory of change as an if–then theory: if certain defined
conditions are present, then certain broad and loosely predictable changes will follow. We
might say that the broad direction of change is predictable, but not its particular trajectory or
manifestation in any particular client. Theory is a broad description of what we experience.
It gives us a way of thinking about and ordering what we experience, and generates questions
for us to ask in experiences still to come. It doesn’t tell us anything useful, definitive or spe-
cific about what we can expect to happen or about the changes particular clients will make.
The second reason is political. Rogers sought always to locate power and responsibility
in the hands of the individual, and was sensitive to the social and political consequences that
would ensue if any one group of people held views as to what would be desirable for others.
‘When the locus of evaluation is seen as residing in the expert,’ he wrote (1951: 224) ‘it
would appear that the long-range social implications are in the direction of the social control
of the many by the few.’ We’ve seen already that this view would run counter to Rogers’s
political leanings. In conversations with and responses to Skinner, Rogers critiqued behav-
ioural theory and practice on the grounds that they privileged the expertise of the therapist,
and that this privilege was socially and politically suspect.
For these reasons, client-centred therapists tend not to think in terms of goals for the
therapy or for their client. It is more consistent with client-centred theory to think of goals in
two other ways:
• The therapy is client-centred and the client has, therefore, the right and the responsibility to discover and
articulate her own goals, and to work towards them in her own way, and at her own pace. Writing about
the attitudes and views of the therapist, Rogers (1951: 20) asks: ‘Are we willing for the individual to select
and choose his own values, or are our actions guided by the conviction (usually unspoken) that he would
be happiest if he permitted us to select for him his values and standards and goals?’ He makes it clear
that in his view effective therapists are permissive rather than prescriptive or directive. One implication
of this view of goals is that client-centred therapists collaborate with their clients to agree the goals of
therapy.
• As client-centred therapists, we have goals for ourselves, and these are generally in the direction of
developing and enhancing particular attitudes towards ourselves and our clients. Bozarth (2001: 197)
puts it this way: ‘The only goal of the client-centered therapist is to be a certain way. This way of being
entails being congruent in the relationship in order to experience unconditional positive regard towards,
and empathic understanding of, the client’s frame of reference.’


I’ve noted above that Rogers’s theory of therapy is an if–then theory: if certain conditions are
present, then certain changes seem to follow. One way to assess suitability, therefore, is to
look at whether those conditions are, indeed, present:
• Are we in psychological contact?

• Is my client aware of some incongruence, or dissatisfaction, or unhappiness?
• Am I able and willing to be congruent, genuine or integrated in this relationship?
• Am I able and willing to accept my client unconditionally?
• Am I able and willing to understand my client and his world empathically?
• Can my client experience my unconditional acceptance and empathic understanding?
Another way of approaching the question of assessment, and in particular on-going assess-
ment, is to do with the process of therapy. Rogers made a number of attempts to articulate
this process, the most well-known of which (Rogers, 1961) refers to seven stages of thera-
peutic movement. This model describes movement from relative fixity or rigidity, towards
greater fluidity and responsiveness. The precise delineations between the seven stages are
not relevant here. However, Rogers suggests (1961: 132) in that chapter that anyone at
stages one or two of this process ‘is not likely to come voluntarily for therapy’, and perhaps
even unlikely to benefit from it. If they do come, he notes (ibid.: 134) that ‘we (and prob-
ably therapists in general) have a very modest degree of success in working with them’.
This makes sense. People at these early stages of process are characterised by emotional
and intellectual rigidity, by a reluctance to share intimately, and by a belief that they are
not responsible for much of what happens to them. These characteristics suggest that they
would probably not consider therapeutic help in the first place, that they would be cautious
about committing to a process of therapy, and that they would therefore be unlikely to
benefit from it.
Life events, such as bereavement, divorce, illness, or redundancy will sometimes prompt
towards therapy someone who would not otherwise have considered it. Some clients are
encouraged or pushed into therapy under threat of separation, redundancy or prison. These
situations are not ideal, and unless a client is willing to engage in the process for themselves,
therapy is unlikely to be effective.
These considerations provide questions we may ask at initial assessment, and which we
may also use to recognise therapeutic movement over time. We can, in effect, use these ideas
about a process from relative fixity towards relative fluidity as a way of assessing whether a
client is benefiting from the therapeutic relationship.

Much of what I’ve written above about unsuitability for individual therapy applies here too.
The questions we ask are the same, and the answers indicate suitability or unsuitability.

One of the critiques of client-centred practice is that it prioritises individual rights and
individual growth over the demands of group or community, and that in this it reflects the
time and culture of its birth and the prevailing interests of its founders. Rogers, however,
became more interested in groups over time, and there is a long tradition of group work and
group encounter in the client-centred world. He was also interested in the relationships
between partners, and wrote in the 1960s about the changing nature of partnerships and some
of the alternatives to traditional models of intimate relationships.

Client-centred practice demands much of the therapist, and historically the person of the
therapist has been seen as an important element in the process of therapy. Taft (1933: 19)
writes:
In my opinion the basis of therapy lies in the therapist himself, in his capacity to permit the use of self
which the therapeutic relationship implies as well as his psychological insight and technical skill.
Rogers (1951: 19) agrees: ‘In any psychotherapy the therapist himself is a highly impor-
tant part of the human equation.’ We may see the personal characteristics of effective
therapists under two broad headings: attitudes towards other people, and attitudes
towards experience. Rogers believed that the elements that make for an effective thera-
pist are more to do with attitudes, beliefs and convictions than skills and techniques; that
the philosophical beliefs of the therapist are the bedrock of her effectiveness; and that
the most significant consideration is (ibid.: 20) ‘the attitude held by the counselor toward
the worth and the significance of the individual’. In essence, Rogers asks us to start from
a belief in the organism’s tendency and capacity to actualise, and to stay open to what-
ever our experiences teach us in relation to that trust. Do our experiences confirm that
we were right to trust, or do they give us cause to question? In that sense, client-centred
practice is a continuing test of a basic hypothesis, and therefore a process of continuous
research.
Client-centred therapists are probably most effective if their own philosophical beliefs
are broadly in line with this hypothesis, and if they are willing to revise their beliefs in
the light of new experiences. This requires a willingness to hold beliefs lightly, and a
reluctance to become dogmatic about anything, even the most cherished and established
tenets of client-centred theory. Rogers wrote (1959: 191) that he was ‘distressed at the
manner in which small-caliber minds immediately accept a theory – almost any theory –
as a dogma of truth’. He saw theory as ‘a fallible, changing attempt to construct a net-
work of gossamer threads which will contain the solid facts’ and serve ‘as a stimulus to
further creative thinking’. This level of scepticism as to theory, and this willingness to
learn from experience rather than from theory, are both characteristic of client-centred
therapists.


Given the central importance of attitudes, a caricature has arisen that client-centred practice
is just a way of being. This usually implies that it is not a way of doing, and doesn’t, there-
fore, involve or necessitate skills, methods or techniques. The attitudes on their own, how-
ever, are therapeutic only if they are lived out or manifested in the relationship. This process
of manifestation, of living the attitudes in the moment to moment reality of a therapeutic
relationship, requires skills. Attitudes in a vacuum are not that helpful: I may be deeply
respectful of my client but this is not much use unless my client experiences my respect in
some way. Skills without underlying attitudes are not that helpful either: I may be skilled in
the demonstration of respect, but unless my client trusts that my respect is genuine it won’t
be helpful. Client-centred therapists need to hold attitudes of deep and enduring respect for
the other person, and to have the skills to live and communicate this respect in practice.
The grain of truth in the caricature is perhaps that there isn’t one set of person-centred
skills that beginning therapists can learn from a handbook. Each therapist has to learn how to
manifest and communicate their trust in and respect for each of their clients idiosyncratically,
taking into account their own personality, style and preferences and the unique qualities of
each individual client (Bozarth, 1984). The practice of client-centred therapy can often feel
like continuous improvisation: experimenting and discovering how to be with a client in
ways that are both informed by a set of disciplined attitudes, and necessarily particular to the
relationship as it unfolds between two unique individuals. Rogers (1986: 135) sums it up:
There is one best school of therapy. It is the school of therapy you develop for yourself based on a con-
tinuing critical examination of the effects of your way of being in the relationship.

Client-centred therapists seek to establish with their clients relationships characterised by
high levels of congruence, unconditional positive regard and empathic understanding.
Congruence: Although we normally associate congruence with Rogers, his recognition of
the idea of congruence in the context of therapy probably comes from Jessie Taft, who wrote
(1933: 118) that ‘the therapist above all must be able to be, what the patient is not for a long
time, spontaneous and aware of his own slightest feeling response’ Rogers (1961: 33)
describes his own experience like this:
I have found that the more I can be genuine in the relationship, the more helpful it will be. This means
that I need to be aware of my own feelings, in so far as possible, rather than presenting an outward
façade of one attitude, while actually holding another attitude at a deeper or unconscious level.
For Rogers, the therapist’s congruence is important for two reasons: it helps make the rela-
tionship real, and ‘reality seems deeply important as a first condition’; and it provides a space
within which a client can seek what is real in her.

Unconditional positive regard: we’ve seen already that a client’s experience of uncon-
ditional acceptance will begin to question and subvert archaic conditions of worth.
Rogers used the word prizing as a synonym for unconditional positive regard, and wrote
(1959: 208) that to prize meant ‘to value the person, irrespective of the differential val-
ues which one might place on his specific behaviors’. In other words, a client-centred
therapist values all of a client’s expressions, feelings and behaviours equally and without
conditions.
Empathic understanding: The task of empathic understanding as Rogers defines it (1959:
210) is to ‘perceive the internal frame of reference of another with accuracy, and with the
emotional components and meanings which pertain thereto, as if one were the other person,
but without ever losing the “as if” condition’. Empathic understanding is perhaps the most
visible of the three therapist conditions. Much of what a client-centred therapist says during
a therapy session will be to do with developing, checking, refining and communicating her
empathic understanding of what her client is experiencing. Empathy itself, says Rogers
(1986: 129) is ‘a healing agent. It is one of the most potent aspects of therapy, because it
releases, it confirms, it brings even the most frightened client into the human race. If a person
can be understood, he or she belongs.’

There are as many relational and therapeutic styles as there are client-centred therapists, and
each client-centred therapist will be slightly and subtly different with different clients and at
different times. Notwithstanding this variety of style, client-centred work is likely to be more
informal than formal; more accepting and understanding than overtly challenging or con-
fronting; more warmly personal than stiffly professional.
Client-centred therapists may disclose more of what they are experiencing than some other
therapists do. There is, however, a significant and useful distinction between self-disclosure,
which describes a therapist’s disclosure of personal material from outside of the therapy ses-
sion, and self-involvement, which describes a therapist’s disclosure of her own responses to
what is happening within the therapy session. Using this distinction, we may say that client-
centred therapy allows for and may even encourage a disciplined self-involvement, and
makes no special case for self-disclosure.

3.5.1 Assessment
Within person-centred thinking there is a range of responses to the idea of assessment.
Many of these responses are negative, and see assessment as inimical to person-centred
practice. Some assessment, though, is inevitable unless we are to agree to work with any-
one and everyone who seeks us out, whatever their presenting concerns and whatever our
level of competence or area of interest. Wilkins and Gill (2003: 184) define assessment as

‘a process by which therapists reach some conclusion as to the possibility or likelihood of

effective working’. It is, therefore, not an assessment of the client, but of the likelihood or
possibility of an effective therapy relationship.
Rogers and Sanford (1989: 1483) are clear:
The single element that most sets client-centered psychotherapy apart from the other therapies is its
insistence that the medical model – involving diagnosis of pathology, specificity of treatment, and desir-
ability of cure – is a totally inadequate model for dealing with psychologically distressed or deviant
persons.
Client-centred therapists do not assess clients or their problems, and client-centred therapy is
more about helping clients examine and bear their lives than it is about treating or curing
them. In this sense, client-centred therapy has more in common with education or philosophy
than with medicine.
Writing about questions raised by other viewpoints, Rogers (1951: 223) argues that all
meaningful therapy is diagnosis, with the proviso that this diagnosis takes place ‘in the
experience of the client rather than in the intellect of the clinician’. This suggests (ibid.: 223)
that therapy is a process whereby a client can symbolise to himself, and perhaps also articu-
late to others, the details of his distress, and that when he has done this the process of
therapy is over:
One might say that psychotherapy, of whatever orientation, is complete or almost complete when the
diagnosis of the dynamics is experienced and accepted by the client. In client-centered therapy one could
say that the purpose of the therapist is to provide the conditions in which the client is able to make, to
experience, and to accept the diagnosis of the psychogenic aspects of his maladjustment.
Assessment in client-centred therapy is less an assessment of the client and his problems, and
more an assessment of two other elements:
• the therapist’s competence, willingness and readiness to begin a relationship;

• the likelihood of that relationship being or becoming therapeutic for the client.

Notwithstanding what I’ve written above about its nature, function and limits, the process of
assessment necessarily involves some thinking about the client. Client-centred theory offers
a number of concepts that help us frame that thinking:
• Client incongruence: is the client aware of some discomfort or distress which therapy might help?
• Conditions of worth: what are the conditions the client believes she has to meet in order to be worthy of
love, respect or attention?
• Locus of evaluation: where does the client look for judgements and evaluations about himself … to oth-
ers or to himself?
• Stages of process: looking at a client’s behaviour, thinking and feeling, where is he on a scale from fixity
or rigidity to fluidity?


The primary and perhaps the only clinical strategy in client-centred therapy is the develop-
ment of a genuinely unconditional positive regard. The client-centred therapist’s primary aim
is simply to accept her client without conditions. Following Bozarth’s reformulation (see
above) this attitude of unconditional acceptance, if it is to be therapeutic, arises from a
therapist’s authentic experience and is communicated by a therapist’s empathic understand-
ing. We might, therefore, say that therapist authenticity or congruence and the communica-
tion of empathic understanding are supporting or subsidiary strategies in client-centred
therapy, and that they support the primary strategy of the development and communication
of unconditional positive regard.
Unconditional positive regard sounds like a tall order, and it is. In an important footnote
Rogers (1957: 102) acknowledges this:
The phrase ‘unconditional positive regard’ may be an unfortunate one, since it sounds like an absolute,
an all or nothing dispositional concept. It is probably evident from the description that completely uncon-
ditional positive regard would never exist except in theory. From a clinical and experiential point of view
I believe the most accurate statement is that the effective therapist experiences unconditional positive
regard for the client during many moments of his contact with him, yet from time to time he experiences
only a conditional positive regard – and perhaps at times a negative regard, though this is not likely in
effective therapy. It is in this sense that unconditional positive regard exists as a matter of degree in any
relationship.

Two quotations articulate the range of responses to the notion of techniques in client-centred
therapy. Bozarth (1996a: 363) argues:
Techniques are, at best, irrelevant and have no value to the fundamental theory of the client-centered
approach. Worse, however, is that techniques may interfere with the client freedom perpetuated by a
client-centered stance and can insidiously contaminate the nondirective position of the therapist.
Brodley and Brody (1996: 370) take a different line:
There is no therapy, of any kind, without techniques. And although client-centered therapy is correctly
described as a theory of values and attitudes, it cannot be practiced without techniques.
Unconditional positive regard is the primary strategy in client-centred therapy. If the develop-
ment of unconditional positive regard depends on a therapist’s authenticity or congruence,
and if its communication depends on a therapist’s empathic understanding, it follows that
techniques in client-centred therapy will relate primarily to congruence and empathic under-
standing.
We’ve seen that congruence is the matching of experience, awareness and communica-
tion. There are therefore two opportunities for congruence (or incongruence): an internal

congruence between experience and awareness; and an external congruence between aware-
ness and communication.
As far as internal congruence is concerned, most of the work happens outside of the ther-
apy session, in training, supervision and personal therapy. Bozarth (1996b) argues that the
function of therapist congruence is to enable the therapist to experience unconditional posi-
tive regard and empathic understanding. It is, in those terms, a preparation to practise, both
in the broad sense that it is a preparation to be a therapist, and in a more immediate sense that
it is a preparation to see a particular client for a particular session. We may see supervision
as a forum within which we develop our own internal congruence in relation to particular
clients.
Some client-centred therapists, such as Thorne (1991), hold a more expansive view. He
sees congruence as more of an external and communicative act, and gives therapists licence
to share what they are experiencing more explicitly and more immediately as they work. He
writes (1991: 189):
Acceptance, empathy and congruence – these three, as always, but the greatest and the most difficult
and the most exciting and the most challenging is congruence.
Therapists holding this understanding of congruence will develop techniques to allow them
to communicate their experiencing in ways that also honour the fundamental trust in the
autonomy and integrity of the client. They will, for instance, recognise what Rogers (1961:
341) calls ‘an important corollary of the construct of congruence which is not at all obvious’:
It may be stated in this way. If an individual is at this moment entirely congruent, his actual physiological
experience being accurately represented in his awareness, and his communication being accurately con-
gruent with his awareness, then his communication could never contain an expression of an external fact.
This is an important point. Therapists who understand congruence to include the communica-
tion of their awareness of their own experience are limited to talking about their own experi-
ence, and can not use congruence to justify saying anything about the client. In terms of
technique, this will involve using language precisely and responsibly: ‘I’m confused’ or ‘I
don’t understand’ rather than ‘You’re not clear.’
Language is important too when it comes to empathic understanding. Client-centred ther-
apy is sometimes described, from the outside, as relying on the technique of reflective listen-
ing. Reflective listening evolved as one way for a therapist to check with her client whether
she had understood her client accurately and comprehensively. It has no intrinsic merit other
than that, and the same function can be served by intonation, look or direct question.
However a therapist does it, two things matter: the empathic understanding, and the client’s
experience of that understanding. Bozarth (1984) argues that reflective listening is no more
than a technique, and that client-centred therapy allows therapists to evolve idiosyncratic
modes of expression informed by their own skills and personalities, the demands of particu-
lar clients and the nature of whatever is happening between therapist and client at any given
moment.


Rogers (1961) describes the process of therapy through seven stages, moving as we’ve
seen from fixity to fluidity. In that same chapter, he describes this movement across seven
continua:
• A loosening of feelings, from relating to them as ‘remote, unowned, and not now present’ towards
embracing them in the present as ‘a continually changing flow’.
• A change in the relationship to experience, from a fixity in which we are remote from our experiencing
and unable to draw meaning from it, towards a capacity to ‘live freely and acceptantly’ in our experienc-
ing and to use it ‘as a major reference for (our) behavior’.
• A shift from incongruence to congruence.
• A move from unwillingness to share ourselves towards a willingness to communicate freely in a receptive
climate.
• A ‘loosening of the cognitive maps of experience’, away from ‘construing experience in rigid ways’ and
perceiving experiences as external facts towards a recognition that we can construe the meanings of our
experience in many ways.
• A move away from blaming others and the world for our problems, and towards recognising our own
responsibility for them.
• A change in the way we relate to others, away from fearing intimacy and towards living ‘openly and freely
in relation to others’.
Rogers (1961: 80) sums up this movement as follows:
We may conclude this section by saying that one of the fundamental directions taken by the process of
therapy is the free experiencing of the actual sensory and visceral reactions of the organism without too
much of an attempt to relate these experiences to the self. This is usually accompanied by the conviction
that this material does not belong to, and cannot be organized into, the self. The end point of this process
is that the client discovers that he can be his experience, with all of its variety and surface contradiction;
that he can formulate himself out of his experience, instead of trying to impose a formulation of self upon
his experiences, denying to awareness those elements which do not fit.
Clients, of course, do not always do as well as we might expect in therapy. Consistent with
an abiding trust in the organism’s capacity and tendency to actualise, client-centred therapists
recognise that they themselves might be responsible if clients are not progressing as they
might want to.
Rogers, for instance, argues (1942: 151) that a client’s ‘resistance to counseling … grows
primarily out of poor techniques of handling the client’s expression of his problems and feel-
ings’. He continues:
More specifically, it grows out of unwise attempts on the part of the counselor to short-cut the therapeu-
tic process by bringing into the discussion emotionalized attitudes which the client is not yet ready to face.
Almost fifty years later, Speierer (1990: 343) says it more crisply:
I view resistance as an error of empathy on the therapist’s side.

Rogers and Speierer invite client-centred therapists to look to themselves and to take responsi-
bility for their own practice if clients are not making the progress they’d expect in therapy.
However we might apportion responsibility, and even if we are not solely or even largely
responsible for a client’s apparent resistance to or failure to benefit from therapy, it seems like
a healthy stance to take, if only because we can at least do something about our own practice.
4 CASE EXAMPLE
4.1 The client

My client, Carla, was a 45-year-old woman, English, and single. She was educated to a high
level, and had had a career that she had enjoyed until she contracted a chronic disease when
she was 40. Her illness was unlikely to kill her, but the medications she was taking to control
her pain and to allow her to move around freely were likely to affect her heart, and she had
been told that she would probably not live much beyond 65. She came to see me to look at
the way she was living, and in particular to ask herself whether she was living her life as she
wanted to, given the limitations her illness imposed.
Carla told me that she lived alone, and had no relatives. She was active in her community
and spent a lot of time at her computer writing and editing neighbourhood newsletters. She
said that she struggled to assert herself, and that she couldn’t say no to requests for help.
4.2 The therapy

I found myself more formal and reserved with Carla than I had expected myself to be. Carla
seemed to express herself freely with me. She would often cry or rage without restraint, and I
wondered whether I was holding myself in a little more because she seemed relatively uncon-
tained. Over time, Carla was adamant that she wanted more from me: more involvement, more
questions, more emotion. I experienced her as demanding, and found myself wanting to give
her less and less. This surprised me. I don’t often feel ungenerous in this way, and I didn’t think
that I was withholding simply because she was demanding. I know that I tend to resist demands
when I think someone expects them as of right, and yet this didn’t seem the whole truth either.
This dynamic came to a head after several months when Carla began to call me once or twice
and then several times a week between sessions, just wanting five or ten minutes to talk about
something each time. I wanted to address this with her before I began to feel resentful, and I
talked it over in supervision. I reminded myself of the core assumption in client-centred thinking
that behaviour is always a person’s best attempt to satisfy needs as experienced in the field as
perceived. I wondered about Carla’s needs, and about her perception of her world. This allowed
me to broach the subject with her from a conviction that she had reasons for doing what she was
doing, and that those reasons were legitimate, even if I was feeling irritated.

Carla was clear about her need: she needed more contact with me. She was also clear about
the world she lived in: therapists never saw their clients more than once a week. Given that
that is what she believed, I could see her behaviour as a creative way of meeting her need,
and I began to feel less irritated. I could also see a way forward, and I’m sure that that helped
dissolve my irritation too. I suggested to Carla that we meet twice a week for a while, or three
times a fortnight, and that’s what we did. After a month Carla felt more sure of her relation-
ship with me and we met weekly again for the rest of our work together.
This incident describes the flavour of our relationship. I had to work harder than I normally
did to feel warm towards Carla, and yet when I put the effort in and began to understand her,
I felt more generous towards her and more accepting of her. My empathic understanding of
Carla communicated my unconditional acceptance of her. More subtly, my effort to under-
stand her empathically also helped develop my acceptance of her.

I was interested in Carla’s assessment of her problems. She saw herself as isolated, and yet
also as beset by demands, which she felt unable to resist. We were both curious about this
apparent paradox, and as we sat with it over some months Carla saw that the demands others
made on her helped her feel connected to life, and gave her something manageable to com-
plain about when she didn’t feel able to complain about the enormity and unfairness of her
illness. As Carla faced her impotence and voiced her rage before a chronic, unpredictable and
incurable illness she began to manage her life a little more steadily, choosing which demands
she wanted to take on and feeling increasingly able to refuse those she didn’t. It seemed to
her that she had been misplacing her complaints, and as she heard herself voice them she was
able to review and assess them herself, and conclude for herself that her anger belonged
elsewhere.

My only intention was to accept Carla as unconditionally as I could. I didn’t find this easy. I
struggled to hear the intractability of her situation, and I sometimes felt irritated by what I took
to be her willingness to see herself as no more than a victim. Yet she was a victim, and I began
to see that just as Carla had been complaining about some things in her life as a way of avoid-
ing others, so I was masking my own impotence and avoiding the pain of sitting with Carla’s
distress by being irritated with her. I worked hard in supervision and I wrote about and
reflected on our relationship between sessions. As I came to know the blocks to and limitations
of my empathy so I began to relax and feel more able simply to be present with her. Empathy
was still a struggle. I’m used to finding empathy relatively easy, and with Carla it was more
the result of a disciplined, conscious and continuous commitment to understand her. She told
me that she felt understood. I don’t think she knew how hard I was working to understand her,
and how far short, in my own assessment, I was falling of my own best practice.
As Carla felt understood, she seemed to soften, and to take more risks. She disclosed dif-
ficult feelings about the loss of her career, and about the fact that she had never had an intimate

relationship. And as Carla softened, I felt more able to attend to her, even though the content
of what she was disclosing was, if anything, increasingly painful for her to admit and for me
to hear.

Carla ended therapy with a statement that she said summed up what she had learned: What
other people think of me is really none of my business. She recognised that she had lived her
life acutely aware of and driven by what she thought other people thought of her. Her closing
statement was her way of saying two things:
• that she was less bothered now about what others thought of her;
• that she saw now that what others thought of her said more about them than it did about her.
In that sense, what others thought of her really was none of her business. She began to
write songs and poetry, bought a dog, and changed her car for something colourful and
frivolous. She also changed her wardrobe, in part to reflect her growing confidence and
changing picture of herself, and in part to recognise that she had until recently lived in the
drab and worthy clothes her family would have been able to afford as a child. She had her
own money now, and could afford to buy more of what she wanted. In theory terms, I
would see this as a move from a locus of evaluation that was largely external, to one that
was largely internal.
By the time we ended our work together Carla was less driven by what she thought others
expected of her, and more willing to be the unique and eccentric woman that she was. I would
also say that she confronted and dissolved a condition of worth that she was acceptable only
if she did what everyone expected of her.
Carla’s experience of feeling accepted in therapy helped her become more true to herself.
She said more than once that she felt loved when she was with me, and that that gave her
confidence to follow her own wishes and needs. My impression is that she thought my
acceptance of her came easily, and I know that it did not. I struggled to feel warm towards
her and to understand her.
If I could do anything differently I would, I think, have worked harder to identify and look
at my own irritation, recognising with Carla that it said more about me and my response to
chronic illness than it did about her. My responses to her were really none of her business.
5.1 Developments
5.1.1 Brief therapy
The dynamics of brief therapy, in so far as they are problematic for client-centred therapy,
are less to do with the limitations of time and more to do with the fact that those limitations

are imposed from outside, for reasons that may have little to do with client need or thera-
peutic process. In that sense, brief therapy compromises client autonomy and limits the
freedom of therapist and client to negotiate and agree about the parameters of the therapy
relationship
There seems no compelling reason to amend client-centred methodology simply
because the number of sessions is limited. It makes sense, I think, for client-centred prac-
titioners to recognise that all therapy is time-limited. Whatever the number of sessions I
may think I have with a client, the only session I know I have is the one I’m in right now.
From this existential perspective, notions of brief, long term or open-ended therapy are
largely irrelevant. Taft (1933: 12) offers us a way of thinking about the clinical implica-
tions of this:
Time represents more vividly than any other category the necessity of accepting limitations as well as the
inability to do so, and symbolizes therefore the whole problem of living. The reaction of each individual
to limited or unlimited time betrays his deepest and most fundamental life pattern, his relation to the
growth process itself, to beginnings and endings, to being born and to dying.
The way we and our clients respond to the necessary limitations of temporal existence tells
us something about our own responses to the challenges and limitations of living.

Along with other major bodies of psychotherapeutic theory and practice, client-centred
therapy results largely from the work of one man, and that man was white and Western and
informed by the spirit of his age, with all of its strengths and limitations. The spirit of
Rogers’s age as he was living it in America was characterised by an emphasis on individual
rights, individual potential and optimism about what was possible.
The emphasis on the individual leads some to ask whether client-centred principles are
relevant to cultures where an individual’s rights are not as important as his responsibilities to
his community. If client-centred theory starts with I, what relevance does it have for cultures
that are more interested in we? Holdstock (2000) has been particularly critical in this area,
and has argued that traditional psychology privileges the Western world and therefore risks
embodying values that are colonial and racist in their assumptions. The very notion of the
self, he argues, is inherently Western, and needs revising if we are to develop a psychology
that is helpful beyond the edges of the Western world.
Lago has also written extensively and helpfully on issues of race and culture. He argues
(2007: 252) that those of us in the majority need to examine our own cultural heritage in some
depth:
Counselling across difference and diversity demands that therapists enhance their awareness of their
own identity development and attitudinal base as well as developing their knowledge of the specific
minority client groups with whom they work … To explore these issues therapists, particularly from
‘majority’ groups in society, may well have to face major challenges to their assumptions, views and
preconceptions.

Although Holdstock and Lago are writing primarily in the area of race and culture, their
critiques hold in other areas of difference too, such as gender and sexuality. Their thinking
encourages us all to acknowledge and examine our own assumptions and biases, and to rec-
ognise how they will be showing in the way we relate to others.

I’ve argued above that many of the limitations of the approach derive from its unacknowl-
edged assumptions and biases, and that these are a product of its origins in a particular place,
time, and culture. These considerations will affect all bodies of theory to some degree.
Client-centred therapy in particular is subject, I think, to two significant limitations. The
first limitation is that it emphasise the needs and rights of the individual over the needs and
rights of the community; and the second is that it doesn’t pay enough attention to limitations.
We can examine these if we look closely at what Rogers took from Angyal, and at what he
didn’t take.
Angyal sees life as a dynamic process consisting of three elements:
• Autonomy: the organism moves in the direction of greater control over its surroundings.
• Homonomy: the organism has a need to belong to something larger than itself.
• Heteronomy: the environment is other and resists control.
Rogers has a lot to say about autonomy, less to say about homonomy, and little to say about
environmental heteronomy.
Dip into Rogers almost anywhere and he’s describing the autonomous reach of the organ-
ism. It’s implicit in his discussions of the fully functioning person, and it’s another word for
having a locus of evaluation that’s internal rather than external. It’s also consistent with his
optimistic, pioneering, individual Americanism.
Angyal (1941: 172) defines homonomy as ‘a trend to be in harmony with superindi-
vidual units, the social group, nature, God, ethical world order, or whatever the person’s
formulation of it may be’. In other words, it’s a trend towards belonging. He goes on to
say (1941: 178) that ‘the trend toward homonomy as a source of profound motivation for
human behavior may not be ignored’. Rogers acknowledges that the organism is inher-
ently pro-social, and that given the right conditions we’ll get along with one another
rather than not. But he doesn’t give it the same value as Angyal, for whom it’s as impor-
tant a trend as autonomy. Rogers, in other words, prioritises individual and autonomous
development over social belonging.
Angyal sees that the organismic trends towards autonomy and homonomy play out in a
world that is heteronomous, or other. The sun shines whether I want it to or not. You and
I are other to each other. Again, I don’t think Rogers really acknowledges the significance
of this. He concentrates rather on the positives of organismic growth and individual
autonomy.


One significant criticism of client-centred practice is that it is naïve and over-optimistic, that
it dwells on the positives of human nature and ignores the human capacity for malevolence,
destruction or evil. There is perhaps some truth in this. Rogers defined his approach in the
beginning in contrast to some of the already established approaches, and it would be under-
standable if he paid particular emphasis to the differences that defined his approach as dis-
tinct from them. He notes (1961: 194):
I have little sympathy with the rather prevalent concept that man is basically irrational, and that his
impulses, if not controlled, will lead to destruction of others and self. Man’s behaviour is exquisitely
rational, moving with subtle and ordered complexity toward the goals his organism is endeavoring to
achieve. The tragedy for most of us is that our defenses keep us from being aware of this rationality, so
that consciously we are moving in one direction, while organismically we are moving in another.
Some of this discussion centres around what seems to me a superficial reading of the notion
of unconditional positive regard, which has little to do with liking, approving of, or colluding
with particular behaviours or beliefs. It is, rather, a recognition and acceptance of what is, and
a commitment to understand rather than judge, evaluate or pathologise what is.
It’s fair, I think, to say that Rogers pays more attention to growth and potential than he does
to the question of evil and depravity. However, we’ve seen that client-centred theory under-
stands psychological distress as resulting from environmental factors that lead to internalised
conditions of worth. We may approach an understanding of evil in the same way. One of the
tasks for client-centred theory over the coming years is to develop a more comprehensive
understanding of and more sophisticated responses to the human capacity for destruction and
depravity, without losing its commitment to seeing and fostering the potential for creativity
and good.
5.4 Controversies
A number of controversies are currently preoccupying theorists and practitioners within the
client-centred world. Many of these controversies relate to the therapist’s role within the
relationship, and specifically to the degree of freedom a therapist has to influence or direct
the process of therapy.
Rogers’s work shows the influence of several different strands of thought: pragmatism,
Christianity, phenomenology, existentialism, holism and liberal approaches to education and
politics. He synthesised these different strands into a more or less coherent system of therapy.
Since his original formulations of the approach, others have emphasised one or other of the
elements that make up the approach, and their different emphases have resulted in a number
of diverging developments. On the one hand, classical client-centred theorists like Bozarth,
Merry and Natiello hold to principles of radical trust in client autonomy and therapist non-
directivity. Drawing on the work of Gendlin, others such as Prouty, Purton and Rennie give

the therapist a more active and visible role in the therapy. Cooper is developing the existential
threads of client-centred theory, and Mearns and Thorne are developing a particularly
European version of the approach characterised by ideas about relational depth, configura-
tions of self and spirituality.
Rogers wanted this to happen. He wrote (1959: 191) about his ‘regret at the history of
Freudian theory’, and continues:
For Freud, it seems quite clear that his highly creative theories were never more than that. He kept chang-
ing, altering, revising, giving new meaning to old terms – always with more respect for the facts he
observed than for the theories he had built. But at the hands of insecure disciples (so it seems to me), the
gossamer threads became iron chains of dogma from which dynamic psychology is only recently begin-
ning to free itself.
Rogers saw this as a risk inherent in the evolution of any theory and wanted to take precau-
tions to prevent theory becoming dogma. This is a clear invitation to current theorists and
therapists to hold Rogers’s ideas lightly, and to test them again and again against their own
experience.
6 RESEARCH
Rogers was interested in research from an early age, and defined it (1959: 188) as ‘the per-
sistent, disciplined effort to make sense and order out of the phenomena of subjective expe-
rience’. As a result of his interest client-centred therapy has been research-friendly for a
long time. Rogers was one of the first practitioners to record and transcribe therapy sessions,
and to examine those recordings for what they could tell us about the practice of therapists
and the process of therapy. In the 1950s he initiated and took part in a five-year research
project with patients diagnosed with schizophrenia. The findings were published as an
edited volume in 1961.
Rogers (1961: 25) identified one of his significant learnings as this: ‘The facts are friendly.’
He continues:
Every bit of evidence one can acquire, in any area, leads one that much closer to what is true. And being
closer to the truth can never be a harmful or dangerous or unedifying thing.
Rogers held this to be the case even when empirical findings challenged his most cherished
assumptions, and even when his ‘pet ideas’ were ‘not upheld by the evidence’. We may want
to make post-modern allowances for the modernist notions of truth implicit in Rogers’s lan-
guage, but the integrity of his intention and endeavour seems clear: he wanted to know what
worked, even if that knowledge challenged or compromised what he thought worked.
Bozarth conducted a meta-study of research findings into the effectiveness of psycho-
therapy. ‘The most clear research evidence’, he found (1998: 19), ‘is that effective

psychotherapy results from the resources of the client (extra-therapeutic variables) and
from the person-to-person relationship of the therapist and client.’ This finding is interest-
ing in that it locates the client’s resources as central to the process of effective therapy,
and both the therapeutic relationship and the skills or competences of the therapist as less
central.
Rodgers (2003) brought a particularly client-centred focus to research, and noted that most
research to date had, ironically, paid attention not to what the client did in therapy but to what
the therapist did. His paper reviewed the research into clients’ experiences of therapy, and
noted a number of things:
• That the variables identified as important by the client correlated more consistently with positive out-
comes in therapy than did the variables identified as important by either therapists or independent
observers. These client-identified variables included the therapist’s credibility, confidence, and interactive
collaboration.
• That clients found it helpful if a therapist engaged with them, understood them and helped them under-
stand what was happening in the process of therapy.
• That different clients used therapy in different ways.
• That clients typically reported lower levels of satisfaction with their therapy than their therapists did.
Stiles et al. (2008) conducted a large-scale study into the effectiveness of three different
models of psychotherapy in primary care within the UK National Health Service: cognitive
behavioural therapy, person-centred therapy and psychodynamic therapy. Their research
addressed the equivalence paradox: that different modalities of psychotherapy tend to have
equivalent outcomes despite non-equivalent theories and techniques. This paradox is also
known as the Dodo verdict after a line in Lewis Carroll’s Alice’s Adventures in Wonderland:
Everybody has won, and all must have prizes. The results of this study upheld the Dodo ver-
dict: that all three modalities achieved broadly similar levels of effectiveness, and the authors
note (2008: 683) that this may be of particular interest to person-centred and psychodynamic
practitioners ‘insofar as these approaches’ comparable effectiveness to CBT in routine prac-
tice may have been unappreciated’.
Identifying the variables that make for effective therapy is difficult. As Stiles et al. note
(ibid.: 383):
More than most medical treatments, psychotherapies must be adapted to the emerging needs of varied
patients in ways that are not specified in a protocol but depend on the skill and interpersonal responsive-
ness of the therapist.
This question affects all research into psychotherapy: how best to develop and implement
rigorous and consistent research protocols in a field that is characterised by qualities such as
wisdom, responsiveness and empathic understanding? These qualities are not easily suscep-
tible to most quantitative research methodologies, and the qualitative methodologies that
might serve are still being developed. Further, research studies indicate general trends, pat-
terns and truths that tell us little about the specifics of individual client relationships.

Responding to Rogers’s assertion that the facts are friendly, and using that line as the sub-
title of his book, Cooper (2008: 4) notes the irony that ‘research itself shows that many
therapists have little interest in, or familiarity with, empirical research findings in their field’.
He articulates (ibid.: 2) the importance and the limitations of research. Research findings,
he writes, can give practitioners
some very good ideas about where to start from in the absence of other information. Research can only
ever tell us about the likelihood of certain things happening, but that knowledge can be enormously
valuable if we have virtually nothing else to go on.
Our relationships with individual clients will change and develop as we get to know them,
but while we wait for that to happen it might help us to know what attitudes and skills previ-
ous clients, therapists and researchers have found to be helpful.
Cooper also points out (ibid.: 3) that the value of research findings may be not that they
teach us how to work with clients, but that they challenge us to revisit and examine whatever
assumptions we might have made about how to work with clients. Bozarth’s research (1998,
above) is an instance of that. Many client-centred therapists were introduced in training to the
idea that the relationship is central to the therapeutic process. Bozarth’s work suggests that
although the relationship is important, it is not as important as the attitudes and qualities that
the client brings to the relationship.
Rogers was passionate about research, and we’ve seen that he was concerned to keep
client-centred therapy and the person-centred approach fresh, fluid and responsive to changes
in culture and environment. It would, I think, have pleased him that the approach he articu-
lated is still, seventy years later, open to and informed by the findings of research.
7 FURTHER READING
Cooper, M. (2008) Essential Research Findings in Counselling and Psychotherapy: The Facts are Friendly. London: Sage.
Rogers, C.R. (1951) Client-Centered Therapy. London: Constable.
Rogers, C.R. (1961) On Becoming A Person: A Therapist’s View of Psychotherapy. London: Constable.
Sanders, P. (ed.) (2012) The Tribes of the Person-Centred Approach: An Introduction to the Schools of Therapy
Related to the Person-Centred Approach (2nd edn). Ross-on-Wye: PCCS Books.
Tudor, K. and Merry, T. (2002) Dictionary of Person-Centred Psychology. Ross-on-Wye: PCCS Books.
8 REFERENCES
Angyal, A. (1941) Foundations for a Science of Personality. New York: The Commonwealth Fund.
Angyal, A. (1965) Neurosis and Treatment: A Holistic Theory. New York: Wiley.
Bozarth, J.D. (1984) Beyond reflection: emergent modes of empathy. In R.F. Levant and J.M. Shlien (eds), Client-
Centered Therapy and the Person-Centered Approach: New Directions in Theory, Research and Practice. New
York: Praeger, pp. 59–75.

Bozarth, J.D. (1996a) Client-centered therapy and techniques. In R. Hutterer, G. Pawlowsky, P.F. Schmid, and R.
Stipsits (eds) (1996) Client-Centered and Experiential Psychotherapy: A Paradigm in Motion. Frankfurt am Main:
Peter Lang, pp. 363–8.
Bozarth, J.D. (1996b) A theoretical reconceptualization of the necessary and sufficient conditions for therapeutic
personality change. The Person-Centered Journal 3(1). 44–51.
Bozarth, J.D. (1998) Playing the probabilities in psychotherapy. Person-Centred Practice 6(1): 9–21.
Bozarth, J.D. (2001) Congruence: a special way of being. In G. Wyatt (ed.), Rogers’ Therapeutic Conditions:
Evolution, Theory and Practice, Volume 1, Congruence. Ross-on-Wye: PCCS Books, pp. 174–83.
Brodley, B.T. and Brody, A. (1996) Can one use techniques and still be client-centered? In R. Hutterer,
G. Pawlowsky, P.F. Schmid, R. Stipsits (eds), Client-Centered and Experiential Psychotherapy: A Paradigm in
Motion. Frankfurt am Main: Peter Lang, pp. 369–74.
Cooper, M. (2008) Essential Research Findings in Counselling and Psychotherapy: The Facts are Friendly. London:
Sage.
Holdstock, T.L. (2000) Re-examining Psychology: Critical Perspectives and African Insights. London: Routledge.
Lago, C. (2007) Counselling across difference and diversity. In M. Cooper, M. O’Hara, P.F. Schmid and G. Wyatt
(eds), The Handbook of Person-Centred Counselling and Psychotherapy. Basingstoke: Palgrave, pp. 251–65.
Rodgers, B.J. (2003) An exploration into the client at the heart of therapy: a qualitative perspective. Person-
Centered and Experiential Psychotherapies 2(1): 19–30.
Rogers, C.R. (1942) Counseling and Psychotherapy. Boston: Houghton Mifflin.
Rogers, C.R. (1951) Client-Centered Therapy. London: Constable.
Rogers, C.R. (1957) The necessary and sufficient conditions of therapeutic personality change. Journal of
Consulting Psychology 21(2): 95–103.
Rogers, C.R. (1959) A theory of therapy, personality, and interpersonal relationships, as developed in the client-
centered framework. In S. Koch (ed.), Psychology: A Study of a Science. Vol. 3. Formulations of the Person and
the Social Context. New York: McGraw-Hill, pp. 184–256.
Rogers, C.R. (1961) On Becoming A Person: A Therapist’s View of Psychotherapy. London: Constable.
Rogers, C.R. (1977) Carl Rogers on Personal Power. London: Constable.
Rogers, C.R. (1986) Rogers, Kohut, and Erickson: a personal perspective on some similarities and differences.
Person-Centered Review 1(2): 125–40.
Rogers, C.R. and Sanford, R. (1989) Client-centered psychotherapy. In H.I. Kaplan and B.J. Sadock (eds),
Comprehensive Textbook of Psychiatry, V, Vol. 2. Baltimore: Williams and Wilkins, pp. 1482–1501.
Speierer, G-W. (1990) Toward a specific illness concept of client-centered therapy. In G. Lietaer, J. Rombauts,
R. Van Balen (eds), Client-Centered and Experiential Psychotherapy in the Nineties. Leuven: Leuven University
Press, pp. 337–59.
Stiles, W.B., Barkham, M. Mellor-Clark, J., Connell, J. (2008) Effectiveness of cognitive-behavioural, person-centred
and psychodynamic therapies in U.K. primary care routine practice: replication in a larger sample. Psychological
Medicine 38: 677–88.
Taft, J. (1933) The Dynamics of Therapy in a Controlled Relationship. New York: Macmillan.
Thorne, B. (1991) Carl Rogers: the legacy and the challenge. In B. Thorne, Person-Centred Counselling:
Therapeutic and Spiritual Dimensions. London and New Jersey: Whurr, pp. 178–89.
Wilkins, P. and Gill, M. (2003) Assessment in person-centered therapy. Person-Centered and Experiential
Psychotherapies 2(3): 172–87.

7
Existential Therapy
Emmy van Deurzen
Existential therapy is first and foremost philosophical. It helps people to understand their
position and situation in the world and encourages them to think more clearly for themselves.
The aim of therapy is for clients to become able to make new choices in line with their care-
fully considered beliefs and values and to find the strength to live life to the full, with passion
and compassion. Past, present and future are seen as equally important in considering the
meaning and purpose of life. Human problems in living are explored with a receptive atti-
tude, rather than with a dogmatic one. The aim is to search for truth with an open mind and
an attitude of wonder rather than to fit the client into pre-established frameworks of interpre-
tation. Context is as important as subtext, so that the political, social, cultural and ideological
aspects of a person’s predicament are explored alongside the unspoken assumptions, preju-
dice and worries that trouble them.
The wider historical background to existential therapy is that of 3000 years of philosophy.
Throughout the history of humankind people have tried to make sense of life in general and
of their personal difficulties in particular. Much of the philosophical tradition is relevant and
can help us to understand an individual’s position in the world. The philosophers who are
especially pertinent are those whose work is directly aimed at making sense of human exist-
ence: the existential philosophers (Deurzen and Adams, 2011).
Kierkegaard (1813–55) protested vigorously against Christian dogma and the so-called
‘objectivity’ of science (Kierkegaard, 1944). He thought that both were ways of avoiding the
anxiety inherent in human existence. He had great contempt for the way in which life was

being lived by those around him and believed that truth could ultimately only be discovered
subjectively by the individual in action. What was most lacking was people’s courage to take
the leap of faith and live with passion and commitment from the inward depth of existence.
This involved a constant struggle between the finite and infinite aspects of our nature as part
of the difficult task of creating a self and finding meaning.
Nietzsche (1844–1900) took this philosophy of life a step further. His starting point was
the notion that God was dead (Nietzsche, 1961) and that it is up to us to re-evaluate exist-
ence in light of this. He invited people to shake off the shackles of moral constraint and
to discover their free will in order to soar to unknown heights and learn to live with new
intensity. He encouraged people not to remain part of the herd, but to dare stand out. The
important existential themes of freedom, choice, responsibility and courage are important
to him.
Husserl (1859–1938). While Kierkegaard and Nietzsche drew attention to the human
issues that needed to be addressed, Husserl’s phenomenology (Moran, 2000) provided the
method to address them in a rigorous manner. He contended that natural sciences are based
on the assumption that subject and object are separate and that this kind of dualism can only
lead to error. He proposed a whole new mode of investigation and understanding of the world
and our experience of it. Prejudice has to be put aside or ‘bracketed’, in order for us to meet
the world afresh and discover what is absolutely fundamental and only directly available to
us through intuition. If we want to grasp the essence of things, instead of explaining and
analysing them we have to learn to describe and understand them.
Heidegger (1889–1976) applied the phenomenological method to understanding the mean-
ing of being (Heidegger, 1962). He argued that poetry and deep philosophical thinking can
bring greater insight into what it means to be in the world than can be achieved through
scientific knowledge. He explored human being in the world in a manner that revolutionised
classical ideas about the self and psychology. He recognised the importance of time, space,
death and human relatedness. He also favoured hermeneutics, an old philosophical method
of investigation, which is the art of interpretation. Unlike interpretation as practised in psy-
choanalysis (which consists of referring a person’s experience to a pre-established theoretical
framework) this kind of interpretation seeks to understand how the person herself subjec-
tively experiences something and makes sense of it.
Sartre (1905–80) contributed many other strands of existential exploration, particularly
in terms of emotions, imagination, and the person’s insertion into a social and political
world. His insistence on the fundamental freedom and nothingness of human beings and
their subsequent desperate attempts at seeming to be something, like an object and living
in bad faith, are now almost proverbial (Sartre, 1956). The idea of the necessity of being
responsible for our own choices and overcoming self-deception is a very important one
when working with people.
From the start of the twentieth century some psychotherapists (e.g. Jaspers, 1951) were
inspired by phenomenology and its potential for working with people. Binswanger (1963), in
Switzerland, was the first to attempt to bring existential insights to his work with patients, in
the Kreuzlingen sanatorium where he was a psychiatrist. Later on Medard Boss, inspired by

EXISTENTIAL THERAPY 157
Heidegger, established Daseinsanalysis, literally the analysis of human existence (Boss,

1957). Independently Frankl developed his logotherapy, or therapy of meaning in Austria
(Frankl, 1967). Much of this continental work was translated into English during the 1940s
and 1950s and, together with the immigration to the USA of Paul Tillich (Tillich, 1952) this
led to the popularisation of existential ideas as a basis for therapy. Rollo May played an
important role in spreading the word (May, 1983; May et al., 1958) and created a solid basis
of interest in the USA, leading eventually to a specific formulation of humanistic-existential
therapy (Bugental, 1981; Yalom, 1980; Schneider and Krug, 2010). Humanistic psychology
was directly influenced by existential ideas, but it mixed these with American positivism,
changing the original meanings.
Britain became a fertile ground for the further development of the existential approach
when R.D. Laing and his colleagues were inspired by existential ideas in their work with
psychosis (Laing, 1960, 1961). Without developing a concrete method of therapy they criti-
cally reconsidered the notion of mental illness and its treatment. In the late 1960s this led to
the start of the Philadelphia and Arbours Associations, which each established experimental
therapeutic communities, where people could come to live through their madness without the
usual medical treatment. Their work continues today, but their focus has shifted to a more
psychodynamic approach.
The impetus for further development of the existential approach in Britain has largely
come from the development of a number of existentially based courses in academic institu-
tions and the founding of the Society for Existential Analysis and the Journal of the Society
for Existential Analysis in 1988. The International Collaborative for Existential Counsellors
and Psychotherapists (ICECAP) was founded in 2006. British publications dealing with exis-
tential therapy include contributions by Cohn (1997), Spinelli (2005), Cooper (2003),
Strasser and Strasser (1997), Deurzen (1998, 2009, 2010, 2012); Deurzen and Arnold-Baker
(2005), Deurzen and Adams (2011).

Existential philosophy considers human nature to be open, flexible and capable of an enormous
range of experience. The person is in a constant process of becoming and changing, filtering and
interpreting new experiences and processing older ones. We create ourselves as we exist and we
have to reinvent ourselves daily. There is no essential self, as we define our personality and
abilities in action and in relation to our environment. This impermanence and uncertainty give
rise to a deep sense of anxiety (Angst), in response to the realisation of our vulnerability and
simultaneous responsibility to create something in place of the emptiness we often experience.
Everything passes and nothing lasts. We are never able to hold on to the present.
Existential thinkers seek to avoid restrictive models that categorise or label people. Instead
they foreground the process of change and development each of us is involved in. They also

look for the universals that can be observed cross-culturally. There is no existential personal-
ity theory which divides humanity into types or reduces people to part components. Instead
there is a description of the different levels of experience and modes of existence with which
people are inevitably confronted.
The way in which a person is in the world at a particular stage can be charted on this
general map of human existence (Binswanger, 1963; Yalom, 1980; Deurzen, 2010). One
can distinguish four basic dimensions of human existence: the physical, the social, the
psychological and the spiritual. On each of these dimensions people encounter the world
and shape their attitude. Our orientation towards the world defines our reality. The four
dimensions are obviously interwoven and create a complex four-dimensional force field
for our existence.
Physical dimension: On the physical dimension (Umwelt) we relate to our environment
and to the givens of the natural world around us. This includes our attitude to the things that
we encounter in the world around us, the body we have, the concrete surroundings we find
ourselves in, the climate and the weather, our material possessions, the bodies of other peo-
ple, our own bodily needs, and our ultimate and inexorable mortality. The struggle on this
dimension is, in general terms, between the search for domination over the elements and
natural law (as in technology, or in sports) and the need to accept the limitations of natural
boundaries (as in ecology or old age). While people generally aim for security on this dimen-
sion (through health and wealth), much of life brings a gradual disillusionment and realisa-
tion that such security can only be temporary. Recognising limitations can bring great release
of tension.
Social dimension: On the social dimension (Mitwelt) we relate to others as we interact with
the public world around us. This dimension includes our response to the culture we live in,
as well as to the class and race we belong to (and also those we do not belong to). Attitudes
here range from love to hate and from cooperation to competition. The dynamic contradic-
tions can be understood in terms of acceptance versus rejection or belonging versus isolation.
Some people prefer to withdraw from the world of others as much as possible. Others blindly
chase public acceptance by going along with the rules and fashions of the moment. Otherwise
they try to rise above these by becoming trendsetters themselves. By acquiring fame or other
forms of power, we can attain dominance over others temporarily. Sooner or later we are,
however, all confronted with both failure and aloneness.
Psychological dimension: On the psychological dimension (Eigenwelt) we relate to our-
selves and in this way create a personal world. This dimension includes views about our
character, our past experience and our future possibilities. Contradictions here are often
experienced in terms of personal strengths and weaknesses. People search for a sense of
identity, a feeling of being substantial and having a self. But inevitably many events will
confront us with evidence to the contrary and plunge us into a state of confusion or disinte-
gration. Activity and passivity are an important polarity here.
Spiritual dimension: On the spiritual dimension (Überwelt) we relate to the unknown and
thus create a sense of an ideal world, an ideology and a philosophical outlook. It is here that
we find meaning by putting all the pieces of the puzzle together for ourselves. For some

people this is done by adhering to the dogma of a religion or some other prescriptive world-
view, for others it is about discovering or attributing meaning in a more secular or personal
way. The contradictions that have to be faced on this dimension are often related to the ten-
sion between purpose and absurdity, hope and despair. People create their values in search
of something that matters enough to live or die for, something that may even have ultimate
and universal validity. Usually the aim is the conquest of a soul, or something that will
substantially surpass mortality (as for instance in having contributed something valuable to
humankind).

Disturbance and health are two sides of the same coin. Living creatively means welcoming
both. Well-being coincides with the ability to be transparent and open to what life can bring:
both good and bad. In trying to evade the negative side of existence we get stuck as surely as
we do when we cannot see the positive side. It is only in facing both positive and negative poles
of existence that we generate the necessary power to move ahead. Thus, well-being is not the
naive enjoyment of a state of total balance given to us by Mother Nature and perfect parents. It
is about being well and has to be negotiated daily in coming to terms with life, the world and
oneself. It doesn’t require a clean record of childhood experience, or a total devotion to the cult
of body and mind. It simply requires openness to being and to increasing understanding of what
the business of living is all about. From an existential perspective psychological well-being is
synonymous with wisdom. This results from being equal to the task of life when it is faced
honestly and squarely. Psychological disturbance is seen as a consequence of either avoidance
of truth or an inability to cope with it. Discontent is generated for many people through self-
deception in a blind following of popular opinions, habits, beliefs, rules and reasons.
To be authentic is to be true to yourself and your innermost possibilities and limitations,
but it also means to be aware of the limits of life and face up to your inevitable failings and
mortality. Finding your inner authority and learning to create an increasingly comfortable
space inside and around yourself, no matter what the circumstances, is a considerable chal-
lenge. As the self is defined by its vital links to the world, being true to your self has to be
understood as being true to life. This is not about setting your own rules or living without
regard for others. It is about recognising the necessities, responsibilities and duties of the
human condition as much as about affirming freedom and insisting on your basic rights.
Many people avoid authentic living, because it is terrifying to face the reality of the constant
challenges, failures, crises and doubts that existence exposes us to. Living authentically
begins with the recognition of your personal vulnerability and with the acknowledgement of
the ultimate uncertainty of what is known.

When well-being is defined as the ability to face up to the disturbing facts of life, the notion
of disturbance takes on a whole new meaning. Problems and obstacles are not necessarily an

impediment to living well, for any potentially distressing situation can be seen as a challenge
that can be faced and learnt from. Problems are first of all problems in living and will occur
at any stage in human development. In fact the only thing you can be sure of is that life will
inevitably confront you with new situations that are a challenge to your established ways.
You cannot avoid having to deal with the negative side of the human paradox. When people
are shocked out of their ordinary routine into a sudden awareness of their inability to face the
realities of living, the clouds start to gather.

Psychological health is a relative concept. Even though we may think of ourselves as well-
adjusted people who have had a moderately acceptable upbringing, unexpected events, such
as the death of a loved one, the loss of a job or another significant sudden exposure of our
vulnerability, may still trigger a sense of failure, despair or extreme anxiety. Everything
around you suddenly seems absurd or impossible and your own and other people’s motives
are in question. The value of what used to be taken for granted becomes uncertain and life
loses its appeal. Your basic vulnerability as a human being emerges from behind the well-
guarded self-deception of social adaptation. Sometimes a similar disenchantment and pro-
found disturbance arises not out of an external catastrophe but out of a sense of the futility of
everyday routines. Boredom can be just as important a factor in generating disturbance as
stress or other forms of crisis.
We might be considered healthy to the extent that we are ready to take challenges into our
stride and learn from them. Ultimately it is the essential human longing for truth that redeems.
We are reminded of truth by the pangs of conscience and the anxiety that we experience when
we try to avoid reality. A sense of courage and possibility can be found by stopping the dia-
logue with the internal voices of other people’s laws and expectations. In the quietude of
being with myself I can sense where truth lies and where lies have obscured the truth.

For many of us it is problematic to live with courage and so we try to hide away from diffi-
culties and truth. The paradoxical effect is that we create new problems in the process. Many
human troubles arise from our tendency to build false security and from living in illusion.
Sooner or later such bulwarks get shaken to expose the cracks. Other human troubles, how-
ever, arise from people never having been able to find any security in life. They never achieve
‘ontological security’ (Laing, 1960), which consists of having a firm sense of your own and
other people’s reality and identity. Genetic predisposition makes some of us more sensitive
and more vulnerable than others. People who have such extraordinary sensitivity may easily
get entangled in the conflicts they encounter in their family or in society. If they are exposed
to particularly intense contradictions (as in certain family conflicts) they may fall into a state
of extreme confusion and despair and withdraw into the illusory security of a world of their
own creation. Both the ontologically secure person who is disturbed by a crisis (or boredom)

and the ontologically insecure person who is overwhelmed by human existence may become
unable to make sense of things.

For some people this struggle with the more unpleasant facts of life can be unremitting. For
other people building up a false self can initially protect but will ultimately lead to break-
down when this falsehood is challenged. No one can maintain their bad faith and illusion of
protection forever. Sooner or later an existential crisis will expose our alienation from our-
selves or from the world. The existential view of disturbance is that it is an inevitable and
even welcome event that needs to be encountered bravely if we are to learn from it. It is in
facing up to our disturbance that we can begin to find a deeper truth about existence and take
stock of our lives. The question is not how to avoid it but on the contrary how to approach it
with determination and curiosity.

If a person is out of touch with their own evasion of the facts of life, they may not even know
that there is a problem. This happens particularly when the person has not been able to create
an inner discourse and sense of self that is strong enough to hold its own. Then a self-perpetuating
negative spiralling downward can happen which leads to confusion and chaos. This is most
likely to occur if we are not linked to a vital support system and do not feel the inner strength
to stand alone and think and act for ourselves to check out that we are in harmony with the
facts of reality.

As long as our family or other intimate networks of reference are strong and open enough to
absorb the contradictions that we get caught up in, distress can be eased and overcome: the
balance can be redressed. But if we find ourselves in isolation, without the understanding and
challenge of a relative, a partner or a close friend, it is easy to get lost in our problems.
Society’s rituals for safeguarding the individual are these days less and less powerful and
secure. Few people gain a sense of ultimate meaning or direction from their relationship to a
personal god or from other essential beliefs. Many feel at the mercy of temporary, ever-
changing but incessant demands, needs and desires. In time of distress there often seems to
be nowhere to turn. Relatives and friends, who themselves are barely holding their heads
above water, may be unavailable. If they are available, they may want to soothe distress
instead of tackling it at the root.

Paradoxically, the institutions in our society often seem to encourage the very opposite of
what they are supposed to be about. When the family becomes a place of loneliness and

alienation instead of one that fosters togetherness and intimacy and when doctors’ surgeries
become places of dependence and addiction instead of centres of healing and renewal of
strength, it is time for essentials to be reconsidered. Much disturbance is not only generated
but also maintained by a society that is out of touch with the fundamental principles of life.
The disturbance of society is sometimes expressed in the distress of those who face a crisis.
2.5 Change
Life is one long process of change and transformation. We are in constant flux. Although
people often think they want to change, more often than not their lives reflect their attempts
at maintaining the status quo. Change feels risky and stability feels safe. As a person becomes
convinced of the inevitability of change she may also become aware of the many ways in
which she has kept such change at bay. Almost every minute of the day people make small
choices that together determine the direction of their life. Often that direction is embarked
upon passively: people just conform to their own negative or mediocre predictions of the
future. But once insight is gained into the possibility of reinterpreting a situation and opting
for more constructive predictions a change for the better may come about. This requires us
to learn to live deliberately instead of by default, and it can only be achieved by first becom-
ing aware of how our daily attitude and frame of mind is set to the kind of automatic function-
ing that keeps us repeating the same mistakes.
It is not easy to break the force of habit, but there are always times when habits are broken
by force. Crises are times when old patterns have to be revised and when changes for the
better can be initiated. This is why existential therapists talk about a breakdown as a possible
breakthrough and why people often note with astonishment that the disaster they tried so hard
to avoid was a blessing in disguise. In times of crisis the attention is refocused on where
priorities lie so that choices can be made with more understanding than previously.
Whether such an event is self-imposed (as in emigration or marriage) or not (as in natural
disasters or bereavement) it has the effect of removing previously taken for granted securi-
ties. When this happens it becomes more difficult for us to obscure the aspects of existence
that we would rather not think about, and we are compelled to reassess our own attitudes and
values. In the ensuing chaos we must make choices about how to proceed and how to bring
new order into our lives.
3 PRACTICE

The goals of existential therapy are to enable people to:
• take stock of their situation, their values and beliefs;

• come to terms with past, present and future challenges;

• become more truthful with themselves;

• widen their perspective on themselves and their view of the world around them;
• find clarity on their purpose and meaning in life;
• understand themselves and others better and find better ways to communicate;
• make sense of the paradoxes, conflicts and dilemmas of their everyday existence;
• liberate themselves from unnecessary alienation and self-deception;
• learn to live well;
• be courageous in facing difficulties.
The word ‘authenticity’ is often used to indicate the goal of becoming true to oneself. This is
a much-abused term, which misleadingly suggests that there is a true self; whereas the exis-
tential view is that self is relationship and process – not an entity or substance. Authenticity
can also become an excuse for people who want to have their cake and eat it. Under the aegis
of authenticity anything can be licensed: crude egoism may very well be the consequence. In
fact, authenticity can never be fully achieved. It is a gradual process of self-understanding,
but of the self as it is created in your relationships to the world on all levels. Helping people
to become authentic therefore means assisting them in gaining a greater understanding of the
human condition, so that they can respond to it with a sense of mastery, instead of being at
its mercy.
The task of the therapist is to have attained sufficient clarity and openness to be able to
venture along with any client into murky waters and explore (without getting lost) how this
person’s experience fits into a wider map of existence. Clients are guided through the distur-
bances in which they are caught and are helped to examine their assumptions, values and
aspirations, so that a new direction can be taken. The therapist is fully available to this explo-
ration and will often be changed in the process.

People who want a specific diagnosis of what ails them and who want to achieve rapid symp-
tom relief rather than to gain understanding, might be better off being referred to other forms
of therapy. Similarly those who have particular physical issues for which medical interven-
tion is required should be referred back to their doctor. Of course in both these situations it
may be that people need something else besides psychological or medical intervention and
that they return for a more philosophical discussion of their position at a later stage. In final
analysis existential work requires a commitment to questioning prejudice and searching for
meaning that is not necessarily immediately welcome to all clients.

Existential therapy is especially suitable for people who feel alienated from the expectations
of society or for those seeking to clarify their personal ideology. It is particularly relevant to
people living in a foreign culture, class or race, as it does not dictate a theoretical doctrine,

but explores a person’s own meanings. It also works well with people confronting adversity
in their lives or who are trying to cope with changes of personal circumstances (or want to
bring those about). Bereavement, job loss or biological changes (in adolescence, middle age
or old age) are a prime time for the reconsideration of the rules and values one has hitherto
lived by. Generally speaking the existential approach is more helpful to those who question
the state of affairs in the world, than to those who prefer the status quo. This approach seems
to be most right for those at the edge of existence: people who are dying or contemplating
suicide, people who are just starting on a new phase of life, people in crisis, or people who
feel they no longer belong in their surroundings.
Even though existential work consists in gaining understanding through talking, the client’s
level of verbal ability is not important. Very young children or people who speak a foreign
language will often find that the simpler their way of expressing things, the easier it becomes
to grasp the essence of their worldview and experience. Existential therapy is suited to many
different settings: individual, couple, family or group. When it involves more than one person
at a time, the emphasis will be on clarifying the participants’ perceptions of the world and their
place in it, in order to encourage communication and mutual understanding.

Good existential therapists combine personal qualities with accomplishment in method, but
on balance the former is more important than the latter. Personal qualities can be described
as falling into three categories: (a) life experience; (b) attitude and personality; and (c) theo-
retical knowledge.
Life experience: Existential therapists will be psychologically and emotionally mature as
human beings. This maturity will manifest itself in an ability to make room in oneself for all
sorts of, even contradictory, opinions, attitudes, feelings, thoughts and experiences. They will
be open-minded and capable of overseeing reality from a wide range of perspectives. They
will also be able to tolerate the tension that such awareness of contradictions generates. There
are a number of life experiences that appear to be particularly helpful in preparing people for
such maturation and broad-mindedness. Cross-cultural experience is an excellent way to
stretch the mind and your views on what it means to be human.
Raising a family, or caring for dependants in a close relationship, is another invaluable
source of life experience relevant to creating an open attitude. Many people have this experi-
ence, which can become one of the building blocks of therapy training. Variety in life, aca-
demic or professional experience can also be an advantage. People opting for psychotherapy
as a second career are often especially suited to existential training. Finally, the sine qua non
of becoming an existential therapist is to have negotiated a number of significant crossroads
in your personal life.
Attitude and personality: Existential therapists should be capable of critical but open
consideration of situations, people and ideas. They are serious, but not heavy-handed,

downtrodden or cynical. They can be light-hearted, hopeful and humorous about the
human condition, whilst intensely aware of the tragic poignancy of much of existence.
They should be capable of self-reflection, recognising the manner in which they them-
selves represent the paradoxes, ups and downs, strengths and weaknesses that people are
going through. They should have a genuine sense of curiosity and a strong urge to find
out what it means to be human. They should be capable of sustaining an attitude of won-
der. Existential therapists will now and then abandon psychological theory altogether and
reach for poetry, art, music or religion instead. They will tend to be quite personal in
their way of working.
Theoretical knowledge: A basic working knowledge of philosophy, that is of the contro-
versies and perspectives that the human race has produced over the centuries, is more useful
to this approach than any other kind of knowledge. Included in this will also be a familiarity
with the history of psychology and psychotherapy and an interest in those scientific ideas that
are relevant to human existence. In other words, a broad and serious study of the human and
social sciences is desirable, so that interventions are based in fact rather than in opinion. A
practical knowledge of human interactions, communication and the dynamics of the thera-
peutic relationship is essential.

Existential therapists need a wide generic training, but they also need to hold all this informa-
tion safely within a philosophical framework. Specific skills of dialectical interaction will be
evident. Self-reflection and a commitment to self-development will also be shown. Here
again it is the quality that will be judged instead of the quantity. Numbers of hours of indi-
vidual and group therapy are not as important as the depth and clarity with which a therapist
is capable of working. Some people will not reach the necessary perspective and depth with
any amount of therapy. Others will be well ahead by having engaged in a discipline of self-
reflection for years. Effective therapists usually demonstrate their ability to think creatively
about complex human dilemmas.

Therapeutic style is flexible and individual. The existential therapist is ready and willing to
shift her approach when the situation requires this.
There are, however, some common features of an existential relationship. The therapist is:
• co-present with the client as an equal collaborator;

• not directive and does not prescribe how to be or think;
• not non-directive, but open and actively engaged;
• directional: enabling clients to discover how they want to progress;
• direct and clear in communication;

• attentive, listening carefully so as to hear and understand;

• mindful of context and subtext;
• committed to using dialogue as the basis of the interaction;
• reflective and self-reflective: aware of bias and prejudice;
• prepared to learn about life from each session.
The client is assisted in finding his or her own perspective and position in the world in rela-
tion to the parameters and limits of human existence. Existential therapists need to learn to
resist the temptation to try to change their clients. The therapy is an opportunity for a person
to take stock of life and of their ways of being in the world. Nothing is gained from interfer-
ing with these. The client is simply given the space, time and understanding to help her come
to terms with what is true and important for her. The therapist does not teach or preach about
how life should be lived, but lets the client’s personal taste in the art of living evolve naturally
as the therapeutic dialogue progresses.
The only times when the therapist does follow a didactic line is when she reminds the
client of aspects of a problem that have been overlooked. She may gently encourage the
client to notice a lack of perspective, think through consequences and struggle with contra-
dictions. She puts forward missing links and underlying principles. The therapist never does
the work for the client but makes sure that the work gets done. The client’s inevitable
attempts to shirk and flee from the task in hand are reflected on and used as concrete evi-
dence of the client’s attitude to life. The same can be said of the actual encounter between
the client and the therapist, which is also reflected on and seen as evidence of the client’s
usual ways of relating.

Generally speaking the therapeutic style follows a conversational pattern. Issues are consid-
ered and explored in philosophical or Socratic dialogue. The rhythm of the sessions will
follow the client’s preoccupations – faster when emotions are expressed and slower when
complex ideas are disentangled. Existential therapists need to learn to allow clients to take
the amount of space and time in this conversation that they need in order to proceed at their
own pace. Existential therapists create sufficient room for the client to feel that it is possible
to unfold their troubles.
Existential sessions are usually quite intense, since deep and significant issues often
emerge. Moreover, the therapist is personally engaged with the work and is willing to be
touched and moved by the client’s conflicts and questions. The human dilemmas
expressed in the therapeutic encounter have as much relevance to the therapist as to the
client. This commonality of experience makes it possible for client and therapist to work
together as a team, in a cooperative effort to throw light on human existence. Every new
challenge in the client’s experience is grist for the mill. The therapeutic relationship
itself brings many opportunities to grasp something of the nature of human interaction.
The therapist, in principle, is ready to consider any past, present or future matter that is
relevant to the client.


3.5.1 Assessment
Assessment is generally conducted by inviting the client at the first session to describe what
it is that brings them to therapy. They may also be asked to tell the story of what is of concern
to them. Some existential therapists have a broader approach and may encourage the client
to give them a brief overview of the salient aspects of their life. Yet others may suggest the
client answers the following questions: ‘Who are you? Where do you come from? Where are
you now? Where are you going? What is stopping you getting there?’ Few existential thera-
pists will provide a formal questionnaire or test procedure. The phenomenological method is
used at all times, to remind the client to describe rather than to interpret their situation and to
put their plight into context rather than to analyse or explain it.

The client is encouraged to come up with their own formulation of the particular difficulties
they wish to tackle in psychotherapy. In subsequent sessions they may be invited to consider
whether their objectives have changed, which is usually the case, and to come up with a new
formulation of what they want to clarify and achieve.

The existential approach is well known for its anti-technique orientation. It prefers descrip-
tion, understanding and exploration of reality to diagnosis, treatment and prognosis.
Existential therapists will not generally use particular techniques, strategies or skills, but they
will follow a specific philosophical method of enquiry, which requires a consistent profes-
sional attitude. This method and attitude may be interpreted in various ways, but it usually
includes some or all of the following ingredients.
• Cultivating a naïve and open attitude: By consistently meeting the client with an open mind and in the
spirit of exploration and discovery a fresh perspective on the world will emerge.
• Spotting themes: Obvious patterns and themes will run through the apparently confused discourse of the
client. The therapist listens for the unspoken links and connections that are implicit in what is said. When
the theme is obvious and has been confirmed several times, the client’s attention can be drawn to it.
• Noticing assumptions: Much of what the client says will be based on a number of basic assumptions
about the world. Generally people are unaware of these. Clarifying implicit assumptions can be very
revealing and may throw new light on a dilemma.
• Pinpointing vicious circles: Many people are caught up in self-fulfilling prophecies of doom and destruc-
tion without realising that they set their own low standards and goals. Making such vicious circles explicit
can be a crucial step forward. With further insight, self-fulfilling prophecies can be tilted in a more posi-
tive direction.
• Checking meanings: By questioning the superficial meaning of the client’s words and asking her to think
again of what she wants to express, a new awareness may be brought about.

• Reconsidering values: Getting clarity about what makes life worth living and which aspects of life are
most important and deserve making sacrifices for is a key step towards finding a sense of direction and
purpose.
• Facing limitations: The therapist will be alert to opportunities to help the client identify the limitations of
the human condition. This means facing up to ultimate concerns, such as death, guilt, freedom, failure,
isolation, meaninglessness, etc.
• Tackling self-deception: Much of the time we pretend that life has determined our situation and charac-
ter so much that we have no choices left. Crises may provide us with proof to the contrary.
• Working with existential anxiety: The anxiety that indicates awareness of inevitable limitations and
death is also a dizziness in the face of freedom and a summoning of life energy. Existential anxiety is
the start of awareness and vitality. Some people have dulled their sensitivity so as to avoid the basic
challenges of life, while others disguise them. Some people simply feel beaten by life. Optimal use of
anxiety is one of the goals of existential work.
• Tracing existential guilt: Therapists watch for existential guilt hidden in various disguises (such as anxiety,
boredom, depression or even apparent self-confidence) for it points to priorities.
• Considering consequences: Clients are sometimes challenged to think through the consequences of
choices, both past and future. In facing the implications of actions, limitations and possibilities emerge
together with a new sense of responsibility.
• Playing with paradoxes: In helping clients to become more authentic the concept of paradox comes into
play. It is vital to check that a person is aware of her capacity for both sides: life and death, success and
failure, freedom and necessity, certainty and doubt. Truth is dynamic, rather than static.

Exploring personal world view: Existential therapy is open to all of life’s dimensions, tasks
and problems, and the therapist will in principle explore together with the client all informa-
tion that the latter brings along. It is essential to follow the client’s lead and understand her
particular take on the world.
Mapping the fourfold world: In using the model of the four worlds, with its physical,
social, psychological and spiritual dimensions and its tensions and paradoxes at each level,
we can more easily make sense of the client’s account of herself as revealing her preoccupa-
tions with particular levels of her existence. A systematic existential analysis (SEA) of how
the client expresses her relationship to the physical, social, psychological and spiritual
dimensions of her world can provide much insight into imbalance, priorities and impasses.
Intuitions, feelings, thoughts, sensations, dreams and fantasies are all explored.
Dream description: Listening to dreams with the four-world map in mind can be extremely
enlightening. The dream is seen as a message of the dreamer to herself. The dream experience
reflects the dreamer’s attitudes on the various dimensions of existence and the client’s dream
existence and world relations are in parallel with those of waking life. Understanding the
dream is not about interpretation but careful description of the phenomena.
Socratic questioning: Questions are often asked in order to explore the client’s worldview
and comprehend it better. Further material is often elicited to check out, confirm or disconfirm
the client’s position in her universe. Sometimes an enquiry might be made along the lines of an
exploration: ‘What makes this so important to you?’, or ‘What is this like for you?’, or ‘What

does it mean to you?’ The question never suggests a solution and never judges right or wrong.
The therapist does not try to catch the client out, nor does she try to be clever.
Enquiring into meaning: All investigations eventually lead to a greater understanding of
what makes the world meaningful to the client. The idea is to assist the client in finding pur-
pose and motivation, direction and vitality. Life is nothing without a deep sense of meaning
and significance in life. Sometimes we need to challenge spurious purpose. Quite often new
interpretations of past or present events are arrived at, altering the client’s orientation to life
and to the future.
Emotional compass: Feelings are of great help in this process. Understanding the meaning
of your emotions and moods, as well as of your thoughts and intuitions is usually productive
and fruitful. Each emotion, sensation, thought, feeling or intuition has its own significance
(Deurzen, 2010, 2012) and the whole range of the emotional spectrum is easy to understand
when using the existential tool of the emotional compass, where each emotion indicates
direction and value. Emotions like shame, envy and hope are indicators of values that are still
missing but implicitly longed for. Love, joy and pride are within the range of emotions that
indicate a sense of ownership of what is valued. Whereas jealousy and anger express an
active response to the threat that what is valued may be lost, fear and sorrow come with the
giving up and eventual loss of what really mattered (see Deurzen, 2012).
Locating beliefs: As we listen to someone we gradually get the picture of how their preoc-
cupations and opinions relate to their underlying beliefs and values. It is important to locate
these carefully and respectfully. Nothing can be gained from opposing the client’s values with
an alternative set of values or coaxing clients into conformity. Existential therapy encourages
self-reliance and inner sense of purpose instead. Nevertheless beliefs can be challenged, ena-
bling clients to be more aware of how their beliefs can encompass a broader frame of reference.
Tracing talents: Many talents, abilities and assets will have been hidden by the client’s
preoccupation with what is wrong with her. The therapist will strive to draw attention to the
wisdom and strength that are lying fallow. Often it is useful for the therapist to build on the
example of the client’s abilities as they come to the fore and use them as the point of refer-
ence for further understanding.
Recollection and forgetting: Memories will be seen as malleable and open to new interpre-
tation. While clients often set out with fixed views of the past they discover the possibility of
reconsidering the same events and experiences from different angles. We influence our future
by what we choose to recollect or forget from the past. We can open new vistas by remember-
ing more fully and letting go of what is no longer of use. When the client realises that she is
the ultimate source of the meaning of her life, past, present and future, living is experienced
as an art rather than a chore or a duty.

The aim of existential therapy is not to change people but to help them to come to terms with
the transformative process of life. The assumption is that when people do face reality they

are likely to find a satisfactory way forward. People are often hurried and under the impres-
sion that they can speed life up and force great rewards out of it with relatively little effort.
One of the aims of existential therapy is to enable people to stop deceiving themselves about
both their lack of responsibility for what is happening to them and their excessive demands
on life and themselves. Learning to measure one’s distress by the standards of the human
condition relieves pressure and at the same time provides a clearer ideological basis for mak-
ing sense of personal preoccupations and aspirations. Clients change through existential
therapy by gradually taking more and more of life’s ups and downs in their stride. They can
become more steadfast in facing death, crises, personal shortcomings, losses and failures if
they accept the reality of constant transformation that we are all part of.
As they are constantly reminded to take time to be still, listen and do their own thinking
on these issues, people get better at monitoring their own actions, attitudes and moods. The
therapy gives clients an opportunity to rediscover the importance of relating to themselves
and make room for contemplation and recreation. Existential therapy teaches a discipline for
living which consists of a frequent process of checking what one’s attitude, inclination, mood
and frame of mind are, bringing them back in line with reality and personal aspirations.
Change is initiated in the sessions, but not accomplished in them. The process of transforma-
tion takes place in between the sessions and after therapy has terminated.
4 CASE EXAMPLE
4.1 The client

Noah is 42 years old when he consults me because of: ‘a deep sense of woe and terror’.
While he acknowledges that he has experienced such feelings for as long as he can
remember, he is now practically paralysed with anxiety on a daily basis. His general sense
of being out of synch with the world has been growing. It has become excruciatingly hard
for him to get up in the morning and go to work. He takes no pleasure in life at all and
expects things to go wrong. He declares that he often wonders why he is not happier as,
considered objectively, he is actually doing rather well on all fronts. He is fairly success-
ful in his profession, though he privately knows that he has allowed his career to become
snagged in the easy rewards of working for a safe company and has given up on any
attempt at making his own mark.
There is zero creativity involved in his job, which is in the creative field. He loathes the
corner cutting that goes on as a matter of course. He takes no pride in his profession but can-
not see a way around this as his family needs the income. He is married to Susie, who is two
years older than him and they have two sons, fourteen and sixteen, who he looks after when
Susie is on night duty. Noah feels incompetent as a dad, as his sons have grown out of need-
ing him. He also thinks Susie no longer needs him. She likes to party with her girlfriends
when she is off work. He hardly sees her these days. He feels useless and often thinks of
killing himself. He admits he is cynical about therapy.

4.2 The therapy

Noah is initially reluctant to be honest and open. During the first sessions he frequently returns
to the theme of his despair. The rest of the time he is not very vocal and often sits still, con-
centrating on something I cannot see, hugging his chest tightly with one arm, whilst covering
both his eyes with the other hand. He repeatedly reminds me that he does not want to speak
about the past. When I ask him why not, he replies that the past is the past and that there is no
point revisiting it. He is stuck in no man’s land: cut off from both past and future. I say this to
him and add that it looks as if his past holds an unmentionable and frightening secret. He looks
worried but refuses to engage. I wait patiently for the veil to be lifted so that we can slip around
the taboo and safely look backwards, long enough to begin building his confidence in facing
past fears. Noah turns up regularly without truly committing himself to the work. He often
complains of the dullness of his everyday existence and the bleakness of the future.
We make a little bit of progress as he accepts that he does not leave himself much room
for movement by maintaining his aloof position and avoiding risk. He may be relatively safe
but for this he pays the terrible price of being frozen. He sees and regrets this, but complains
of other people not showing him any interest or warmth. He particularly bemoans Susie’s
disinterest in him. I gently remind him that he is not showing much interest in her either. He
actually grins as if he is pleased about this and it is good to see a flicker of emotion, so I
decide to turn up the heat and ask him what Susie thinks of his disinterest in her. He shows
a flash of anger. ‘Ah,’ I say, mildly, ‘that hit a nerve.’ He replies crossly that it is impossible
for him to show an interest in her as she could not care less and does not give a hoot about
him. ‘She is much more interested in having fun with other people.’ He sounds bitter. For the
first time he is strongly emotionally engaged. ‘And you deeply resent this,’ I note, kindly and
quietly. He nods and fixes my gaze, watching me like a hawk as I prepare to speak again. I
pause and search for the right words to challenge him without putting him off: ‘But you are
not telling her about this, are you? You watch her getting it wrong without telling her how
you feel or what you want.’ I suspect this to be the case as it is what he does with me, but I
want to provoke him into speaking his own mind.
When he notices that I am genuinely interested in what he feels and believes he says
calmly: ‘I do care for Susie and want her to care for me, but I know she doesn’t.’ I nod my
understanding of his assumptions: ‘you care too deeply to take a risk and find out if that is
true?’ He says hesitantly: ‘I don’t think anyone has ever really cared for me.’ I feel moved by
this glimpse of his hidden sorrow. He seems deeply miserable. I remain silent for a bit, find-
ing a safe place to be at ease in his darkness, before saying softly: ‘Nobody? Not even your
parents?’ I can practically hear him wondering whether to tell me more as he turns his head
away from me, clearly in pain. He vaguely nods, looking down, avoiding my eyes. When he
lifts his head, there is fear in his eyes. I look back at him kindly, nodding gently, opening my
hands towards him, palms up, as if to say: ‘over to you’. He thinks for a while and then
accepts the invitation, speaking of the past, sending out a painful probe into the root of his
discomfort and unhappiness.

All of a sudden there is plenty to say as Noah tells me about his nightmare childhood. I
listen, horrified but fascinated and absorbed by his story. I let him find his own path, follow-
ing the flow of his emotion. Noah was the only child of parents who were always fighting.
His mother drank gin like milk. His dad tolerated the situation. Mom had many boyfriends.
Noah used to hide and watch them get drunk with mom while dad was out working. One day
his mother went off with a boyfriend never to return to live with them. It happened while dad
was at work and Noah was home. He did not know what to do. He was nine years old. He
felt paralysed and guilty. His dad was devastated and refused to do any work or housework
for months. Noah learnt to do the shopping, the cooking and the washing. He looked after
dad until dad started going back to work. Then he became terrified that dad too would leave.
Sometimes he was hopeful that mum would return. One day she did briefly, but she was so
drunk that he was ashamed of her. She threatened him with a kitchen knife, shouting at him
not to tell dad that she had been home to pick up her things. He was too frightened that dad
would collapse again if he spoke about it, so he didn’t.
After that he never mentioned mum and asked dad to change the locks. He never felt quite
safe again. He wasn’t sure whether he loved his mom and wanted her to come back, but he
always knew she would not. He was sure she didn’t love him. He wasn’t sure of dad’s love
either, but he tried to be good to him to earn it. Sometimes he wished his dad were like other
dads, sometimes he wished he too would leave, so that he could be alone and no longer fear
abandonment. Sometimes he thought he would be better off dead but he never tried to kill
himself as he worried about the effect this would have on his father.
He kept his head down and worked hard in school. The next thing was that he left home to
go to university, knowing he would never return to live back home again. He met Susie; she
was a popular girl and he could not imagine why she wanted to be with him, but somehow she
did. He helped her find the money for an abortion, even though it was nothing to do with him,
as he had not slept with her yet. He asked Susie to marry him to make up for the abortion and
she was happy to do so. They were very young and he knew she was sleeping around. He
accepted this as he had accepted his mother’s bad behaviour, not feeling he had a choice in the
matter. When their first son was born five years later, he wasn’t sure he was the father, but never
asked. By this time he had a steady job. He was almost certain that his second son, born two
years later, was his, as he looked like him from the start. Soon after the birth of his second son,
his own dad died of prostate cancer. He heard some years later that his mother had died of drink
related problems. It was a relief to be an orphan at last, he claims. But he sounds deeply upset
and his voice wavers, though he contains his distress and there is no hint of tears. When I com-
ment on his strength in speaking about all this, he waves the compliment away and says he
normally just doesn’t think about any of it. He wants to be free of these affections that hurt him.
To be an orphan, to him, means not to have to carry his parents’ burdens any longer. He agrees
when I point out that he has learnt that love is a burden rather than a gift.
Now that the story is out Noah can speak about his relationship to Susie in a different way
too. He can see that he and Susie have become alienated from each other. The thought of her
leaving him is constantly at the back of his mind. He fully expects it to happen. I point out
that he probably thinks it would be a relief, since loving her is a burden. He acknowledges

this as true and realises he almost tries to make it happen, and yet he is terrified of being
alone. He wants to talk about his despair and I honour his wish to stay focused on his inner
isolation and terror. I accept that the starting point of the exploration has to be the centre of
his personal experience and I follow his sense that life has become bleak and is leaking mean-
ing from every pore. We agree that this experience is the result of what he has learnt about
life, i.e. that nobody can be trusted and no-one will ever love him just the way he is. It is
dawning on him that he may be wrong about this. I remark that he has also learnt that he can
actually cope very well alone, so that the despair is more about the fear of abandonment than
about managing his life on his own. He is grateful for this remark and allows himself a tiny
smile. Over the weeks that follow he begins to find words to articulate all of this more and
more sharply and it amazes him each time he sees a new connection and understands his own
world better. He realises he keeps Susie and the boys at bay, for fear of being vulnerable to
their rejection. Next he realises he makes them reject him by remaining aloof and emotionally
unavailable. Occasionally he starts calling himself a coward, but he is able to see how he has
in fact dealt with difficulty in unusually courageous ways. He is astonished to find that I am always
on his side and wanting to understand better. He is amazed at the notion that I am champion-
ing instead of judging him. It moves him.

Noah does not think he is depressed. He thinks that he is not fit for life and that life is not fit
for him. He believes this may be a genetic problem. He thinks he has inherited his mother’s
bad character, but won’t describe to me what this means. After some discussion, he agrees
that the problem is that he has no sense of purpose and has no idea what would make life
worth living. Noah recognises that he feels confused about his role in the world and in his
sons’ lives and that he is highly insecure in relation to his wife Susie, whom he perceives as
very together and independent. We agree that the most important thing for us to work out is
what would make his life worth living and lift him from his despair. He would love to feel
there is something worth living for and to feel motivated to actually get up in the morning.
We agree to work towards this end. I am aware that in spite of this consensus Noah has not
really told me what it is that is wrong with his life.

Working with Noah means exploring multiple themes at the same time, until they unravel
well enough for him to see them clearly and firmly get a hold of each separate idea, so
that he can begin to use it and reweave it into a new understanding of life. The idea of
being able to revisit the past without fear is the absolute key to this and we practise this
stoically until he feels at ease in the past as much as in the present. His excitement about
being able to be creative rather than just reactive in his life is a revelation and the first
happy feeling he expresses is about this discovery that he can change and learn. He is
amazed at how blind he has been all his life, keeping his eyes tightly shut for fear of lurk-
ing dangers. He is excited about exploring different ways of looking at the world and

becomes able to take stock of the many ways in which past experiences continue to over-
shadow the present. We get better together at sticking with the whirlwind of dark and
threatening emotions that past events set off in him and he begins to take pride in facing
his demons. He sees that there is nothing wrong with him or his character, but that there
was much wrong with his life.
As his confidence grows the idea of him being brave becomes a reliable touchstone for
him. He asks himself constantly whether he is plucky or pusillanimous and gets good at
tracing moments of each in his childhood and early adulthood. It takes a little longer for
him to apply all this to his present life with Susie and the boys, not to mention to his role
at work, where he is an absolute avoider of conflict. The more we look at the reverberations
of these qualities not just in him but in mom and dad as well, the less he condemns his
parents for their poor parenting skills, seeing that he himself has not been such a great par-
ent to date either. A big jump is made when he takes the initiative of talking to his sons
about himself and his childhood. He feels they respect him for the first time, as they are
rather stunned by his disclosure. He is beginning to believe my words now when I affirm
him and he takes some credit for having managed his catastrophic circumstances rather
better than he thought he had. He is keen to claim the notion that there is still plenty of
room for further improvement. This means we are now talking about changing the future
for the better. Noah relishes the process and begins to write about it, asking for books he
might read to help him.
Throughout the therapy it is my aim to make as much room as possible for Noah’s
moods and emotions, since they always clearly point towards his unacknowledged values
and beliefs. I encourage him to experience the importance of his own feelings and intui-
tions and to explore the warmth of his existence. He becomes quite good at spotting his
beliefs and values. He realises that he has acted as if he has to prioritise others and endear
himself to others by providing services. He also notices the dark meanings he was attach-
ing to human relationships. He experiments with doing things differently, trying to col-
laborate with others instead and later on he realises it is even possible to find ways of
allowing others to please you and give them the pleasure of having a positive effect in
your life. As he gains confidence, things look different and life isn’t all bleak and horrible
any more.

When we stop therapy, Noah has accepted that life is a mixed blessing and that he is strong
enough to deal with its challenges and difficulties having had much experience in doing so.
He can now make sense of his life’s story as one of trials and tribulations, which he is good
at tackling and overcoming. It is a true hero’s journey and he can see that he has achieved an
enormous amount without much help from anyone in the past. He knows that he stops him-
self progressing by hiding away and disconnecting from the world. His tendency to go it
alone continues to be a problem but he is on the road to learning to trust others and connect
to them, which is all we were aiming to achieve. His purpose in life is now to just get better

at all this all the time. He has faith in his growing strength in doing so and feels more robust
than ever before.
He has discovered that both his sons and Susie do love him and that he can bring their love
out by showing them his love. He is learning to stop assuming so much about other people
and to check things out with them instead. He still finds critical comments very hard to deal
with. Much remains to be done, but Noah wants to do it rather than avoid the problems. He
has learnt that life and human beings are never perfect but always perfectible and he is keen
on engaging rather than disengaging with life.
5.1 Developments
5.1.1 Brief therapy
Existential therapy by its emphasis on the limits of life is well placed for offering brief
therapy. The lack of time in short-term therapy will invariably bring up existential issues
around death, disappointment, aloneness and human limitations. This can increase the inten-
sity of therapy. Even one off sessions of existential therapy are by no means out of the ques-
tion, as a review of a person’s basic aims and attitude to life can make for a vigorous thera-
peutic discussion that can have considerable impact on a person’s life. But usually there will
be some further sessions to develop and review these themes. I often work with interspersed
sessions, for instance seeing clients coming to me from abroad for a one-off double or triple
session, followed up by yearly single or double sessions to review progress and keep clarity.

Existential therapy, as a philosophical method, situates human problems within their wider
context. This pertains to the narrow interpersonal and familial context, but also to the social
and cultural context within which a person is located. It also includes a necessity to be aware
of the political and moral climate in which a person is operating, as this often directly
impacts on the way in which an individual perceives possibilities and blockages in life.
Therefore the existential approach is highly context and diversity sensitive and prized by
people all over the world. It is ideology neutral and can adapt to many different contexts,
cultural, social, political, religious and also in relation to gender or sexual politics. It is as
relevant to children, who often wonder about their place in the world, teenagers, who strug-
gle to establish a personal belief system, young adults who come up against power struggles
in the work place and in relation to their parents, mid-lifers who wish to reconsider their life
and challenge the values they have so far lived by, mature people dealing with end of career
issues, or those who are ageing and beginning to face the end of their lives. Existential
therapy has been applied to many different settings and specialist contexts with much suc-
cess for this reason (Cooper, 2003).


The practical limitations of the approach have already been referred to in the section on selection
criteria. As the approach does not stress the illness–health dimension, people who directly want to
relieve specific symptoms will generally find the existential approach unsuitable, though they may
discover that symptoms tend to disappear when more fundamental life issues are addressed.
The existential therapist neither encourages the client to regress to a deep level of depend-
ency nor seeks to become a significant other in the client’s life and nurture the client back to
health. The therapist is a consultant who can provide the client with a method for and sys-
tematic support in facing truth. The client is encouraged to relate to herself and get a fresh
perspective on her way of being in the world. This requires clients to be willing to work quite
hard. Good existential therapists bring out this capacity for authenticity, but some therapists
might do this in a manner that is harsh rather than helpful.
Perhaps the most absolute limitation is that of the level of maturity, life experience and intensive
training that is required of practitioners in this field. Since existential therapists aim to be wise and
capable of profound and wide-ranging understanding of what it means to be human, the criteria
of what makes for a good existential therapist are rather high. One can imagine the danger of
therapists pretending to be capable of this kind of wisdom without actual substance or inner
authority. Little would be gained by replacing technological or medical models of therapy, which
can be concretely learned and applied by practitioners, with a range of would-be existential thera-
pists who are incapable of facing life’s problems with dignity and creativity themselves.

Existential therapy is most often criticised for its emphasis on philosophy and ideology and for
exacting so much personal engagement and clear thinking from clients. It is considered to be most
effective with people who have a certain level of intelligence. While this is true in the sense that
existential therapy would probably not be the first port of call for work with people with learning
difficulties, it is a method that actually applies well with children, teenagers or those with autism,
as it can adapt easily to different levels of existential concerns. The existential method is by no
means a cognitive one, but addresses the whole way of being in the world of each person.
Existential therapy has also been criticised for attracting clients who feel disinclined to trust
other human beings because they perceive the existential approach as leaving them in total con-
trol. This criticism is often justified and needs to be countered by the therapist’s gentle way of
bringing the client around to facing this issue. Well-trained existential therapists will know how
to turn solitary and narcissistic clients towards a more engaged and trusting existence.
5.4 Controversies
The major controversies within the existential school are those of the disagreements
between different groups about their preferred method. Logotherapists have established a

separate niche for themselves and on the strength of Frankl’s work have been able to teach
a quite strongly formalised method, which has found a following internationally but which
has remained somewhat exclusive and is not based so much in philosophical practice. The
same is true for Daseinsanalysts, who have also established strong networks and who follow
the work of Heidegger and Boss most carefully, but are less impressed with a more broadly
based philosophical outlook. Within the field of existential therapy itself there are also dif-
ferent camps.
These divide most clearly between the North American based existential-humanistic thera-
pists and the European based existential therapists who work from a broader philosophical
platform. The latter has sometimes been referred to as the British School, though this is actu-
ally widely spread through Europe, including in Eastern Europe and Scandinavia as well as
in countries like Portugal, Poland, Ireland and Greece. This approach is also established in
Israel, Australia and Russia. Within the British or European school itself there are varieties
of practice, depending on whether people opt to combine existential therapy with a person-
centered, humanistic stance (Cooper and Spinelli), a psychoanalytic stance (Laing, Cohn) or
whether they practise purely from a philosophical base (Deurzen, Adams, Strasser).
6 RESEARCH
Research in the sense of randomised controlled trials (RCTs) or quantitative studies has never
been a priority for people practising existential therapy. Existential therapists prefer an experien-
tial exploration over a positivistic one and research in this field has generally concentrated on
case studies or other qualitative methods. There has been a large amount of phenomenological
research on existential issues (Yalom with Leszcz, 2005) and on the now well-established doc-
toral programmes in existential counselling psychology much heuristic, phenomenological and
hermeneutic research is being carried out. We need to bear in mind that existential therapy is in
itself a phenomenological exploration, which has validity in its own right.
Cooper, in his Existential Primer (2012) notes a number of recent research projects that
pursue a more positivistic line, including a systematic review of studies on the outcomes of
existential therapy. Around 20 randomised controlled trials (RCTs) of existential therapies
were found. A recent study by Craig, Cooper and Vos describes some new studies on existen-
tial therapy currently being conducted (Craig et al., 2012).
7 FURTHER READING
Cohn, H.W. (2002) Heidegger and the Roots of Existential Therapy. London: Continuum.
Cooper, M. (2003) Existential Therapies. London: Sage.
Deurzen, E. van (2010) Everyday Mysteries: Handbook of Existential Therapy, 2nd edn. London: Routledge.
Deurzen, E. van (2012) Existential Counselling and Psychotherapy in Practice, 3rd edn. London: Sage.
Yalom, I. (1980) Existential Psychotherapy. New York: Basic Books.

8 REFERENCES
Binswanger, L. (1963) Being-in-the-World, trans. J. Needleman. New York: Basic Books.

Boss, M. (1957) Psychoanalysis and Daseinsanalysis, trans. L.B. Lefebre. New York: Basic Books.
Bugental, J.F.T. (1981) The Search for Authenticity: An Existential-Analytic Approach to Psychotherapy. New York:
Irvington.
Cohn, H.W. (1997) Existential Thought and Therapeutic Practice. London: Sage.
Cooper, M. (2003) Existential Therapies. London: Sage.
Cooper, M. (2012) Existential Primer. London: Sage.
Craig, M., Cooper, M., Vos, J. (2012) Existential Therapies for Psychological Distress in Adults: A Systematic Review
and Meta-Analysis. BACP conference presentation.
Deurzen, E. van (1998) Paradox and Passion in Psychotherapy. Chichester: John Wiley & Sons, Ltd.
Deurzen, E. van (2009) Psychotherapy and the Quest for Happiness, London: Sage.
Deurzen, E. van (2010) Everyday Mysteries: Handbook of Existential Therapy, 2nd edn. London: Routledge.
Deurzen, E. van (2012) Existential Counselling and Psychotherapy in Practice, 3rd edn. London: Sage.
Deurzen, E. van and Adams, M (2011) Skills in Existential Therapy, London: Sage.
Deurzen, E. van and Arnold-Baker, C. (2005) Existential Perspectives on Human Issues: a Handbook for Practice.
London: Palgrave/Macmillan.
Frankl, V.E. (1967) Psychotherapy and Existentialism. Harmondsworth: Penguin.
Heidegger, M. (1962) Being and Time, trans. J. Macquarrie and E.S. Robinson. New York: Harper & Row.
Jaspers, K. (1951) The Way to Wisdom, trans. R. Mannheim. New Haven and London: Yale University Press.
Kierkegaard, S. (1944) The Concept of Dread, trans. W. Lowrie. Princeton, NJ: Princeton University Press.
Laing, R.D. (1960) The Divided Self. Harmondsworth: Penguin.
Laing, R.D. (1961) Self and Others. Harmondsworth: Penguin.
May, R. (1983) The Discovery of Being. New York: W.W. Norton.
May, R., Angel, E. and Ellenberger, H.F. (1958) Existence. New York: Basic Books.
Merleau-Ponty, M. (1962) Phenomenology of Perception, trans. C. Smith. London: Routledge & Kegan Paul.
Moran, D. (2000) Introduction to Phenomenology. London: Routledge.
Nietzsche, F. (1961) Thus Spoke Zarathustra, trans. R.J. Hollingdale. Harmondsworth: Penguin.
Sartre, J.P. (1956) Being and Nothingness: An Essay on Phenomenological Ontology, trans. H. Barnes. New York:
New York Philosophical Library.
Schneider K. and Krug, O.T. (2010) Existential-Humanistic Therapy, Washington: American Psychological
Association.
Spinelli, E. (2005) The Interpreted World: An Introduction to Phenomenological Psychology, 2nd edn, London:
Sage.
Strasser, F. and Strasser, A. (1997) Existential Time Limited Therapy. Chichester: John Wiley & Sons Ltd.
Tillich, P. (1952) The Courage to Be. Harmondsworth: Penguin.
Yalom, I. (1980) Existential Psychotherapy. New York: Basic Books.
Yalom, I.D. with Leszcz, M. (2005) Theory and Practice of Group Psychotherapy. New York: Basic Books.

8
Gestalt Therapy
Dave Mann
The Second World War had ended when two psychoanalytically trained German immigrants
arrived in New York City. Having fled Nazi Germany to South Africa via Holland, Fritz and
Laura Perls brought with them a richness of experience gained from meetings and study with
a host of great thinkers who were to influence the creation of a new psychotherapy grounded
in phenomenology and a worldview of holism known as field theory. Amongst those influ-
ential figures were the holistic psychologist Kurt Goldstein with whom both had worked, the
social psychologist Kurt Lewin, Jan Smuts the South African prime minister and author of
Holism and Evolution and the Gestalt psychologists, who provided them with the organising
principal for gestalt therapy as an integrating framework (Yontef, 1993). Laura had studied
with the existential philosopher Martin Heidegger, the Gestalt psychologist Max Wertheimer
and the existential theologians Paul Tillich and Martin Buber. Fritz’s training analyst had
been Wilhelm Reich whose work on body armour shaped his clinical thinking. Further influ-
ences were the philosopher Sigmund Friedlander, from whom he developed the concept of
creative indifference and the analysts Karen Horney and Otto Rank who stressed the impor-
tance of establishing meaning in the here and now.
The dogmatism of classic psychoanalysis never rested easily with the Perls and in 1947 the
first statement against the approach was published: Ego, Hunger and Aggression – a Revision
of Freud’s Theory and Method. Published under F.S. Perls’s authorship, the text reveals that
Laura Perls had considerable input into the work.

The couple set up the New York Institute for Gestalt Therapy and it was here they met the
revolutionary social and political radical, Paul Goodman. A prolific writer over a broad range
of fields including psychotherapy he was hired to co-author Gestalt Therapy: Excitement and
Growth in Human Personality (Perls, Hefferline and Goodman, 1951), which first named
gestalt as a therapy. The New York Institute’s ideas began to interest others in the USA.
Subsequently, the Cleveland Institute was created and developed an intensive training pro-
gramme that took gestalt therapy further afield theoretically and geographically.
However, Fritz was becoming restless. He found his home at the Esalen Institute,
California where he attained celebrity status. Unfortunately, some of his work there led to
misconceptions about gestalt therapy, such as it being solely technique-based and lacking
theory; many merely copied what they saw Fritz doing. The mid-1960s saw an explosion in
the popularity of gestalt fuelled by the counterculture of the time. Esalen and Fritz were at
the centre of this growth movement whilst back in New York Laura Perls, Paul Goodman and
others continued to practise in accordance with the original text.
Around the time of Fritz’s death in 1970, gestalt began to grow in Britain. Initially region-
alised trainings delivered their principle trainer’s favoured version of gestalt, before training
became more formalised in the 1990s. In 1993, the United Kingdom Council for
Psychotherapy (UKCP) was formed and many programmes aligned their syllabuses with the
requirements for UKCP registration. Institutes developed partnerships with universities and
offered a range of qualifications up to doctorate.
Gestalt had moved from the radical and rebellious towards the establishment where it
stands, albeit somewhat uncomfortably, today. There are gains in that gestalt is now more
widely accepted as a theoretically rigorous therapy. Part of the sacrifice, however, appears to
be a loss of the adventurous, mischievous and occasional outrageousness of the approach –
the stuff from which genius and controversy emerge.

Central to gestalt theory and the image of the person is the concept of self as process. Self is
seen as an ever-changing process always adjusting in relation to our environment. To illus-
trate the fluid nature of self we use verbs as describers rather than the fixity of nouns. Self is
discussed as selfing outlining the fluid relational process that takes place in the formation of
our self-in-relation.
One cannot step twice into the same river, nor can one grasp any mortal substance in a stable condition,
but it scatters and again gathers; it forms and dissolves, and approaches and departs. (Heraclitus)
That said the river does have a character that defines it as a river and as a particular river
amongst rivers. Likewise we have a character made up of sedimented beliefs and ways of

GESTALT THERAPY 181
relating that will remain relatively constant. The person and the environment are considered
as one constellation of independent factors and any behaviour is viewed as being embedded
in this context.
2.1.1 Contact and the contact boundary

Our process of selfing takes place in the between of relationship, where something
emerges that is more than the sum of its parts. A person exists within a field of relations
in her environment with constant interplay between the two at the contact boundary. This
term boundary can be misleading as there is no sharp line where I end and other begins.
The contact boundary is more of a meeting place for individual and environment the way
in which a shoreline meets the sea, a fluid place where I differentiate the ‘me’ from the
‘not me’.
2.1.2 Figure and ground

This key concept is central to gestalt therapy theory. Figures in the form of needs, desires,
noticing and reactions are constantly emerging from the background of our experience. We
are always organising our field in relation to our here and now needs. The process of figure
formation is of particular interest to gestalt therapists as it reveals how we make sense of our
world in the present. The influence of the historical ways in which we have configured our
world influence the figure that emerges from our ground.
2.1.3 Creative adjustment

We are always in contact with our environment. Through a process of creative adjustment we
have the capacity to turn up or down the volume of our contact. The ways in which we cre-
atively adjust to our environment will be evident in our ways of being in the world in the
broadest sense. The way we carry our bodies, how we walk, talk, breathe, move towards,
move away from, express, feel, think, behave and how our environment moves towards and
away from us, for the process of creative adjustment is not a one-way street and nor does the
process originate from ourselves.
2.1.4 Here and now focus

Gestalt’s here and now focus was borne out of the Perls’s criticism of Freud’s archaeo-
logical approach. A client’s here and now experience does not need to be interpreted;
it can be directly contacted. This is achieved through phenomenological inquiry by the
therapist that aims at description of how and what the client reaches out to in their
environment at that moment. Misunderstanding often centre around a belief that gestalt
therapists relentlessly focus on the here and now without appreciation of the client’s
history or their aspirations for the future but, ‘Every present includes in the end
through its horizons of immediate past and nearest future the whole of possible time’
(Merleau-Ponty, 1962: 109).


Although we believe that a human being finds the best possible way of creatively adjusting
to their world, problems occur when creative adjustments are outdated. An example might
be a person who during an abusive childhood creatively adjusted to that environment by
becoming practised at hiding through taking up little physical and psychological space.
When this relational style is taken into present relating in safe environments today the
person deprives himself of support that is now available and also deprives the world of his
full creative abilities. This is an example of a fixed gestalt. Fundamentally, psychological
disturbance through a gestalt lens can be summed up as present-field incongruent ways of
relating.
Nothing happens in isolation. To embrace a gestalt situational outlook is to locate dis-
turbance not within the confines of a person’s so-called psychopathology, but instead in
the interactions between people and their situations (Parlett in Woldt and Toman, 2005).
If a person is suffering then his situation is suffering too. A failure to recognise this dis-
locates the person from their situation and the conflict in that situation of which the per-
son is but a part.
For growth to take place we need to meet with difference, yet meeting with too much
difference without being sufficiently grounded can lead to a collapse into anxiety. Anxiety
in gestalt is seen as excitement that has insufficient support and manifests in rapid and
poorly differentiated figure formation as flitting attention leads to a cluttering of ill-
defined gestalts.
In my work in psychiatric institutions in the 1980s I witnessed the dramatic restriction
of encountering difference in an environment situated separate from the community. A
rigid routine with restricted choice resulted in entrenched institutionalisation amongst
patients. We could say that this was a ‘side effect’ of treating mental illness and in some
cases might have been indicated. However, when reading patients notes who had been in
that institution for 40 or 50 years I discovered that some of their original ‘mental illnesses’
had been having an illegitimate child or suffering from epilepsy. Their current ‘illness’ had
been created in relation to the restrictive nature of their day-to-day environment. Whilst
this is a dramatic example of how rigidity between self and environment can restrict
growth, before we recoil in horror perhaps we should consider how the institutions we are
a part of restrict as well as facilitate growth. The architecture of our attitudes reveals itself
in the architecture of our world.

Health in contemporary gestalt therapy is seen as the ability to focus upon the present with
reference to the past that then informs future expectations, plans and action – the present is not
shut up in itself (Merleau-Ponty, 1962). Healthy relating in gestalt is the ability to move along
an awareness continuum in relation to our environment, health being our capacity for creative
adjustment to new situations. It is in the interplay between environment and organism at the

GESTALT THERAPY 183
contact boundary when we encounter difference that growth takes place and for that to happen
we need sufficient self and environmental support.
In healthy functioning figures that emerge from our ground are well defined with good
form. Healthy functioning is in essence being attuned to our current environment in the here
and now so that we can moderate our contact and integrate difference. We need contrast and
difference to be aware of what is – fish do not know that they are wet!
Ways of conceptualising a healthy gestalting process have been devised using a cycle of
experience model. A four-phased model by Perls, Hefferline and Goodman (1951) laid the
ground for more recent developments of the construct that further break down the phases of
experience (Zinker, 1977; Joyce and Sills, 2010; Mann, 2010). The phases in mapping a
healthy gestalt cycle are:
• Sensation – a sensation emerges, e.g. dryness of mouth in thirst, shock and numbness in bereavement.
• Awareness – the person begins to make sense of the sensation.
• Mobilisation – the person moves to satisfy the emerging need, e.g. to find a drink, to cry or express anger
in bereavement.
• Action – the person begins to perform a task to satisfy the need, e.g. fills a glass and moves it
towards her mouth, or in the case of an emotional need eyes begin to prick, breathing quickens,
cheeks redden.
• Final contact – the person is in the experience, e.g. swallowing the liquid, expressing the emotion.
• Satisfaction – the immediate need is satisfied, e.g. thirst is quenched; the force of expressing the emotion
is felt.
• Withdrawal – the person withdraws from this particular gestalt that may be part of a larger gestalt as in
bereavement or seeking a career.
• Void – there is space left for the person’s next need to emerge.
Conceptualising experience in this way can be useful if we remain mindful that the person is
not as separate from their situation as such maps implicitly suggest.

From a gestalt viewpoint psychological health and psychological disturbance cannot be
separated from physical disturbance/health or the health/disturbance of the person’s environ-
ment. Relational ruptures of all kinds affect how we contact the world. We all live through
degrees of relational ruptures and in a good enough upbringing there will be sufficient repa-
ration. However, if relational repair is absent or minimal, the person creatively adjusts to that
situation to manage the rupture. What is wrong between environments and individual can be
internalised resulting in the person creating a self-perception divorced from the relationships
from which it emerged. Such a process has its origins as a survival strategy.
The Law of Pragnanz: originating from gestalt psychology asserts that a person will always
organise herself in the best possible way in relation to the prevailing conditions of the situation.
It follows that the development of any ‘psychological disturbance’ will in fact be a situational

disturbance. Any conceptualisation of disturbance or health and how it is acquired through a

gestalt lens is a conceptualisation that should be considered as belonging to the whole situation
(Perls, Hefferline and Goodman, 1951: 134) rather than the individual.
However irrational another’s behaviour appears to us, when considered in the fullness of
its emergence and function over time it will make sense in terms of how the person creates
meaning. Every individuals ground is different therefore we all perceive our phenomenal
world differently. So-called dysfunction and disturbance resides in personal narrative, which
forms in relation to our world and is shaped by the cultural ground upon which we stand. The
world may be made of atoms but it is held together by stories.

As gestalt is underpinned by a belief in self-as-process the dividing lines between interper-
sonal, intrapersonal and environmental are distinctly fluid.

Any ‘intrapersonal process’ can only be understood when considered in relation to a wider situ-
ation in which it will have had a function. Sedimented creative adjustments that have formed
over many years are invariably difficult to change, whether outdated or not. Human beings are
inherently creative but can use their creativity to deny, destroy as well as nourish their being.
We all carry fixed gestalts and to challenge them can rock our ground. Just consider how
difficult you may find it to break engrained habits. Fixed patterns of behaviour are under-
pinned by a perceived lack of support for new ways of being. Often the person experiences
a polarised split within himself that frequently has an accompanying internal commentary.
Perls christened one such polarity a top dog/under dog dichotomy (Perls, 1969). The top dog
is fuelled by introjects, what we believe we should or ought to do, we can also think of it as
the voice of our will. The underdog is more spontaneous, rebellious and impulsive. An
example of this dialectic might be:
Top Dog: I really must lose some weight and watch my drinking.
Underdog: What difference are a few beers going to make? You only live once.
Each pole is self-righteously dismissive of the other consequently the individual remains
stuck between contradictory viewpoints. Resolution of this conflict requires both poles devel-
oping an appreciation of the others position. Disturbance is maintained by constantly circling
around the conflict with no movement into action.
2.4.2 Interpersonal mechanisms and environmental factors

It is antithetical to gestalt to separate the interpersonal from the environmental as it is the
interplay between person and environment ‘that constitutes the psychological situation, not

GESTALT THERAPY 185
the organism and environment separately’ (Perls, Hefferline and Goodman, 1951: xxix). I
will therefore consider these two aspects together.
Experimenting with new ways of being that have no guarantee of achieving a desired
change can lead to a collapse into anxiety if we are not adequately supported. Stuckness has
its attractions. What is known as the familiarity boundary in gestalt identifies that we gravi-
tate towards the familiar irrespective of the health/unhealth of the situation. As we have seen
an individual can creatively adjust in ways that served her in the past but no longer serve her
in the present, perpetuating isolation, loneliness, relationship dissatisfaction. The often not-
so-comfortable slippers of familiarity can blind us to what is. Hence, the founders of gestalt
identified its only goal as being awareness.
2.5 Change
We do not aim for change in gestalt but heightening awareness is itself a catalyst for change.
Two theories regarding change are discussed below; both emerged experientially through
personal experience.
The Zeigarnik effect (unfinished business): The Zeigarnik effect is concerned with our
need to complete the uncompleted. It is not always possible to achieve completion in the
actual situation, but if some form of resolution is not achieved we can become cluttered with
incomplete gestalts that seek expression psychologically and physically.
Bluma Zeigarnik was a Russian gestalt psychologist who studied the effects of unfinished
business on individuals. She conducted research that showed that waiters with incomplete
orders would readily recall the order but as soon as it was complete it was forgotten, leaving
space for the next gestalt. However, it was in her personal life where she gained the most
profound insight into the effects of unfinished situations. In 1931 her husband was arrested
suddenly and she never saw him again. Zeigarnik found it increasingly distressing to live in
the family home with her two children surrounded by memories of her husband, so she
moved to nearby Moscow. Rather than her distress improving she became increasingly anx-
ious as she avoided visiting places that held memories of her husband. She made the coura-
geous decision to return to the old family home. Having returned her anxiety began to ease.
She improved further as she began to visit places around Moscow that held memories of her
husband. By doing so she had creatively discovered a way of achieving closure.
The paradoxical theory of change: Beisser’s theory states that ‘change occurs when one
becomes what he is, not when he tries to become what he is not … one must fully experience
what one is before recognising all alternatives of what may be’ (Beisser, 1970: 77).
Beisser was an athletic, attractive man, a US ranked tennis player, when at 32 he was struck
down with polio. Having been an active man he was paralysed, struggled to eat and needed
an iron lung to breathe. Following a period of depression Beisser began to accept his condi-
tion and developed his theory based on his personal journey. His friends offer accounts of his
popularity and generosity; he enjoyed a constant stream of visitors, his relationships reflect-
ing his own self-acceptance. Movingly, towards the end of his life Beisser said that were it

possible to be given the choice of returning to the athletic man he once was and not develop
paralysis he would decline. He had truly accepted who he was.
3 PRACTICE

The aim in gestalt therapy is to heighten awareness, to enable the client to be in contact with
what is. Within this aim is the freeing of blocks that inhibit flow between figure and ground.
If outdated creative adjustments are updated in relation to the current situation the client is in
a position to develop support for new ways of being. However, our task in raising awareness
does not lie solely with the individual and how he is impacted by his world. Raising aware-
ness involves exploration of a multi-directional relational matrix including raising awareness
of how the client impacts the world, what is happening between the client and her world and
how events are co-created.
Healthy functioning is characterised by a free-flowing process of gestalt formation and
completion along an awareness continuum in relation to the situation that faces us. Gestalt
therapists aim to facilitate the client’s ability to creatively adjust in the best way possible in
relation to their world’s varying demands. In such a process the person is fully in touch with
their situation, the figures that emerge from their ground are bright and the relationship
between figure and ground has fluidity. Each emerging figure is experienced and managed
leaving it to fall back into the ground of the person’s experience, enriching that ground. An
analogy can be drawn with nature as the apparent ‘death’ of all kinds of organic life literally
falls into the ground to nourish it.
However, I would like to add a caveat. The struggle in attempting, and perhaps failing, to
achieve free-flowing movement is itself growthful. A perpetual effortless flow in our relating,
void of relational ruptures is probably closer to an image of hell than nirvana. There is an
ancient Persian curse; ‘May your every desire be immediately fulfilled.’ Outdated creative
adjustments are not likely to remain outdated in every situation encountered, it is easy to see
them as relics from the past to be consigned to the great rubbish bin of life, when in fact they
are valuable developmental skills part of a repertoire of ways of being.
In heightening awareness we seek to discover with our clients how they restrict the flow
of experience between self and environment, for whilst this may serve to regulate uncertainty
it can leave the person living in a shrunken world with limited possibilities.
3.1.1 Resistances, moderations and interruptions to contact

Different ways in which we adjust our contact with the environment have been identified and
discussed throughout gestalt’s development (Perls, 1947; Perls, Hefferline and Goodman,
1951; Polster and Polster, 1973; Zinker, 1977; and others). These processes that were origi-
nally referred to as resistances have journeyed through a host of descriptive terms including:

GESTALT THERAPY 187
moderations, interruptions, modifications and disturbances. Of these processes gestalt thera-

py’s founders discussed at length introjection, projection, confluence and retroflection.
You might experience something is inside which belongs on the outside. This means introjection. Or, you
experience something which is outside and it belongs to your organism. This is projection. Or again, you
might experience no boundaries between your organism and your environment. That’s confluence. Or
you might experience a fixed boundary with no fluid change. This means retroflection. (From and Muller,
1977: 83)
Below I offer short definitions of the seven most commonly referred to moderations to con-
tact with examples. I have defined these processes individually but the reader needs to remain
mindful that they interrelate and that all creative adjustments are co-created amongst multi-
directional fields of relationships.
Desensitisation: The person anaesthetises himself from his environment. Evident in a
numbing during an initial shock reaction in trauma or when a runner develops an injury but
continues without awareness of pain.
Deflection: Direct contact is avoided through indirect relating. This is noticeable in
language, e.g. the use of ‘the royal we’ rather than ownership through ‘I’ language, relat-
ing a current response in the past tense or ‘watering down’ a reaction. This verbal turning
away from direct contact is likely to be matched bodily, e.g. fleeting eye contact, shallow
breathing. Deflection is considered to be a sub-process of retroflection (Polster and
Polster, 1973).
Egotism: I step outside myself and watch myself in relation to the other rather than being
fully present in relationship. Spontaneity is blocked by control. Constructive use could be
observing myself in discussion with a senior manager at work who is treating me unfairly
before I make a considered response.
Introjection: The person swallows whole a way of being in relation to their environment
resulting in the creation of an internalised rulebook of how to be in the world. In this embod-
ied process material is taken in without assimilation. There are many cultural introjects,
gender specific introjects, parental, those that come from religious doctrine, education to
name but a few. The concept originated from Perls’s interest in the child’s development of
dental aggression, the ability to chew over what was taken in.
Projection: In projection there is a splitting process where part of the person is disowned
and thrown out onto the environment. Projection tends to occur when an aspect of the person
does not fit with their self-concept. A person can disown her creativity or an emotion and
project this onto another. Within this matrix we probably don’t see things as they are, rather
as we are. A whole set of qualities and characteristics or a whole person can be projected onto
another, such a process is usually described as transference.
Retroflection: A hardening of the contact boundary marks the process of retroflection,
contact between environment and organism is dulled as energy is held in and/or turned
inwards. The individual splits himself into the aspect that does and the aspect that is done
unto, which may show in language, e.g. ‘I am angry (the doer) with myself (the done unto).’

Retroflection is visible in ways that characterise withdrawal from the environment – paleness,
shallow breathing, muscular armouring, and restricted movement. There are two forms of
retroflection, in the first the impulse is turned against myself. Fritz Perls referred to an
extreme manifestation of this process when he described suicide as the retroflective form of
homicide. The second is doing to myself what I need from the environment and is sometimes
referred to as proflection. It manifests is such behaviours of self-soothing. Retroflection
usually requires considerable internal energy; the person aggresses on themselves rather
than the environment.
Confluence: Geographically the term confluence describes two rivers meeting and their
merger into one. This sums up the process when confluence is discussed regarding human
relating – the person merges with their environment. Whilst enduring confluent relating can
lack vibrancy, energy and avoids potentially growthful conflict, an inability to be confluent
deprives a life of the joys of falling in love, the ability to sense another’s experience or
merge with their environment and lose oneself in an experience such as meditation or sing-
ing with others.
(a) Dimensions of contact and withdrawal Contacting always consists of polar actions
such as connection-withdrawal, involvement-isolation, separation-merger (Merleau-Ponty,
1962). Between these poles lay continuums and the greater the person’s capacity to move
along each continuum, the greater their capacity to creatively adjust to a variety of life situ-
ations. The aforementioned moderations describe one point on a continuum. No area of the
continuum is healthy in itself, for example, a mother may forget herself when caring for an
infant and this will be needed at times in that situation. It is when that mother’s children are
adults and she continues to block her awareness of her own needs that it becomes a problem-
atic fixed gestalt (Mann, 2010). From a gestalt field perspective self-awareness develops
between contact boundaries not behind them.
An example of continuums of contact and withdrawal with reference to MacKewn (1997)
are outlined in Figure 8.1:
In gestalt we aim for field-congruent awareness extending the person’s ability to move
along their awareness continuum. This continuum will include the ability for the client’s
awareness to be lively, vivid, spontaneous, fully in contact with their own needs, but just as
important are the qualities at the other end of the continuum – automatic, interrupted, rigid
Desensitisation------------------Sensitivity---------------------------------Hypersensitivity/allergic reaction
Deflection-------------------------Staying with------------------------------Being mesmerised
Introjection------------------------Questioning, assimilation-------------Refusal to accommodate
Retroflection----------------------Expression--------------------------------Explosion
Projection--------------------------Owning------------------------------------Own everything/literalness
Confluence------------------------Differentiation----------------------------Isolation
Egotism----------------------------Spontaneity------------------------------Lack of all field constraints
Figure 8.1 Continuums of contact and withdrawal

GESTALT THERAPY 189
and blocked ways of being with the capacity to diminish contact. To achieve movement along
the client’s continuum both poles need sufficient support.
Cautionary note: A problem with theorising on contact interruptions/moderations whether
considered on a continuum or not, is that it implicitly invites a one person rather than a rela-
tional perspective. This conflicts with the goal of gestalt therapy to promote awareness of the
whole situation and the whole situation’s impact on the client in the here and now. Theoretical
maps and models can be useful but they are not the territory, we perceive relationship not
processes or isolated things.

As a relational psychotherapy gestalt cannot be contraindicated with any individual but may
be inappropriate in particular therapist–client relationships. When deciding whether to work
with a particular client it is not a case of whether gestalt therapy is suitable, but what type
of gestalt approach is indicated and whether the therapist has the ability, experience and
personal resources to work with this person. Gestalt therapy has been inaccurately carica-
tured as a confrontative therapy suitable only for clients with plenty of ego-strength. A judg-
ment of a person as unsuitable for gestalt therapy will say as much about the assessor as it
will the client.

Stratford and Brailler’s (1979) excellent metaphor of the use of ‘glue’ and ‘solvent’ in
therapy offers a starting point in deciding whether a particular client–therapist pairing is a
good fit. Questions for the therapist in the selection process revolve around what is needed
and whether she can offer a sufficiently adhesive or solvent approach, together with an abil-
ity to slide along an adhesive–solvent continuum in the service of the client.
It is usual practice to have an initial mutual assessment session(s) to assess whether client
and therapist feel that they can work together. Below I offer a less than comprehensive sum-
mary of what a good enough match may depend upon:
1. If within this relationship I can provide a sufficient balance between holding and challenge.
2. If as a therapist I feel that I have sufficient skills, support and availability to work with this client.
3. Does this client press triggers for me in relation to my history? If so can I bracket that material suf-
ficiently to be present for the client? Are there experiences in my history that may enhance therapy
for the client?
4. Is there a sense of connection between the client and myself? If there is a struggle with connection can
we work with it?
5. How self-disclosing/non-self-disclosing am I as a therapist and how does this fit with this person?
6. Do I know someone who would probably be better suited to working with this client? In view of their
issues might it be better for them to see a male/female?

7. Do I have sufficient specialist knowledge to work with this client?

8. Might couples therapy or group therapy be more appropriate for this client?

Whilst study of texts and theory is of great importance, the gestalt approach needs to be learnt
‘from the inside’ – experientially in a fully embodied way. Training to be a gestalt psycho-
therapist is a long process that does not end upon qualification. Trainee therapists are required
to be in on-going personal therapy throughout their training and many choose to remain in
therapy beyond. We need to practise what we preach in owning our vulnerabilities and short-
comings as well as our strengths and abilities. We need to develop an awareness of our shadow
qualities and seek to stretch the continuums between our polar abilities. We need resilience and
to be able to support ourselves healthily in our own nourishing relationships outside our work
as therapists. Above all we need a commitment to be the best therapists we can be.

The most effective gestalt therapists have the ability to use themselves in the give and take of
the therapeutic dialogue, using their reactions with the client to inform the next step in the
therapeutic process. To do so requires self-awareness, or to be more specific self-in-relation
awareness, to understand ones reactions and separate out the reactive from the proactive. Even
then one of the most important skills for any gestalt therapist is the ability to be uncertain and
stay with uncertainty.
Emotional literacy coupled with trust in ones creativity and the courage to step out from
a ‘therapist role’ is a skill that coupled with resilience to shame enables the therapist to
remain present in their relationship with the client and model a healthy process.

The therapeutic relationship in gestalt therapy is underpinned by three interconnected phi-
losophies described as the pillars of gestalt (Yontef, 1993). These are:
(a) Field theory – the person’s experience is always viewed in the full context of their whole situation.
(b) Phenomenology – the search for understanding through what is obvious and/or revealed.
(c) Dialogue – concerned with a specific type of contacting that goes beyond words and is concerned with
what emerges in the between of relationship.
These three philosophies weave in and out of each other in the gestalt therapist’s relationship
with her client. If one of these philosophies is not practised then gestalt therapy is not being
practised.

GESTALT THERAPY 191
(a) Field theory

There is no field, situation or life-space1 per se that is perceived by all. In describing a situ-
ation it needs to be referred to in relation to its perceiver. The person and the environment are
viewed as a single constellation of independent factors with all behaviour embedded in a
context. Gestalt therapists are interested in the process of how we organise ourselves during
our transition from one situation to another.
The way in which we map our landscape depends upon our need at that moment in time.
A client may persistently perceive herself in a negative light due to past experience that now
colours her present experience and future expectations. Areas in which she feels incompetent
become figural for her as she patterns events in a way to confirm her self-perception, for
instance, a mother is critical of herself for not being fully alert at all times when attending to
her infant whilst ignoring her good parenting. Although the client may perceive a problem as
being in her it is always of her situation.
We cannot work with an entire situation, a field so wide to encompass the clients past,
present and future in relation to their world. In the therapeutic relationship we pay attention
to what is figural but always in relation to the client’s ground. This relationship between
figure and ground begins to reveal itself from the first moment of meeting, not only in spo-
ken ‘information’ but in the way in which the client holds himself, the way he meets with
his environment, the way he bodies forth. A gestalt therapist maintains a process view of the
client’s story and situation seeking to heighten awareness of repeating patterns, rather than
investing in problem solving. Holding a field perspective is a difficult paradigm shift.
However, to practise gestalt therapy that shift needs to be made.
(b) Phenomenology
A client entered my therapy room and noticing a piece of abstract artwork on the wall com-
mented, ‘That’s a nice mix of reds and greens – it produces a lovely blue hue.’ It’s maroons
and blues, I thought, there’s no green. Neither of us was wrong.
The therapeutic relationship is configured to gain an understanding of how clients make
sense of their world. We do so through phenomenological inquiry designed to uncover the
person’s act of intentionality, the way mind and body stretches forth towards the appearance
of things and translates them. In this emergent process what the person reaches out to and
how they reach out is of interest to gestalt therapists. If the client moves on quickly the figure
may not fully form, something that is common in anxiety states. Conversely the client can
become figure bound, as a forthcoming exam, a family members illness or thoughts of self-
harm dominate to the exclusion of available supports.
To fully appreciate the way in which another makes sense of the world we need to suspend,
as far as possible, our experience of the world. The aim is to be touched by the client’s expe-
rience with a similar wonder to that seen in a child’s eyes when they encounter something for
1
The field theorist Kurt Lewin (1952) used the terms field, situation and life-space interchangeably in
his work.

the first time. The phenomenologist Edmund Husserl designed a three-step process to tran-
scend our experience of the world, the three steps being:
1. Bracketing – The therapist sets assumptions and expectations of how things are or should be aside, liter-
ally bracketing off the way she interprets the world.
2. Description – Rather than seeking explanations the therapist seeks description. The therapist’s interven-
tions are also descriptive rather than interpretive. Experience is carried in the body but it is for the client
to put this into words.
3. Horizontalisation – Anything the client says or does is afforded equal significance. The recounting of a trau-
matic experience is initially considered no more or less significant than say, the client shuffling in their chair.
Most gestalt therapists would agree that rather than transcending our perception of the world
we can only, ‘slacken the threads which attach us to the world’ (Merleau-Ponty, 1962: xiii).
Martin Heidegger’s existential phenomenology is of great relevance in the therapeutic
relationship in gestalt therapy. This is the phenomenology of being and being-in-the-world
concerned with how we make sense of our existence. The starting point for existentialism is
that life does not have meaning in itself, but we construct meaning, ultimately leaving us
alone with the meaning we make. The paradox is that although I need others to exist I exist
alone with my reality. Existentialism is characterised by uncertainty, the only certainty being
that life will end. Ultimately we have the choice of whether to live authentically or inauthen-
tically, a choice broadened with increased awareness.
(c) Dialogue
Buber (1958) described the relational stances of I–Thou and I–It as representing the primary
attitudes of human relating. In I–It relating we are objectifying and more concerned with
doing than being. In I–Thou relating both parties surrender to the between of the relationship,
a process in which the other’s humanness is confirmed. It is the flow of connection and
separation between these poles that we pay attention to with our clients. The therapist can
only create the conditions for I–Thou relating it cannot be coaxed for as soon as I–Thou is
aimed for it is objectified and becomes an ‘It’. It is the therapist’s willingness to hold an I–
Thou attitude in a dialogic relationship throughout their contact with clients that creates the
ground for the client to engage in such profound and potentially healing relating. However,
let us not lose sight of the value of I–It relating for we need to do as well as be.
Without It a human being cannot live. But whoever lives with only that is not human. (Buber, 1958: 85)

Whilst every gestalt therapist will have their own unique style it needs to be underpinned by
the philosophies discussed above. It is up to every individual gestalt therapist to find their
way of integrating these philosophies into their work. Individuals with a broad range of rela-
tional styles practise gestalt therapy. Some therapists are highly experimental and dramatic
using plenty of physical movement, whilst others engage more verbally and are more contained

GESTALT THERAPY 193
in their relational style. Gestalt therapists can vary greatly in the degree in which they self-
disclose, use creative materials, use humour to name but a few areas. What is of paramount
importance is that the therapeutic relationship is shaped in the service of the client. Whatever
the relational style of the therapist we are in the business of assisting the client in discovering
meaning rather than interpreting. Hence, the significance of tears is for the person who is
crying, the meaning of muscular tension is for the one who is tense, the importance of avoid-
ing eye contact is for he who looks away.

Assessment, case formulation, therapeutic strategies and techniques all go hand in hand; in
gestalt therapy all are process-oriented and therefore fluid and open to immediate re-evaluation.
3.5.1 Assessment
From initial assessment throughout the process of working with a client we are considering
how she makes and breaks contact and how this relates to her presenting problem. The way
in which the person bodies forth (or away from) a situation reveals something of how that
person perceives that situation and reflects meaning, intention and direction of the client’s
bodily felt sense of the situation.
The only ‘assessment tool’ used in gestalt therapy is the therapist herself. Paying attention
to her reactions to the client can elicit information about how the client may relate in the
world as long as the therapist is vigilant in separating out her proactive material and holds
any hypotheses lightly (Mann, 2010). With a focus on the between of the relationship she will
shuttle back and forth between how the client makes and breaks contact and how she is
adjusting her level of contact.

Assessment and case formulation is most effective if it is descriptive, dynamic and fluid and
underpinned by the belief that all reality is co-created. Although gestalt therapy is renowned
for its focus on the here and now, the present moment emerges from a rich developmental
history of past relationships that are enquired into as needed through a lens of attempting to
understand how the client’s current reality in their current situation has been shaped by their
past and shapes their relating now.
Assessment and case formulation takes place on a macro level, working towards the client’s
goals, but importantly this process is replicated at a micro-level in a single session or a few
minutes of a single session. For example, a gestalt therapist notices her client’s lip quivering,
words falter, and breathing become shallow as the client discusses his unsatisfactory relation-
ship with his partner (assessment). She hypothesises that her client may be armouring himself
against expressing an emotion and having seen similar behaviour in him before wonders
whether this is habitual, perhaps underpinned by introjected beliefs (case formulation).


For gestalt therapy to be practised any strategy or technique needs to emerge from phenom-
enological dialogue with the client in relation to their field.

In the above example the therapist’s hypothesis informs the next step or therapeutic strategy.
She may suggest that the client makes eye contact and breathes more deeply to counter
deflective behaviour and increase contact, thereby providing an opportunity to undo retro-
flection and build ground to explore possible underlying introjects. This is an example of a
therapeutic strategy at a micro level that will be influenced by the prevailing field conditions
(see above, Section 3.4.1). At a macro level an overarching fluid strategy will be held, which
will include how solvent or adhesive the therapist needs to be with the client. The number of
sessions available, the level of competence of the therapist and the support systems the client
has beyond the therapy room will all be significant field conditions that directly influence
therapeutic strategy. Particular strategies will need to be developed in relation to working
with risk (see Mann, 2013; Joyce and Sills, 2010).

(a) Experimentation How a client organises himself in relation to his situation can be
challenged through the creation of a ‘safe emergency’ (Perls, Hefferline and Goodman, 1951: 65)
in which the client is able to experiment with different ways of being in the therapy room.
The limits to the range of experiments are restricted only by the limits of the therapists and
client’s combined creativity, coupled with the ethical and therapeutic boundaries of the
relationship. Most experiments in gestalt therapy are simple interventions such as inviting a
client to sit back and feel the support of the furniture if he appears overly self-supporting,
inviting a client to deepen her breathing, make eye contact, use less words, increase
ownership through the use of more direct ‘I’ language. We invite a supported movement away
form the client’s familiarity boundary (Polster and Polster, 1973).
Gestalt experimentation can take the form of bodywork, sculpting, physical movement,
dance, enactment or ‘homework’ between sessions and involve a range or ‘props’ such as
sand-trays, paints, toys or pebbles. Whatever the experiment consensus should be reached
between therapist and client with the experiment graded appropriately – we learn to swim
before diving off the high board!
A well-known gestalt experiment that sadly is often abused by poorly trained therapists is
‘the empty chair’ or ‘two chair work’. Devised by Fritz Perls to complete unfinished busi-
ness, integrate disparate parts or polarised qualities in the person and bring archaic influences
into the here and now, it has inaccurately been portrayed as a way of characterising gestalt or
as a quick way of facilitating change. As with any experiment the figural new way of being,
witnessed by a caring therapist, falls into the ground of the therapeutic relationship and it is
in that ground that lasting change takes place.

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(b) Directing and increasing awareness The aim is to heighten the client’s awareness of
her internal world and intersubjective relating through fluid movement across three zones of
awareness identified by Perls (1969):
• Inner zone – internal phenomena such as feelings, emotions, dream world and bodily sensations.
• Outer zone – where we make contact with our outer world through our senses. This is concerned with
our perception of our world and our behaviours and actions.
• Middle zone – our cognitive processes, memories, imaginings, fantasies and daydreams.
Fluid movement across these three areas is deemed healthy but how this manifests will
depend upon the health or otherwise of the situation. A here and now experiment that
explores the person’s ability to relate from each area is simply to complete the following
sentences: I see … (outer zone), I feel … (inner zone), I imagine … (middle zone).
In expanding awareness we might work with polar qualities in the client in relation to self-
concept (Zinker, 1977) such as hardness–softness, fluidity–rigidity, caring–ruthless, topdog–
underdog polarity or in relation to dimensions of contact. A man whose self-perception is as
a ‘hard man’, who habitually disowns his ‘softer’ qualities, may benefit from experimenting
with some of those softer ways of being. A woman who is still and ‘contained’ may be invited
to experiment with movement and taking up space.
If a client disowns her shadow qualities with support she can be assisted by the therapist
to discover what richness may emerge from re-owning them. Although clients may be resis-
tive of moving into such areas one of my favourite stories offers a metaphor for how the
client’s view of the world can change from such an experiment. The writer Guy de
Maupassant lived in Paris and despised the Eiffel Tower so he spent many hours lunching in
the restaurant at the top. By going into something he despised he gained an unspoilt view of
his beloved Paris.
(c) Rupture and repair The nature of relationship is that it is a series of misattunements
and re-attunement. Watch a good enough mother with her infant and you will witness a
repeating rupture and repair cycle. This isn’t so much a ‘strategy’ or ‘technique’ it is just
what happens in a relational therapy. Our task as therapists is not to eradicate misattun-
ement from our practice, but through vigilance track when such relational ruptures occur,
acknowledge our part in that break in contact and be willing to reach out into the between
to repair it. Muscles grow through exercise that creates minute ruptures to the tissue that is
then repaired. Remain still for a prolonged period and muscles atrophy. The same can be
said of relationships.

Change is inevitable. Walking through the door of a therapy room creates an opportunity
for life-enhancing change. To appreciate how this opportunity may be achieved we need to

create the conditions where the client can appreciate that he is the author of his life, whilst
also gaining an appreciation of how his current behaviour has developed and what his
investment is in his current way of being. Clients often come to therapy wanting to rid
themselves of a particular way of being, but we cannot simply wipe out behaviours or
unwanted emotional responses nor would we want to. We need to see them as valuable
energies that can be reinvested.
The process of change leads the client away from their familiarity boundary. We use the
term growing edge to describe that place where behind the client is all that is familiar and
ahead is the unknown. Denham-Vaughan describes this place as the liminal space – a place
of teetering uncertainty. ‘This place, space and/or moment in time is characterised by a will-
ingness to let go of anything familiar, and an openness to what is emerging’ (Denham-
Vaughan, 2010: 35). Change our thought and the world around us changes.
4 CASE EXAMPLE
4.1 The client

Michelle, a 40-year-old businesswoman, strode into my therapy room and sat erect on the
edge of the sofa. Her demeanour matched the first impressions I had formed during her forth-
right request for therapy over the telephone a week earlier – sharp and to the point. She told
me that she had seen a few therapists over the years and considered herself self-aware, but
continued to suffer from a cycle of depression.
At first glance Michelle looked as though she took care of herself, she seemed well
groomed, there was an aroma of expensive perfume and her two-piece suit looked pristine.
However, a closer look revealed ‘cracks’ in her heavily applied make-up. She wore that suit
like armour and her movement appeared stiff and controlled. Michelle breathed shallowly
and muscularly appeared tense. Her cuticles around her varnished nails appeared sore and
red, an ‘angry’ rash peeked out from beneath her white blouse the cuffs of which illuminated
two nicotine-stained fingers. So much about Michelle carried a hard edge, yet beneath the
mascara her eyes held a surprisingly contradictory softness.
4.2 The therapy

I enquired what Michelle would like to gain from therapy. She leaned forwards meeting me
with an intense look. ‘I came to see a gestalt therapist because I want challenge,’ she
announced. I let a few moments pass. ‘I’ve got a suggestion,’ I replied. ‘Try breathing into
your stomach, sit back and let the furniture support you.’ Michelle looked surprised but awk-
wardly followed my suggestion. Though still noticeably tense, her muscles had relaxed a few
degrees as she struggled to take deeper breaths. ‘Can you feel the sofa against your back?’ I

GESTALT THERAPY 197
enquired. She replied with a quiet ‘yes’ in a voice that held none of her earlier sharpness. Her
eyes became a little fluid. She’d been challenged and that was enough for now I thought. I
invited her to tell me her story.
Michelle had experienced an isolated upbringing. An only child, her parents had relocated
several times due to her father seeking different posts as a university lecturer. Every couple
of years Michelle had been uprooted from her school and friends and consequently gave up
on making friends. Her mother she described as an ‘unassertive wallflower’. Michelle had
vowed ‘never to be like that’. In the absence of close relationships she had thrown herself
into her schoolwork, a pattern repeated through university and into her working life. She
lived alone with her cats and had a long-term partner who lived nearby but appeared emotion-
ally distant. Michelle had no children ‘and had never had any desire to have any’.

Michelle’s apparent desire for confrontative challenge in therapy reflected her retroflective
process in challenging herself that had formed in relation to the sparseness of supportive
relationships during her life. She had learnt to self-support from a young age. Any emotional
nurturance had been conditional upon measurable achievement, leading to an introjected
message that unless she ‘achieved’ she was unworthy. She worked excessive hours without
breaks, skipped meals, drank ‘a little too much wine’ and filled her weekends answering
emails. This woman drove herself hard. My interest centred on the under-developed ends of
Michelle’s continuums of hardness-softness, self support-environmental support, strength-
vulnerability and isolation-confluence.
I was also struck by my reaction to Michelle. In the co-transference I expected to feel
critical or harsh towards her, but felt protective, even fatherly, towards this pinstriped
achiever. I also recognised a possible parallel process in that I can overwork. I needed to
work as hard as needed but also to sit back and relax into the sessions to model a healthy
process.

I recognised a need to increase Michelle’s awareness of how she diluted her level of contact
with me. She spoke quickly, in general terms and flitted from one subject to another. I invited
Michelle to use present centred language and to be aware of her bodily reactions as she
spoke. I suggested an experiment that we practised together, simply to form a sentence with
the two words ‘I’ and ‘You’ in it. Below is an edited section of our dialogue:
Michelle – What’s the point in doing this? What’s it going to achieve?

Dave – I’m suggesting an experiment, we might not achieve anything. Do you want to quit trying this
with me before we’ve even started? (I use more immediate language.)
Michelle – Okay. I think you’re winding me up!
Dave – (Smiling) I’m amused by your response.

Michelle – I’m irritated by you laughing at me.

Dave – I didn’t mean to upset you ... I feel warm towards you.
Michelle – uh … I … er … feel a bit thrown …
Dave – (Non-verbally I invite Michelle to continue.)
Michelle – … thrown, yes … thrown by you.
Dave – I am touched by you.
Michelle – This is really difficult.
Dave – You’re doing fine. Just try to own your ‘this’ and try including an ‘I’ and a ‘you’.
Michelle – Phew ... I find it difficult to speak to you directly.
Dave – I really appreciate you experimenting with something that’s difficult for you.
Tears began to roll gently down Michelle’s cheeks. She made a few attempts to deflect from
her emotions, but then made contact with humour. ‘I suppose you’re going to ask me to
breathe,’ she said. I didn’t need to.
Over the following weeks we explored Michelle’s need to fill space with work, she had
created a field in which she saw her company as dependent upon her – she didn’t recognise
the co-dependence. An experiment revealed that Michelle’s whole identity was tied up with
work and facilitated movement. We simply alternated between asking each other, ‘Who are
you?’ Michelle initially answered with a series of work-related roles, but when she ran out of
work-related titles she struggled to continue. Her face began to redden, her eyes cast down
as her body crumpled slightly. With shame in the air I wondered whether to end the experi-
ment. Instead I invited Michelle to note her bodily reactions, whilst gearing my ‘who are you’
responses towards roles and interests that I already knew were close to those present in her
life. My response of ‘a husband’ helped put Michelle in touch with the area of her life where
she was ‘a partner’. So our dialogue continued, my ‘son’ was met with her ‘daughter’ my
‘animal lover’ met with her ‘cat lover’.
Michelle’s energy increased as she began sharing more freely before out of the blue she
shifted to contacting areas she aspired to be – dancer, painter, teacher. After the exercise
Michelle surprised me again. She looked at me directly and said, ‘I really appreciated you
helping me out there.’ It was an immediate moment, I shared that I felt moved by Michelle.
An intimate dialogue followed in which Michelle shared her struggles in moving from the
security of what she knew, she shared her fear of letting go in case nothing was there, of
moving closer to her partner in case he rejected her. ‘I’m forty-four, everyone sees me as
successful and confident and really I’m scared, Dave.’ I shared with Michelle that I loved her
plain humanness and my appreciation of the risks she had taken in therapy.
The dialogue that emerged from this experiment proved to be a catalyst for Michelle to
experiment with new ways of being beyond the therapy room. As with any experimentation
these were graded and I helped support her in formulating them. An early step, to take breaks

GESTALT THERAPY 199
during her working day, appeared simple but was radical for Michelle as she sat with her
laptop free anxiety in a coffee bar. However, she was able to support herself sufficiently with
the knowledge that nothing new could emerge into filled space. It was her increasing ability
to tolerate space in therapy that had laid the ground for this movement. The pattern of her
willingness and courage to risk in the therapy room was mirrored in her life. She enrolled for
Salsa classes and began art classes. Not everything went smoothly, her relationship with her
partner eventually collapsed in the wake of her desire for a closer relationship. A brief period
of negative transference with me followed, as she blamed me for her relationship breakdown,
but having journeyed through this our therapeutic relationship deepened.

Work continues with Michelle fleshing out her life both inside and outside the therapy room.
Her field is less cluttered with tasks and she has increased her interpersonal and environmen-
tal support systems. As I write she is wrestling with a decision to make a career change by
moving into teaching. Introjects surface, ‘I can’t at my age’, ‘I should stay with what I know’,
but Michelle is now better able to counter such arguments, support for an opposing polarity
has increased. Her story, of which I am but a part, continues.
5.1 Developments
5.1.1 Brief therapy
If we are to respond to the demands of the field in which we live with its restrictions through
diminishing services and financial constraints, as gestalt therapists we need to offer more
than long-term psychotherapy. What is essential in providing brief gestalt therapy is that we
remain true to our philosophy in delivering a process focused rather than a solution focused
therapy.
Gestalt’s present-centred focus in relation to the client’s background makes it well suited to
brief therapy; in fact much of Perls’s workshop demonstration sessions could be described as
brief therapy. Notions that the client needs buckets of ego-strength, are able to self-support,
and are crystal clear on what they wish to gain from therapy are misplaced – I contend that
most people can benefit from gestalt brief therapy. What is crucial is the skill of the therapist
in being able to grade their approach appropriately, being particularly vigilant in tracking
relational ruptures in the therapy and be willing to meet the client where she is with acknowl-
edgement of the limitations of what change is possible in the time available.

As outlined, gestalt therapy emerged from a rich and diverse background that should equip its
practitioners well for working with diversity. Standing upon the three pillars of field theory,

dialogue and phenomenology, together with our grounding in holism and belief in self-as-process
the gestalt therapist should be able to gain an embodied appreciation of difference. However,
gestalt therapy, along with many other psychotherapies, has been criticised in the past for its
application to only certain percentages of the population, namely middle-class, educated,
European-descendent individuals. Perls’s and his contemporary’s emphasis on the individual
above community in his years at Esalen, and the implicit intolerance of processes such as con-
fluence and introjection led to a distancing from more community-based cultures. Relational
gestalt schools have redressed this confluent phobic attitude to a large degree but considerable
challenges lay ahead in reaching certain sections of our multicultural communities.
Gestalt therapy is more effective in reaching other areas of difference such as the gay
population. However, within gestalt there are imbalances that reflect societal imbalance, an
example being the disproportionate amount of men in senior positions compared with the
gender split in a new training group.

The limitations of the gestalt approach lie between the client – therapist relationship together
with the limitations imposed by the situation i.e. the clinical environment, number of sessions
available, financial constraints, client’s and therapist’s backgrounds. The limitations cannot
be assessed in a linear way as something always emerges that is more than the sum of its
parts. The limits of the possibilities of dialogues are shaped by the limits of awareness
(Buber, 1958).
The cultural ground upon which we stand dictates that there are disturbed individuals
whereas from a gestalt perspective there are only disturbed situations to which the individual
creatively adjusts. The limitations of the approach are the limitations of the collective creativ-
ity of the situation of which the client and therapist are figural. However, creativity requires
a holding structure and part of that structure is knowledge of therapeutic strategies for work-
ing with a range of presentations so wide that it cannot and is not covered by gestalt therapy
theory alone, e.g. cultural difference, mental health disorders, working with disability. We
need to be aware of the areas our training programmes do not equip us to work with and be
willing to undergo further training beyond our modality as needed.

As discussed earlier some of the criticisms of gestalt therapy are based on a misunderstanding
of the nature of the approach, which must in some way be co-created by gestalt therapists.
For example, a perceived need to repeatedly undo retroflection has led some therapists to
perform dramatic cathartic experimentation repeatedly, particularly around the expression of
anger, in the name of gestalt therapy. It has been repeatedly shown in research that the expres-
sion of anger has strengthened a neural aggressive pattern (Grawe, 2004; Petzold, 2006 in

GESTALT THERAPY 201
Staemmler, 2009) and that some catharsis causes more harm than good. However, we need
to be wary of rebounding to an opposite polarity. Undoubtedly, Fritz Perls was a showman in
some of his work but much of his and his contemporaries’ work and thinking was sensational
for all the right reasons.
Some criticisms of certain ways of practising gestalt are that an over-emphasis on the present
moment fails to appreciate that the present moment nestles in a continuum of time. There is also
a distinct tendency in the gestalt literature when discussing awareness to place a heavier empha-
sis upon sensory and bodily experience with comparatively few references to cognitive aware-
ness. This may represent the remnants of gestalt’s rebellion against the form of psychoanalysis
practised at the time of gestalt’s birth. My view is that awareness is awareness and that a fully
embodied awareness requires an integration of all modes of experiencing.
A frequent criticism of gestalt is that it lacks a coherent developmental theory. I question
this believing that gestalt’s developmental theory is implicitly contained within field theory
and Lewin’s thinking in relation to the life space, but accept that this has not been clearly
articulated. Gestalt therapists understand development not in terms of continually gaining
new abilities but as a continually evolving re-organising process between the person and their
situation. Infant research is increasingly becoming integrated into gestalt from Intersubjectivity
theory and Daniel Stern’s (1998) work has been integrated into many gestalt practitioners’
theoretical frames.
Gestalt uses idiosyncratic language that tends to distance from experience rather than
connect – ironic for a therapy concerned with awareness and contact. The development of a
more user-friendly vocabulary would increase the approaches appeal to the masses and help
facilitate communication between gestalt and other modalities.
There has been a tendency amongst some contemporary gestalt therapists to deconstruct
existing theory. If we believe self is always in process then the self of gestalt will always be
in a deconstructing and constructing process. However, although construction is taking place
a possible criticism is that the balance needs to be redressed. A valid criticism levelled at the
cycle models is that they promote an individualistic view of experience. They suggest that
first there is an individual followed by an interaction with the environment: ‘they imply that
the individual system is superior to the situation’ (Wollants, 2012: 93).
5.4 Controversies
Around the area of ‘body work’ and touch controversy has never been far away and false
truths together with fixed ideas form. Often for good reasons, protective of self and other,
many therapists avoid touch in their practice. However, if we omit touch from the therapeutic
encounter we deprive the relationship of discoveries that could not be made in any other way.
Even though we may be able to hold another with our eyes there is a danger that we could
move from an embodied way of relating to placing a greater and greater emphasis upon ver-
bal communication with all the restrictions of language. Touch is one of the first ways in
which we make contact with the world as infants and our bodies quite literally resonate from

that contact. The more disembodied a culture, the more controversial working with touch and
the body becomes and the greater the potential for a Cartesian division between body and
mind.
The subject of bracketing has led to controversy within gestalt due to what I perceive as
some misunderstanding of the concept of bracketing when applied to interactions between
human beings rather than perception of inanimate objects. Bracketing within transcendental
phenomenology ‘is aimed at understanding the object and not the experience or existence of
the individual’ (Yontef, 1993: 16) and in this understanding Husserl considered that one could
reach objectivity. Of greater clinical relevance in gestalt is existential phenomenology, which
holds no such beliefs with the process of bracketing seen as a way of heightening one’s
awareness of ones biases to be in a place to be touched by meeting with the client’s experi-
ence as if for the first time, a meeting and an experience that is profoundly subjective.
6 RESEARCH
As gestalt therapists we are natural researchers as we repeatedly engage with a client’s

experience of their world. In any gestalt research the researcher/therapist is committed in
their involvement with the area being researched rather than observing data from a dis-
tance. Just as we may consider the relationship as being the therapy, the researcher is the
research.
Compared to some other approaches qualitative research is relatively thin on the ground
in gestalt. A contributory factor may be that the nature of the gestalt relational approach
does not lend itself to qualitative research, with its measuring and rating systems, as read-
ily as those from other approaches such as behavioural modalities. However, quantitative
research has been conducted using the Clinical Outcomes in Routine Evaluation (CORE)
system by gestalt therapists the majority of whom were delivering therapy in primary care
(Stevens et al., 2011). This study ran over a three-year period and showed that 74% of
clients showed recovery or improvement. The closest similar studies from practitioners of
other modalities (CBT, psychodynamic, person-centred) working in primary care revealed
very similar outcomes (Stiles et al., 2008; Mullin et al., 2006), 78% and 72% respectively.
These studies appear to add substance to the notion backed by research and meta-analyses
that it is the therapeutic relationship that is of far greater significance in determining
favourable outcome than the modality. Lambert (1992, in Hubble et al., 1999) provided
empirically well-grounded estimates that therapeutic change is approximately 40% due to
extra-therapeutic factors, 30% due to the relationship with the therapist, 15% due to expec-
tancy and hope factors and 15% due to the techniques and models of individual approaches.
A further review of meta-analyses by Lambert and Bergin (1994) into The Effectiveness of
Psychotherapy revealed ‘only modest evidence’ to suggest that one modality was more
effective than another, the abilities of the individual therapists irrespective of their thera-
peutic orientation appeared to be the most important factor in determining therapeutic
outcome in many of the studies and meta-analyses.

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Stumpfel’s (2006) study in which 74 published research studies were reanalysed in 10

meta-analyses seriously challenges any misconception that gestalt therapy is unsuitable for
clients experiencing mental health problems. Psychiatric patients with a range of diagnoses
including schizophrenia, affective disorders, functional disorders, substance abuse, anxiety
states and personality disorders were studied. Some studies included subjects with dual or
multiple diagnoses. In total efficacy testing was completed on data from around 4500
patients treated, approximately 3000 were treated using a gestalt approach with the balance
being treated by other approaches or were untreated controls. Around two-thirds of the 38
outcome studies collected data from a control group and 21 of the outcome studies obtained
follow-up data. In around 25% of the studies gestalt was combined with what the author
considered compatible approaches such as process-experiential therapy, the remaining 75%
investigated identified ‘classical gestalt therapy’ in at least one treatment condition. The
wide range of different and complex diagnoses covered in these studies confirmed the suit-
ability of gestalt therapy as an effective approach for patients using psychiatric services,
including those with complex symptoms. It also confirmed the effectiveness of the approach
in working with anxiety-based disorders.
To offer a flavour of the breadth of some of the gestalt research completed, Spagnuolo-
Lobb (1992, in Brownell, 2008) conducted experimental research with 250 pregnant
women entitled ‘Childbirth as Re-birth of the Mother’. These women aged 16–35 years
were split into three groups, one trained in a gestalt approach to childbirth, another trained
in respiratory autogenic training and a group that received no training. The average dura-
tion of labour in the gestalt-trained group was 4 hours less than those that received no
training and 2 hours less than those that received respiratory autogenic training, with the
gestalt-trained subjects perception of themselves during childbirth being more positive
than the other two groups. Spagnuolo-Lobb hypothesises that in birth the mother has the
opportunity to re-experience her own birth in a more adult and active way thereby reduc-
ing trauma. Like any other contact experience she identified that birth can be divided into
four phases: fore-contact, contact, final contact and post-contact (Perls, Hefferline and
Goodman, 1951).
Greenberg (in Brownell, 2008) has completed process outcome research using a process
research strategy he developed called ‘task analysis’. His research projects are based on
two-chair experimentation and as such are technique based being concerned with the resolu-
tion of intrapsychic conflict, decisional conflict, conflict resolution and unfinished business.
Comparison studies showed that use of the two-chair technique was more effective in reduc-
ing indecision than behavioural problem solving, with both groups faring better than the
waiting-list control. In a number of studies of major depression in which two-chair experi-
mentation was used in conjunction with a person-centred approach, Greenberg reports
‘improved outcome in depression, global symptoms, self esteem and interpersonal prob-
lems’ (ibid.: 67) over the person-centred approach alone with improvement maintained at
six and eighteen-month follow-up. A further study, using an empty-chair technique in rela-
tion to abusive and/or significant others, ‘achieved significant improvements in multiple
domains of disturbance’ (ibid.: 68); these improvements were sustained at nine-month fol-

low-up. It needs to be noted that although Greenberg identifies his approach as gestalt, his
studies revolve around a single experiment that originated in gestalt rather than a fully inte-
grated gestalt approach.
A wider sharing of research findings is a growing edge for gestalt practitioners. However,
the subject of research is a wide one and gestalt possesses some fine thinkers who have
engaged in detailed research in formulating a diverse set of clinical arguments. These have
been committed to the pages of some excellent in-depth journals: The British Gestalt
Journal, The Gestalt Review (USA), The Gestalt Journal (USA) and The Gestalt Journal of
Australia and New Zealand, to name a few of those written in English. This body of work
helps facilitate on-going phenomenological action research, holistic enquiry and heuristic
research in the give and take of clinicians daily work with clients.
7 FURTHER READING
Hycner, R. and Jacobs, L. (1995) The Healing Relationship in Gestalt Therapy – A Dialogic / Self Psychology
Approach. Highland, NY: Gestalt Journal Press.
Mann, D. (2010) Gestalt Therapy: 100 Key Points and Techniques. East Sussex: Routledge, Taylor & Francis.
Robine, J-M. (2011) On the Occasion of the Other. Goldsboro, ME: Gestalt Journal Press.
Wollants, G. (2012) Gestalt Therapy: Therapy of the Situation. London: Sage Publications.
Yontef, G. (1993) Awareness, Dialogue and Process: Essays on Gestalt Therapy. New York: Gestalt Journal Press.
8 REFERENCES
Beisser, A. (1970) The paradoxical theory of change. In J.Fagan and I. Shepherd (eds), Gestalt Therapy Now, New
York: Harper.
Brownell, P. (2008) Handbook for Theory, Research and Practice in Gestalt Therapy. Newcastle: Cambridge
Scholars Publishing.
Buber, M. (1958) I and Thou (2nd edn). Edinburgh: T and T Clark (originally published in 1923).
Denham-Vaughan, S. (2010) The liminal space and twelve action practices for gracious living. British Gestalt
Journal 19(2): 34–45.
From, I. and Muller, B. (1977) 'Didactical notes' in B. Muller (1996) Isadore From’s contributions to the theory and
practice of Gestalt Therapy. The Gestalt Journal 19(1): 57–81.
Grawe, K. (2004) Neuropsychotherapy (Psychological Therapy). Gottingen: Hogrefe.
Hubble, M, Duncan, B.L., Miller, S.D. (eds) (1999) The Heart and Soul of Change: What Works in Therapy.
Washington, D.C.: American Psychological Association.
Hycner, R. and Jacobs, L. (1995) The Healing Relationship in Gestalt Therapy – A Dialogic / Self Psychology
Approach. Highland, NY: Gestalt Journal Press.
Joyce, P. and Sills, C. (2010) Skills in Gestalt Counselling and Psychotherapy (2nd edn). London: Sage.
Lambert, M.J. and Bergin, A.E. (1994) The effectiveness of psychotherapy. In A.E. Bergin and S.L. Garfield (eds)
Handbook of Psychotherapy and Behavior Change (2nd edn). New York: Wiley. pp. 143–89.
Lewin, K. (1952) Field Theory in Social Sciences. London: Tavistock.

GESTALT THERAPY 205
Mann, D. (2010) Gestalt Therapy: 100 Key Points and Techniques. East Sussex: Routledge, Taylor & Francis.
Mann, D. (2013) Assessing suicidal risk. In G. Francesetti, M. Gecele, J. Roubal (eds), Gestalt Therapy in Clinical
Practice: From Psychopathology to the Aesthetics of Contact. Milan: FrancoAngeli.
MacKewn, J. (1997) Developing Gestalt Counselling. London: Sage.
Merleau-Ponty, M. (1962) Phenomenology of Perception. Translated from French by C. Smith. London: Routledge
and Kegan Paul Ltd.
Mullin, T., Barkham, M., Mothersole, G., Bewick, B., Kinder, A. (2006) Recovery and improvement benchmarks for
counselling and the psychological therapies in routine primary care. Counselling and Psychotherapy Research
6: 68–80.
Perls, F. (1947) Ego, Hunger and Aggression. London: George Allen & Unwin Ltd.
Perls, F. (1969) Gestalt Therapy Verbatim. Moab, UT: Real People Press.
Perls, F, Hefferline, R, Goodman, P (1951) Gestalt Therapy: Excitement and Growth in the Human Personality.
London: Souvenir Press.
Polster, E. and Polster, M. (1973) Gestalt Therapy Integrated: Contours of Theory and Practice. New York: Vintage
Books.
Robine, J-M (2011) On the Occasion of the Other. Goldsboro, ME: Gestalt Journal Press.
Staemmler, F-M. (2009) Aggression, Time and Understanding. Cambridge, MA: Gestalt Press.
Stern, D. (1998) The Interpersonal World of the Infant. New York: Karnac.
Stevens, C., Stringfellow, J., Wakelin, K., Waring, J. (2011) The UK Psychotherapy CORE Research Project. British
Gestalt Journal 20(2): 22–7.
Stiles, W.B., Barkham, M., Connell, J., Mellor-Clark, J. (2008) Responsive regulation of treatment duration in rou-
tine practice in United Kingdom primary care settings: replication in a larger sample. Journal of Consulting and
Clinical Psychology 76: 298–305.
Stratford, C.D. and Brallier, L.W. (1979) Gestalt therapy with profoundly disturbed persons. The Gestalt Journal 2:
90–103.
Stumpfel, U. (2006) Therapie der Gefuhle (Research Findings on Gestalt Therapy). Cologne: Edition Humanistische
Psychologie.
Woldt, A. and Toman, S. (eds) (2005) Gestalt Therapy: History, Theory, and Practice. London: Sage Publications.
Wollants, G. (2012) Gestalt Therapy: Therapy of the Situation. London: Sage Publications.
Yontef, G. (1993) Awareness, Dialogue and Process: Essays on Gestalt Therapy. New York: Gestalt Journal Press.
Zinker, J. (1977) Creative Process in Gestalt Therapy. New York: Vintage Books.

9
Transactional Analysis
Charlotte Sills
Transactional analysis was founded by Eric Berne (1910–70), whose aim was to create an
accessible, potent way of understanding self, personality and relationships, that could be used
effectively in all walks of life and by clients, psychotherapists and psychiatrists alike.
The name ‘transactional analysis’ (known as TA) refers to the analysis of how people com-
municate and relate to each other (how they ‘transact’). TA uses observation of here and now
interchanges (the interpersonal) in order to improve communication and also as a route to
understanding personality (the intrapsychic or internal world). The analysis of the transac-
tions is based on Berne’s theory of ego states – Parent, Adult and Child – three different ways
of being that shape our internal world and our behaviour. It is interesting that Berne named
the approach for the interpersonal element of human experience. It underlines the idea that
everything we need to know about the personality is in some way happening now in a per-
son’s relationships with others and that if we examine them closely we will be able to under-
stand how the overt behaviour of relating is a manifestation of their inner world – their fears,
their needs and desires, their self-image and even the parts they hide from themselves.
Berne was passionate about developing a theory that could be used to empower patients.
Instead of seeing themselves as hapless victims of bad luck, they could take responsibility for
themselves, including for deciding what their problems were and how the treatment should
progress. He was the first to talk about the therapeutic contract (see below) and he translated
complex ideas into simple ones, putting them into a social, relational context – for example,
transference and Freud’s ‘repetition compulsion’ becomes life scripts and ‘psychological

games’, which can be analysed as ‘ulterior transactions’. This accessibility of theories and
concepts has been one of the great contributions of TA to psychology and psychotherapy in
general.
The history of Berne and of TA is well-documented (see e.g. the ITAA website). Key mile-
stones are: by 1956 Berne was holding weekly meetings of interested mental health profes-
sionals, under the name the San Francisco Social Psychiatry Seminar; this led later to the
foundation in 1964 of the International Transactional Analysis Association (ITAA) and in
1974 the European Association of TA (EATA). In 1961 Berne published Transactional
Analysis in Psychotherapy, which drew together all his TA theories to date. It presents a
complete view of TA’s theory of personality, psychotherapy and communication. As well as
some 70 articles, he wrote five more TA books before his death in 1970 (two of which were
published posthumously), including in 1964 Games People Play which, though written for
professionals, became a best-seller and introduced into common usage such TA terms as the
deceptively glib ‘I’m OK – You’re OK’; ‘games’ (co-created patterns of relating); and
‘strokes’ (units of recognition). Intuition and Ego States, which was published in 1977, is a
collection of the papers written between 1949 and 1959 that track the development of Berne’s
ideas based on the informal naturalistic research into intuition and non-conscious communi-
cation that he carried out with his colleagues.
Since the 1960s, TA has developed its theory, applications and organisation. There are
more than 10,000 members worldwide in a network of affiliated national and regional
organisations in over 90 countries, under the umbrellas of the ITAA, EATA and the
Australasian FTAA (Federation of TA Associations). These associations collaborate to
provide an international system for the accreditation of practitioners, supervisors and
trainers.
The UK Association of Transactional Analysis (UKATA) was formed in 1974, and in 2010
The Scottish Transactional Analysis Association (STTA). Britain is also home to the
International Association of Relational Transactional Analysis (IARTA), a special interest
group established in 2009 with a worldwide membership. Between all these organisations
and others devoted to organisational and educational TA, there are more than 1000 people in
the UK actively involved in practising TA. The TA psychotherapy qualification is recognised
by the current national organisations of psychotherapy and counselling. Many TA psycho-
therapy training programmes are validated as Masters degrees and several individuals have
achieved doctorates or are engaged in doctoral studies.
1.1 Influences
Berne was well-read and well-travelled. His early books are full of references to a wide range
of authors, not only from psychology and psychoanalysis but also from literature, history,
mythology and so on. Thus the influences on his thinking are many.
Foremost is humanistic psychology. Although Berne originally trained as a psychoana-
lyst and this profoundly affects his theories and models, it is the humanistic beliefs about
human beings, their motivation and their potential, that shape the therapy and the way it is

TRANSACTIONAL ANALYSIS 209
conducted. TA’s philosophical tenets are based on a belief in the value and equality of
human beings (encapsulated in the notion of I’m OK – You’re OK). TA’s principles concern
mutual commitment in the contract, empowerment of the client, the transparent use of
accessible theory, and belief in self-responsibility and change: this makes the humanistic
tradition TA’s home.
However, in terms of its theories and focus, there are many other influences (see Clarkson,
1992), and TA theories reflect a creative integration of ideas and concepts from:
psychoanalysis: from which comes careful attention to both conscious and unconscious processes, recog-
nising the importance of internal conflicts and patterns of relating to self and others;
existentialism and phenomenology which leads to a focus on what is using observation and dialogue;
social psychiatry which emphasises the impact of social stressors, oppression and other life circumstances
on mental health;
behavioural psychology/cognitive behavioural therapy which brings a more behaviour-focused approach
to helping people change dysfunctional thinking, behaviour and emotional responses, which suited
Berne’s pragmatic views on change.
1.2 The image of the person

1.2.1 The philosophy
TA’s philosophy is grounded in the belief in human beings’ capacity to think and take respon-
sibility for themselves and their behaviour. It holds the position ‘I’m OK, You’re OK’, which
represents two profound and challenging ideas. The first is ‘I am – You are’, a deeply exis-
tential position representing the simultaneous separateness yet connectedness of human
beings. The second is ‘OKness’, the humanistic influence, the belief in the value of human
beings and trust in their innate capacity for empathy.
1.2.2 A theory of motivation: the hungers

From that philosophical stance, according to Berne, all human beings are born with a number
of ‘psychobiological hungers’, which drive and motivate us. They are linked to but go beyond
physical survival needs. The core hungers are:
For stimulus, contact and recognition: we are hard-wired to need relationships for our physical and psycho-
logical well-being. We need to be recognised and acknowledged as separate beings (I am – You are)
but we also need to feel connected and accepted. Erskine (1993), building on the work of Kohut,
elaborates this fundamental human hunger and identifies eight relational needs (for example, to love
and be loved, to be heard, to have our experience confirmed) that underpin our being in the world.
For structure and predictability: People get very anxious if there is not enough structure in their lives and
will go to great lengths to impose it. They will make sense of their experiences and live according to
that ‘made meaning’ in order to achieve a sense of mastery, even if that meaning is detrimental,
damaging or limiting.

For incident: Paradoxically, people also crave incident and novelty. Too much structure leads to stagnation
and boredom, and again, people will go to lengths to create excitement – sometimes at the expense
of their peace and happiness.
These hungers are in a constant state of tension and balance with each other. Ideally, we live
that balance flexibly.
1.2.3 The development of personality

The interplay between the psychobiological hungers and our relational experiences in the
world leads to the formation of personality, represented in the model that is the cornerstone
of TA theory and practice. Berne described three internal systems called ‘psychic organs’ that
organise experiences in the mind. They are the neopsyche, exteropsyche and the archeopsy-
che and they manage the tension between our basic needs and the demands of the environ-
ment. However, he was most interested in the manifestation of these systems as dynamic,
enduring states in the personality that are experienced and enacted as reality. These states of
the ego he called Parent, Adult and Child (see Figure 9.1), defined as ‘coherent systems of
thought and feeling manifested by corresponding patterns of behavior’ (1972: 11). Parent ego
states are thoughts, attitudes, feelings and behaviour that are learned or ‘introjected’ from
parent or other significant figures. Child ego states are enduring experiences from childhood,
a blend of instinctual needs, the psychobiological hungers and adaptations to the environ-
ment. Thus Kiera, who swore she would be a different mother to her own children, hears to
her horror her mother’s voice come out of her mouth as she imposes the same rules that she
had followed in her childhood. Yet at another time, in the presence of her partner’s angry
Feelings, attitudes,
Parent sensations, thoughts
introjected from parent
figures
sensations, thoughts
Adult that are here-and-now
responses to the
present situation
Child sensations, thoughts
that are carried
forward from
childhood
Figure 9.1 Ego states

feelings, she experiences a familiar childhood anxiety and finds herself agreeing to things she
doesn’t want to do. Adult ego states are thoughts attitudes, feelings and behaviour that are
appropriate to here-and-now. When Kiera becomes aware of her stomach tensing and the
familiar cowering sensation, she takes a moment to reflect, notices the simultaneous pressure
to ‘do as your told’. She reminds herself that she is now grown up and chooses how she will
respond to her partner. The ego states’ relationship to each other – the internal dialogue – also
demonstrates the representation of early relational experiences and is therefore an object rela-
tions theory (theory of implicit relational patterning).

1.3.1 Acquisition of psychological disturbance
TA, like most approaches to therapy, is interested in how the past influences the present.
Ways of being-in-the-world are developed – largely in childhood, but also at any significant
period in our lives – and these patterns, refined and adapted over time, become our identity
and shape the way we act in the present moment. With his theory of ego states, Berne offered
a framework for understanding those repeating patterns. The ego states are contained within
a wider life narrative, which he called Script and which he defined in 1961 as an ‘extensive
unconscious life plan’ (1961: 123) that reflects the ‘primal drama of childhood’ (1961: 116).
In 1972 he referred to script as ‘a life plan based on decisions made in childhood, reinforced
by parents, justified by subsequent events and culminating in a chosen alternative’ (1972:
446). Of course, many or even most of the ‘decisions’ are non- or preverbal adaptations.
Everyone has a script, in that everyone was shaped by early life experiences and developed
patterns of being with self and with others – some of them positive and nourishing, some more
habitual and limiting, some clearly rigid and negative. Psychological disturbance implies a
script that is acquired under enduring pressure or in conditions of trauma where a person’s
psychological and emotional ‘survival’ is at stake. It creates patterns of being-in-the-world that
exclude vital parts of self and self-needs; these patterns are experienced as not amenable to
adjustment even when the threat is past. They are experienced literally as ‘how life is’.
This interferes with the ability to be intimate with oneself and others. The therapist aims to
help a client understand and ‘loosen’ script (the Greek word analusis, from which analysis
derives, literally means the loosening of bonds). To do so, TA offers a large number of theories
and models that describe personality and behaviour and the development and maintenance of
patterns. It is not possible to include them all here but for a readable description of all the
concepts, where they are introduced gradually, see for example Woollams and Brown’s Total
Handbook of TA (1979), which though out of print remains one of the best overviews of the
approach, or Stewart and Joines (1987). For an account of theory as applied in a ‘helping
relationship’ (in particular counselling, therapy and coaching) see Lapworth and Sills (2011).
In this chapter I describe the core theories and their application. In order to do so, I offer
a simple visual way of understanding the process of script development, which is shown in
Figures 9.2 (Sills and Salters, 1991). This is The Comparative Script System (or simply the

Script System). It illustrates how both healthy and unhealthy conscious or non-conscious
patterns are developed.
There are four segments to the Script System– they are drawn as a wheel in order to
attempt to capture the dynamic nature of learning and repeating. Segment A represents
original experience. This can be any event at any time, but here I will take childhood experi-
ence as the major theme. Human beings are meaning-making creatures; this is part of how
we meet our need for structure. Out of any original experience there is meaning making and
adaptation to that felt meaning (Segment B), which happens at many levels from the con-
scious and cognitive through to emotional, visceral and non-conscious. It leads to relational
expectations and conclusions about self and the world, which become the person’s identity.
As a result, in the here and now, when faced with a stimulus that is reminiscent of the early
experience, the person has internal/intrapsychic (Segment C) and external/interpersonal
responses (Segment D). The important effect is that the behaviour manifested at Segment D
is very likely to elicit or co-create the familiar relational response from the environment
which recreates a similar experience to that at Segment A.
In Segment A of the wheel – The original experiences – we think of the dynamic inter-
play between our ‘nature’ (including our hungers) and the environmental response. Repeated
relational experience or one-off trauma have a powerful impact on the developing psyche,
which adjusts and adapts itself to survive physically and psychologically, as well as being
THE WIDER WORLD
A Back there and then

Repetitions of the
dynamics of
original
experiences
and events
D B
Meaning making
Observable
Assumptions about
behaviour and
self, others and the
communication
world
style
Patterns of relating
C
Patterns of
thinking,
feeling and
fantasising
Expectations THE WIDER WORLD
and
Here and now
imagination
Figure 9.2 The comparative script system

shaped by ‘what is’. The infant does not have choices for how to feel and be – he is within
and part of his relational field (in TA terms, this is the protocol (Berne, 1961).
One of the models TA uses to think about the influence of the environment on the developing
child is the ‘script matrix’ (originally developed by Steiner, 1974/1990). The diagram is tradition-
ally drawn with three sets of ego states – for the child and his two parents or ‘significant powers’
in his early life (see Figure 9.3). These parental influences transmit ‘messages’ about how the
child should be. These can be clear directives – advice and slogans about how to get on in the
world, such as work hard, take care of others, smile and the world smiles with you and so on.
They can lead to what TA calls ‘Drivers’ (‘Please’, ‘Try hard’, ‘Be perfect’, ‘Be strong’, ‘Hurry
up’, ‘Take it’) upon which our sense of ‘OKness’ depends. Often they are underpinned and rein-
forced by messages which, while they are supportive of the advice, are undermining to the
child’s self. They are normally unconscious or unintended, non-verbal and emotive. They were
categorised by the Gouldings (1979) into twelve injunctions, each of which starts ‘Don’t …’ and
puts a limitation on full and healthy functioning – from the devastating ‘Don’t exist’ or ‘Don’t
be you’, to ‘Don’t grow up’, ‘Don’t feel’, ‘Don’t think’ and so on. The necessary use of words
to describe these messages has a tendency to imply that they were given verbally or at least
cognitively, but of course, this is not the case. They are conveyed and internalised by the child
viscerally and emotionally as impressions or urgent pressures; they are sometimes self-created
as necessary adjustments. The result is the child’s script – his conclusions or adaptations to the
world around him. There is a third type of message in the script matrix, which is the ‘programme’
or what the child sees modelled to him by those around him. Thus a parent might consciously
urge her son to work hard and think carefully. However, under stress she might panic and have
no ability to cope with problems. It is the modelled behaviour that is likely to have more impact.
In the traditional model of the script matrix, the messages are indicated with uni-directional
arrows pointing from the parents to the child, indicating the power imbalance. However,
more recently (e.g. Summers and Tudor, 2000) transactional analysts have been using the
double-headed arrow to indicate that even from birth the relationship between child and car-
egiver is co-created and mutually shaped. The research into infant development (e.g.
Trevarthen www.educationscotland.gov.uk/earlyyears/prebirthtothree/nationalguidance/
conversations/colwyntrevarthen.asp) shows clearly the dynamic and co-responsive relation-
ship between infant and mother. It is important to add that while the script matrix focuses on
the all-important early years of scripting, which is usually familial (as in Figure 9.4), script
messages are transmitted by society, education and culture, as well as by friendship groups
or organisational dynamics.
Segment B of the wheel describes the structure of the personality as it is formed by the
experiences at A. Here the major concept is the structural model of ego states as described
above. Other TA concepts that describe this ‘meaning making’ adaptation are the Frame of
Reference (Schiff et al., 1975), Early Decisions (Goulding and Goulding, 1979) and Life
Positions (Berne, 1966).
Example: (A) Sophie was adequately cared for by her mother but her father was distant
and irritable most of the time and sometimes drank heavily. At those times he had verbal and
physical fights with her mother, whom Sophie often saw miserable and weeping (Program).

Mother/primary Father/second
caretaker important caretaker
Child
P P
A A
C C
Figure 9.3 The development of script

Script matrix – a representation of the interplay between child needs and environmental pressure
P – P Directives about how to be in the world
A – A Program: modelling
C – C Injunctions – unconscious messages from the world to the child or self-created by the child in order
to adapt to demands.
When Sophie tried to intervene, she was roughly pushed out of the way. She wished that
someone would be strong enough to stop this situation, but no-one helped her (injunctions
relating to having needs and being powerless). (B) Sophie grew up with anxiety and tension
in her body and a ‘Be strong’ driver, with a fear of men and with a Child belief that women,
and herself in particular, were powerless and miserable. The world did not care.

A healthy script is one where the learned patterns are appropriately flexible and responsive
to a changing world, and where a person’s basic needs and hungers are adequately met. For
example, the child who learns to read with pleasure and success and with the support of his
parents, is likely to develop beliefs and patterns about successful learning, which he will
bring to every future learning situation – approaching new challenges with interest and con-
fidence, and seeking help appropriately (see Figure 9.4).

THE WIDER WORLD
A Back there and then
Needs adequately
met
Relationships
mutually
rewarding
D B
Creative behaviour Life position of ‘I’m
and flexible, OK and You are
responsive OK’
communication Positive
style sense of self
C and others
Feels interested
and ready to learn
generates options
and alternatives THE WIDER WORLD
Here and now
Figure 9.4 A healthy cycle
Health in TA means living with:

awareness – mindful contact with and consciousness of our senses and experiences in relation to our-
selves and others;
spontaneity – full contact with our self-experience (reflexivity) such that we can respond ‘choicefully’ to
the moment;
intimacy – relating to other with the unreserved sharing of thoughts, feelings and responses.

The Script System wheel clearly demonstrates how script is perpetuated. Segments C and D
represent the later experience and behaviour of the scripted individual, which emerge from
script and also maintain it.
But first, why should we continue to repeat our scripts despite the fact that we are ill-served
by them, and often even after we have begun to recognise them? There are several reasons
that relate to profound levels of unconscious meaning making.
Script provides structure and predictability and usually just enough recognition and incident to fulfil our
psychobiological hungers. That recognition and incident might be painful or distressing, but at least it

is familiar and reliable; we can, in a sense, control it. In a strange way, it becomes a habit that passes
the time between birth and death. Thus we avoid the fear of uncertainty. Clearly this level of meaning
of script is not in our conscious mind.
Script seems necessary for our survival. Normally the negative aspects of our script were formed as a
result of a repeated carelessness, neglect or trauma in our childhood. In these situations, our hungers
and relational needs were severely compromised and we took on the adaptations, very often closing
down entirely on our original need and the grief and pain of its not being met. Continuing in our script
allows us to avoid that original pain.
The intrapsychic mechanisms by which people maintain their scripts are contained in
Segment C. TA is rich in theories to understand this internal process – called Redefining. This
word has a specific meaning in TA – it refers to the way people filter or distort data in order
to continue to see things according to their script assumptions and patterns. A detailed
description of the elements of redefining would be excessive here. Therefore I continue the
example of Sophie, indicating in italics where the concepts might be used so that the inter-
ested reader can explore further (see recommended reading).
As a result of the process of Sophie’s scripting she grew up timorous and subdued. At
school she was anxious and wary around a male teacher, discounting the friendliness and
gentleness of his manner and instead noticing his frown as he looked out of the window.
She imagined that he was frowning because he was thinking about her poor behaviour
(redefining thought process) and discounted the fact that it was starting to rain heavily and
it was time for outdoor games. As a teenager, she was attracted to the rough and bullying
boys, whom she found familiar. In her conscious mind, however, she wanted to avoid the
sort of marriage that her parents had had, so she married a policeman, whom she believed
would behave properly. Sadly, that wasn’t the case. She felt powerless and miserable – a
racket (see below).
Also in Segment C, lie our feelings and sensations which – born of our script, are likely to
be familiar and habitual ones, but because feelings always ‘feel’ very real and immediate,
they also ‘feel’ like the truth. TA refers to these repeated script-bound feelings as ‘rackets’,
supposedly because like a protection racket they protect the bearer against a painful experi-
ence at the cost of another painful one, but which is presumed to be the lesser of two pains.
Of course, the racket pain is usually much more enduring and debilitating. But the important
thing is that usually a script was developed when the child’s feelings seemed intolerable and
overwhelming to him, so he closed them down and adapted to the situation. In adult life,
people still have a mainly unconscious fear that if they allowed themselves to feel their deep-
est pain, they would be overwhelmed (or someone else would). One of Berne’s colleagues,
Fanita English, describes how a racket feeling is a ‘substitute’ for another feeling. Sometimes,
it is as simple as family pressure that develops a racket – a boy being told that ‘big boys don’t
cry’ learns to feel angry instead, or numb or confused – anything that is more acceptable to
his loved ones. A fearful mother urges her children never to make a fuss, or a war veteran
father advocates ‘keeping your head down’ and the children develop a racket of anxiety and
under-assertiveness.

(a) Segment D. External manifestations of script The manifestations of our redefining

process emerge in our behaviour and again TA has many concepts to analyse this.
(b) Functional modes of ego states Functional modes (Lapworth and Sills, 2011) are the
functional or attitudinal manifestation of ego states (see Figure 9.5). These can be experi-
enced internally (Segment C) but are most evident in a person’s behaviour. The model is
based on what is foreground about the functional process of an ego state. Thus a Parent ego
state is often recognisable by two power-taking positions: Nurturing and Controlling (NP and
CP). Either of these can be healthy and positive as in being compassionate and supportive or
setting good boundaries, or they can be oppressive (to self or other) as in bullying, smother-
ing or patronising. Adult mode is predominantly reality testing, reflection and so on. While
Child mode can either be a manifestation of all the capacities with which a human being is
born – emotions, needs, curiosity, sexuality, excitement – encapsulated in the term ‘Natural
Controlling Nurturing
parent parent
Adult
Compliant
Adapted child Free or
natural
child
Rebellious
Figure 9.5 Functional modes of ego states

Child’ – or it can be the way a person has learned to adapt to his environment – either by
complying to the demands of parents and others or by rebelling against them, either of which
positions is not free expression but a response. The functional mode is conveyed not only by
words but by body language, gestures, voice tone and metaphors.
(c) Transactions Transactional analysis ‘proper’ refers to the analysis of communication –

either single interactions or ongoing relational patterns. Berne (1961) identified three types of
transaction, each accompanied by a ‘rule’ of communication. They are called complementary,
crossed and ulterior transactions. They emphasise the co-created nature of relating – the influ-
ence we have on each other as we consciously or unconsciously direct our communications to
different ego states. Figures 9.6a, 9.6b and 9.6c illustrate them and, indeed, they are simple to
understand diagrammatically; a verbal description is somewhat cumbersome.
As you will see from the diagrams, ulterior transactions contain two levels of meaning.
The first is at what is called the social level of meaning, in other words the actual words and
gestures that are made. The second level is ‘psychological level’, where another meaning is
conveyed. Often the social level is apparently Adult to Adult, but the psychological meaning
is evident in the particular choice of words, facial expressions, eye movements, body postures
and the like.
‘What is the time?’ might seem A→A but the tone and body language convey the ulterior
‘Are you late again?’ Berne’s third rule of communication is that the outcome of any interac-
tion is determined at the ulterior level. In this example, the response to ‘What is the time?’
A complementary transaction is one in which the transactional vectors are parallel and the ego state
addressed is the one which responds.
P P
A t’ A
res
d’ nd
tire na
so do
w
’m
‘I Sit
S– ou
.
ry
oo
C hp C
– ‘O
R
So long as the transactions remain complementary, communication may continue indefinitely.
Figure 9.6a Complementary transactions

A crossed transaction is one in which the transactional vectors are not parallel, or in which the ego state
addressed is not the one which responds.
S –’I blame the government’

P P
A A
R – I don’t have any
evidence to support that.
C C
The rule is: when a transaction is crossed, a break in communication results and one or both individuals will
need to shift ego-states in order for communication to be re-established.
Figure 9.6b Crossed transactions
In an ulterior transaction, two messages are conveyed at the same time. One of these is an overt or social
level message, The other is a covert or psychological –level message. They can be angular (involving three ego
states) or duplex (involving four ego states).
Sp – Late
P again? P
Ss – What’s the time
A A
Rs – I won’t be a minute.
Rs – I’ve messed
C up again C
The rule is: the behavioural outcome of an ulterior transaction is determined at the psychological level and not
the social level.
Figure 9.6c Ulterior transactions

the hearer received the ulterior and responded with ‘I won’t be a minute’ (with the comple-
mentary ulterior AC→CP conveying the anxiety) – but she may have said ‘Oh stop nagging’
(crossing the ulterior CP→AC).
If the psychological or ulterior message is congruent with the social level – as in when
Mary smiles in pleasure as she says ‘How nice to see you again’ then the communication
is rich and full of contact. Problems occur when the ulterior message is at odds with the
overt one, in particular when, as if often the case, neither party is fully aware of that level
of interaction. Frequently it is through this ulterior level of communication that we con-
vey the deeper script expectations of which we are barely aware ourselves.
An exchange of complementary ulterior (and unconscious) transactions, which are at odds
with the social level, is likely to lead to a reinforcement of both people’s scripts. This in TA
is called a game. Games are the building blocks of script, their ‘payoff’ comes about at the
end of the exchange when something happens to make the ulterior interchange overt –
normally this is a relational repeat – a re-experiencing of the original script protocol.
There are many models for analysing and understand the deeper meaning of games.
Perhaps the best known and most immediately recognisable is the Drama Triangle (Karpman,
1968, Figure 9.7), which maps the dynamics of the dance of love and power, in three classic
attitudes of Persecutor (dominator or bully), Rescuer and Victim. Karpman describes how as
a game unfolds, the players move between these positions – starting in their preferred ‘social
role’ but finishing in the script-reinforcing one.
Sophie, seeking safety, had married a policeman. However, when her husband came
home stressed and traumatised from his work, he drank too much, became abusive and
often hit her. At first, she would argue with him but ultimately did nothing to change
the situation. (At first Sophie’s ostensible relationship was Child to Nurturing Parent.
However, the ulterior message, to which her husband would respond, could be summa-
rised as ‘I am a victim to be abused’.) Only when one day she saw the horrified face of
her own little girl did she realise how she was passing on her script. She decided to seek
therapy.
Persecutor Rescuer
Victim
Karpman (1968) suggests that whenever people play games they are stepping into one of three script roles –
(not Adult) either Persecutor, Rescuer or Victim.
Figure 9.7 The drama triangle

Game payoffs Psychological and Back there and then

biological hungers for
structure/containment,
relationship and novelty
plus
Early experiences
Ego states
Transactions Script matrix
(complementary, Relational events
crossed, ulterior) introjects etc.
Games DRIVERS Parent Adult Child
Drama triangle P R Structural analysis

Script decisions
Relational Patterns
V
Repeated patterns of Contaminations ‘internal working models
behaviour/speech etc. of relationships’ Bowlby
Feelings, thoughts Core beliefs
and fantasies
Transference and counter-
transference experience
Discounts and grandiosity
Here and now Internal functional modes
CP, NP, A, FC, AC (compliant or rebel)
Internal dialogue
Figure 9.8 Psychological theories
Figure 9.8 maps all these concepts onto the Script System diagram.
Figure 9.9 focuses the Script System in the relational field (Sills and Mazzetti, 2010)
wherein two Script System diagrams are shown to represent two people. One Script System
has been ‘flipped’ so that the segments go from left to right rather than right to left. This
brings the two Segment D areas ‘face to face’ with each other. The relational space between
the two people is illustrated in the double-headed arrow – graphically illustrating the extent
of the genuine contact between the two. A wide arrow (Figure 9.9a) indicates a richness of
interchange, with each person bringing as much of themselves into the relationship as they
can. Figure 9.9b shows a thin arrow, the co-created relationship between the two, which is
largely dictated by the recreation of old patterns and is almost totally transferential. The
transferential enactment is the Game.

The impact of the environment is an intrinsic part of the process of script formation and
maintenance. Social and familial factors have been clearly described in the previous sections.

Relational
field
A A
B D
D B
C C
Figure 9.9a
Relational field
A A
B D
D B
C C
Figure 9.9b
1.5 Change
From the TA perspective, change is accomplished in a variety of ways. Being a humanistic
approach, TA’s foundation is the natural healing power of the organism – Berne called it
Physis (1972: 98) ‘which eternally strives to make things grow and to make growing things
more perfect’. The implication here is that if the person is given the right conditions (cf.
Rogers’ person-centred approach and the conditions for growth) – the opportunity to get his
needs met enough to live in harmony with himself and others, the opportunity to live in a
society where he is respected – he will naturally resolve his difficulties and thrive. However,
transactional analysts believe that they can give Physis a helping hand!
1.5.1 Strengthening awareness

In TA the process is called ‘Decontamination’. This refers to the fact that Adult capacities become
‘contaminated’ with parental prejudices, opinions and ways of being and/or ingrained Child deci-
sions and feelings (see Figure 9.10) such as Sophie’s belief that she was powerless. A person might
therefore think he is in Adult ego state but actually be shaped and influenced by long-standing
patterns of thinking, feeling, sensing and behaving. Raising awareness of our full here and now
experience, including moment by moment feelings, thoughts, fears and urges, helps us understand
what we are bringing into the present – who we really are at that moment. Often just becoming
fully aware of how we are behaving according to an archaic script is enough to allow us to change.

Figure 9.10 ‘Contamination’ of the adult ego state by unconscious parent

influences and archaic child adaptations
This is sometimes supported, where appropriate, by what is called psycho-education. Berne

intended that his patients read his books and collaborate in the diagnosis and the treatment plan.
It is not always the case, but some clients thrive on the feeling of being in charge of their lives
that can come from understanding their own ego states, patterns of transacting, games and so on.
1.7 Deconfusion
‘Deconfusion’ is the process of working with the Child – and sometimes the Parent – ego
state, when these states affect and even dominate here and now function. It involves the
Client re-experiencing early relational states, often through the transferential encounter, but
doing so in the presence of his own, observing Adult and in the context of an ‘I’m OK, You’re
OK’ working alliance where the therapist is willing to hear and collaborate in exploring and
understanding the patterns as they occur. This can enable the expression of repressed feelings
and the detoxification of script beliefs.
In addition, there are many schools of TA (see for example Tudor and Hobbes (2007) for
a description of these). Each of them has elaborated the core theory and practice to develop
and refine particular angles of psychotherapy with the script. For example, Redecision
therapy (Goulding and Goulding, 1979) focuses on the early decisions (Segments A and B
of the Script System) that are accessible to conscious awareness. It elaborates a theory of
impasses to describe inner conflict and, using psychodramatic techniques, facilitates the
client’s resolution of them. In Cathexis TA, the emphasis is on correcting disordered think-
ing (Segments B and C) and passive behaviours. Constructivist TA focuses on the narrative.
And so on. Thus TA can respond flexibly to the particular needs of the client.
All the approaches are well described elsewhere, so in the example below I propose to
focus my attention towards the ‘relational turn’ in psychotherapy. Relational transactional
analysts see change as occurring largely in the way the relationship to self and others, in
particular the therapist, is recreated, explored and understood in the here and now.

2 PRACTICE

In very general terms, the goals of TA therapy are aligned to its philosophy. In other words,
The achievement of the contract – the client takes charge of his life and lives it more effectively in his
own terms.
The development of awareness, spontaneity and intimacy (as defined above) – allowing us to know our-
selves more deeply, to know others and allow others to know us.

TA has been used successfully in settings ranging from prisons to schools and from psychi-
atric hospitals to private practice; it is also established in countries with very different cul-
tures all over the world. Therefore any unsuitability of a potential client would be likely to
be related to ‘fit’ between the competence, style and experience of the practitioner and the
particular needs of the client, rather than to the limitations of the approach. Having said that,
the philosophy and principles described above tend to preclude clients whose organic condi-
tion or mental abilities render them genuinely unable to commit to a realistic contract. The
basic model of communication is often used as social skills training with, for example, those
with serious learning difficulties; but generally an inability to engage with a mutual commit-
ment would limit the effectiveness of psychotherapy.

TA is both a group and individual therapy and most clients can benefit from both or either.
Clients who, at initial assessment, are deemed to have serious disruption to their capacity to
make relational bonds at a pre-verbal level (see for example Hargaden and Sills, 2002) would
benefit from individual therapy at the outset so that there is the possibility of re-establishing
this attachment capacity.

2.3.1 Personal characteristics of effective therapists
A TA therapist needs to be willing to model the sort of mutuality and respect implied by the
philosophy and principles. Indeed, she should model, as far as possible, the goals of therapy
described above:
Willingness to commit to achieving the mutually agreed contract in which trust in the client’s capacity to
think for himself and take responsibility for himself is manifest.

Awareness, reflexive spontaneity and capacity for intimacy developed through willingness to notice,
reflect and explore herself and her responses. This involves committing herself to doing her own
personal work and using supervision in order to be aware and mindful of herself in relationship.
2.3.2 Skills shown by effective therapists

A TA therapist needs to be able to engage and attune, to connect and deeply engage with the
client in order to listen not only to what is said (the social level) but also what cannot be said –
the ‘inarticulate speech of the heart’ (in the words of Van Morrison, 1983), the levels of meaning
and experience that are non-conscious and non-verbal. At the same time she must have the abil-
ity to be separate, cool-headed, sometimes questioning or challenging – deeply engaged but not
over-invested.
In relation to the theory, therapists need to develop the skill of being informed by the con-
cepts yet using them flexibly and subtly to work with clients – not simply choosing ‘some-
thing from the TA trolley’ (Sonia Mathias, personal communication) and fitting the client to
it. There is also a skill to psycho-education – sharing concepts and ideas with a client at an
appropriate time to increase his self-understanding and without making him feel that he is
being objectified.

The philosophy of TA, the assumptions about human worth and self-responsibility described
above, lead to two principles of practice. The first is the contractual method, whereby the
course of therapy is contained by an agreement and commitment between therapist and client,
about the direction of the work and how it will be carried out. This is in contrast to the view
that the therapist is the expert who decides what the problem is and how it should be
addressed. Clients are assumed to be the best expert on themselves.
The second principle is ‘open communication’ which entails an authentic empathic meeting
between therapist and client in which both bring themselves fully to the encounter. Berne is
reported to have said that anything that couldn’t be said in front of a patient is not worth saying,
which was a radical statement in those – and even these – days. He was revolutionary in conduct-
ing ‘staff – patient – staff’ case conferences in the psychiatric hospitals. Patients and medical staff
met together and openly discussed the progress of the patients, and indeed the staff.
It is interesting to note that these principles accord directly with those identified by out-
come research as part of the working alliance which is essential to effective therapy (see e.g.
in Horvath and Greenberg’s (1994) edited book on The Working Alliance, Bordin’s definition:
empathic bond between client and therapists, combined with clear agreements about goals
and tasks). Willingness to engage with the client in this way, learning from the dynamics
between the two people, is also a central skill of the relational psychotherapist who sees the
process of relating (to self and to others) as the central vehicle of both script formation and
of change.


However, with this as a foundation, each therapist bringing him or herself to the encounter with
a client, will have his or her own unique style. The more relational a perspective the therapist
takes, the more he will bring his or her own authenticity and deepest responses. Having said
that, the different schools or traditions lend themselves to different styles. The Cathexis tradi-
tion may take a more directive or creative, action-oriented style as might the Redecision school.
The integrative or psychodynamic traditions might be more enquiring in style.
Being a relational therapist means that potentially all of the rich theory of TA is used –
much of which, as far as the author knows, is unique in offering a straightforward genuinely
‘two-person’ theory of human interaction. The difference in practice from other traditions
within TA is, as Emmanuel Ghent suggested, that it is a type of ‘sensibility’ rather than a set
of theories. In other words, his or her style will be guided by certain principles (Fowlie and
Sills, 2011), summarised as:
Relationship is the central vehicle for change – relationship with self (structural analysis of ego states and
the development of awareness and spontaneity); with others and with the organisation or community
(transactions, games etc.).
Relating is a ‘two-way street’ – a process of mutuality in which both people are touched and changed by
the encounter. We shape and are shaped by each other at many levels – some of them non-conscious
(domains of transference (Hargaden and Sills, 2002)).
Each person cannot help but bring to the encounter the influences of her history, her culture, her gender,
her age as well as her script. This leads to the co-construction and multiplicity of meanings – the
necessity of uncertainty. Knowledge is seen as a process of enquiry rather than a fixed object of truth.
The therapist’s responses (countertransference) are considered relevant – as potential information (this
response has been evoked in this moment with this person) and also for collaborative dialogue.
Thoughtful reflexive attention is essential.

2.5.1 Assessment
In assessing the client, the TA therapist will, as will any ethical therapist, listen to the client’s
story – both what has brought them to therapy and also their history – in order to establish
whether there are any risk factors that demand immediate attention or any specific issues that
might need a specialist. A formal diagnostic system such as the ICD can also be useful for
clarity and in order to benefit from relevant existing knowledge and literature, especially if
working in a multi-disciplinary setting, which involves communicating with other involved
professionals. Then the practitioner (with the client) carries out an assessment using TA
theories, articulating the essential features of the client’s script and its impact in the client’s
life, as observed by the client and therapist. The Script System described in this chapter can
be a useful assessment tool. The therapist will use those concepts with which they are most
familiar and that support their particular approach, for example, a redecision therapist will be

thinking in terms of script decisions, impasses and games. The therapist, especially a rela-
tional one, will also use as potential information, his or her own responses to the client and
the types of transactions that occur between them.

Amongst the theories used, the structural model of ego states will certainly be an underpin-
ning assessment tool, and Berne’s four ways of diagnosing an ego state (1961) will be key.
The Script System also provides the basis of the case formulation – capturing the essential
features and dynamics of the client’s difficulties and offering a way forward for the therapy.
Part of the assessment includes the client’s accessibility to work on behaviour and social
control (Segment D), on here-and-now feelings, thoughts, bodily sensations, images
(Segment C), on core beliefs and decisions (Segment B) and on patterns of relating (internal-
ised in Segments A and B) and enacted (see Figures 9.9a and 9.9b).

Broadly the therapeutic strategy has a number of phases, although attempting to define stages
is always questionable as there will inevitably be a fluid moving back and forward as differ-
ent ego states emerge.
Building the working alliance and negotiating the contract(s).

Raising awareness and strengthening Adult understanding (decontamination).
Building self-reflection and reflexivity: a compassionate ‘inner eye’ (NP).
Identifying areas of ‘confusion, conflict and deficit’.
Deconfusion of the Child and Parent. Work with C and P as necessary. Relational psychotherapists under-
stand that much of what goes on is unconscious or preconscious so that the careful engagement with
transferential levels of relating (ulterior transactions) and use of countertransferential responses
(social diagnosis of ego states) will be appropriate.
Supporting integration into everyday life – practising new behaviour.
Termination.

In 1966, Berne described eight ‘therapeutic operations’ that the therapist uses to accomplish the
contract. They are: interrogation, specification, confrontation, explanation, illustration, confir-
mation, interpretation and crystallisation. In 2002, Hargaden and Sills re-visioned these in the
context of a relational perspective and renamed them empathic transactions. The intention was
partly to soften their ‘certainty’ and locate them within an empathic field (remembering that
empathy means not simply warm and supportive understanding but deep resonance with the

experience of the client, even when this is difficult, painful or unattractive). There was another
intention which was to demonstrate how any of the ‘operations’ can be made not only by the
therapist but also by the client as understanding emerges in the process of the conversation.
They are not interventions that one person ‘does to’ another. Thus, in brief:
Enquiry and specification: a collaborative exploration of the client’s phenomenology and
situation, paying attention to the felt experience of both therapist and client and how they are
responding to each other. Ego states that might have been out of the client’s awareness, even
deeply disavowed, can gradually emerge from the realm of the sub-symbolic, to the symbolic
and then into language.
Confrontation: Contradictions in the juxtaposition of different truths emerge and are
noticed and explored
Explanation: a narrative concerning the meaning of events is created; TA concepts may be
used to make sense of feelings and behaviour
Illustration: the therapist (though potentially the client also) uses metaphors, stories,
analogies, self-disclosures to highlight the shape and implication of identified patterns.
Humour may be used to invite gentle acceptance of the human condition.
Confirmation and interpretation: there is increasing awareness of repeating patterns of
feeling thinking and behaviour – the deeper meanings of games and script are recognised
including as they emerge in the transferential domains (Hargaden and Sills, 2002) – introjec-
tive (relationally needed) projective (the repeated script pattern) and transformational (a deep
form of attuned resonance).
Crystallisation: The juxtaposition is recognised between the early protocol (past patterns
of relating) and here and now relational possibilities.
At any point in the process, the therapist might use:
Holding: offering a silent, powerful presence in the face of strong Child emotions, a pres-
ence that is not rejecting and is neither collusive nor retaliating.
Throughout the therapy the therapist remains aware of her own responses and feelings, know-
ing that although they are shaped by the transferential relationship and also by her own past and
experiences, they may, if carefully offered, lead to a collaborative conversation about meaning.
(a) Other techniques The section on techniques has been given a relational steer, reflect-
ing my own personal interests, but there are many other rich techniques in TA that have
emerged from the different schools. Some that are associated with traditional Gestalt therapy
are common especially in the Redecision school – such processes as ego state dialogues (‘two
chair’ work), role-plays, experiments (Goulding and Goulding, 1979). The Cathexis school
(Schiff et al., 1975) gave rise to elaborate procedures of reparenting – and so on.

The successful change process includes change in behaviour, relationships, feelings, thoughts
and beliefs. The actual process depends on the personality and strengths of the client. For

some clients, change starts with understanding and insight (including challenging previously
held beliefs). As long as this insight involves the awareness of and expression of feeling, it
leads to changes in behaviour and patterns of relating. For other clients change emerges from
experiencing a here-and-now relationship with the therapist in which old patterns are inevi-
tably repeated and made conscious, new ones risked and deepest meanings discovered or
created. This is accompanied by changes in experiences outside the therapy room – experi-
ments, practice and mindfulness. Yet other clients start with making behavioural changes –
what Berne called ‘social control’.
Lack of therapeutic progress can be linked to various factors, the commonest of which are:
an unclear agreement between therapist and client as to the direction and tasks of the therapy can for
example undermine the client’s responsibility for the ‘work’ or lead to confusion about what is
involved;
cognitive understanding that is not accompanied by deep connection with self-experience;
deep feeling and experience that is not linked to thinking and understanding, so that no bridge is built
between the emotional and historical with present Adult understanding;
as in any therapy the client can become dependent on the new relationship with the therapist and omit
to make changes in his outside life.
The therapist needs to monitor the progress of the therapy, including her own preferences and
proclivities in style, in order to make sure that she is not co-creating one of these unproduc-
tive processes. This is where regular supervision is of course essential.
3 CASE EXAMPLE
3.1 The client

Stan, a 39-year-old male, had first seen a coach at the suggestion of his HR director, to under-
stand how Stan’s behaviour in the workplace had contributed to his being overlooked for
promotion to positions for which he was ostensibly the best candidate. When coach and client
met, they identified his lack of proactivity on his own behalf and his general air of disinterest
in life, both personal and professional. However, the coach had realised that this absence of
vital connection went deeper than a failure to achieve promotion; he suggested that Stan
engage in some psychotherapy for a deeper exploration. Stan was very willing to agree,
though it was clear that he had no idea how a ‘deeper exploration’ might be of benefit.
Our first session was spent getting to know each other, finding out how he felt about the refer-
ral and attempting to identify his goals for therapy. I say ‘attempting’ because other than to under-
stand his lack of promotion, he seemed not to have any desires for himself. As we talked, he
described a life devoid of passion and stimulation; he couldn’t remember feeling differently –
although he was aware of feeling ‘a bit depressed’ when he saw that other people ‘seem to have

more fun than me’. Gradually, however, he began to get more curious and interested in the notion
that somewhere along the line he must have lost his zest for life. He acknowledged that in theory,
being a normal baby, he must once have experienced feelings and desires! What had happened to
them? He began to like the idea of ‘having more of myself’ so we agreed to work together, initially
for ten sessions, first to clarify what the issues might be and then to explore them.
3.2 The therapy

As a way of creating a working alliance, I invited Stan to talk about whatever was on his mind
or interested him. His rather flat affect and ponderous manner – although in his late 30s he
seemed much older – made me fairly sure that it would be an unusual experience to have
someone listen and attend to him with care and attunement and I hypothesised that this would
be essential in his establishing a sense of ‘self in relationship’ that felt more juicy and vital.
In terms of the domains of transference (Hargaden and Sills, 2002) I was thinking about the
introjective transference and the basic therapeutic transaction (Figure 9.11). I was also aware
that our similarity of culture (we were both white, British) and age (I was probably his
mother’s age), there was ample room for the projective transferential relationship to flourish.
This hypothesis was partly a subjective sense of him, but reliably supported by the assess-
ment. Using the Script System (Figure 9.12), I was able to put together a picture of his develop-
ment that was as devastating as it was inevitable.
Social level
Ulterior level
Social level: Client: Here’s my issue –

Therapist: I am interested to hear about it
Ulterior level:
Client: Am I OK? Are you OK?
Therapist: I’m OK, You’re OK
Figure 9.11 The therapeutic transaction


Section A: The early experience: Stan had been born to a mother who suffered from depres-
sion, especially after giving birth. By the time that Stan was born, his older brother was
already eight years old and Stan had almost no memory of him. There had been two pregnan-
cies between the first and second sons, but both had miscarried in the second trimester. Stan’s
father was away on business most of the time.
Stan’s earliest memory was of being in the lounge; night was falling but no one had put the
lights on; his mother was sitting motionless in a chair and he was ‘playing’ on the mat, though
he didn’t remember having toys. (I hypothesised injunctions against his needs for contact and
relationship, possibly even the crippling ‘Don’t exist’.) He remembered being a bit older and
looking out of the window at the other children playing in the street. He had not been allowed
to go out to play because his mother was afraid that it was a rough neighbourhood. This then
was his early protocol – being in a world that was bleak and empty, with a mother who was
over-protective and at the same time unavailable.
Section B: internal structure: Stan’s meaning-making, his script, both at the level of earliest
non-conscious relational patterns and also at the level of conscious memory was that his sense
of self-with-other was bleak and un-nourishing, that, while others seemed to enjoy life, it had
little to offer him.
Segment C and D: here-and-now experience: At school, he had found it hard to make
friends and did not join in activities like football practice or the school concert. It seemed
Back there and then

Friendless, isolated
existence
Depressed mother
Isolated childhood
Life position of
Doesn’t socialise ‘I’m alien’ ; others
or seize job or life have fun but
opportunities, not me. Life is
acts withdrawn bleak
Feels cut off –

often bored,
miserable and
resentful
Here and now
Figure 9.12 Stan – a negative cycle

that the teachers did not appear to notice his isolation. He was therefore co-creating repeats
of his original experience of a bleak landscape where other people had fun but he did not.
As an adult he had a series of jobs, which he carried out competently. He was heterosexual
and had had some girlfriends but none seemed to have become important, indeed most of
them sounded as if they had been in the Victim position, requiring Rescuing. Stan’s father
had died some years before, and he spoke of it without emotion. His mother had pre-senile
dementia and was in long-term care. He rarely saw his brother. He had few friends and said
that he spent most of his leisure time watching television or reading. As Stan told his story,
he did so without much energy other than a slight sense of depressed resentment. When I
asked him directly how he felt as he remembered the events he described, he sighed and
said ‘not great’.

From the start, I found Stan challenging to work with. We were very different personalities,
and at first I kept forgetting that empathic enquiries into his emotional state or what he might
want, would be met with ‘Fine’ or ‘What do you mean?’ or worse, a long intellectual descrip-
tion of himself as if he were a dissected frog (interestingly his first adult job had been as a
lab assistant, when dissections were his daily task). In addition, the stultifying early protocol
had the effect of collapsing the space between us; the experience of vitality, of co-created
relationship where novelty might occur, seemed impossible. We sat in a sort of mutual life-
lessness (I hypothesised a particular level of ulterior transactions known as transformational
transference (Hargaden and Sills, 2002)). I struggled to stay engaged.
Things improved when I began to focus on Stan’s behaviour and bodily sensations as a
route through to deeper experience. In terms of the Script System, therefore, we started
with identifying his behaviour – both in terms of his transactions with the world (largely
dry and withdrawn) and also his ‘micro-movements’ in the sessions with me (Section D).
Inviting him to connect with what he was experiencing (Section C) as he took the actions
or non-actions he described, began to ignite an interest in and engagement with his own
embodied self that was clearly new to him. The Process of ‘Decontamination’ was under-
way, but simultaneously ‘Deconfusion’ or in Stan’s case rediscovery, of his Child ego state
was also happening.
Stan had already been introduced to some of the models by his TA coach and he was keen
to build on that. To help him think about his behaviour at work, we talked about ego states
and transactions, encouraging him to be more aware of different options as he related to
people. As he began to connect with his immediate experience and the edges of his feelings
and fears, suddenly the theories became full of meaning as he understood how the ulterior
level of his communications conveyed the bleakness of his expectations (see Figure 9.13).
The impact was profound between us when one day he said that he could not attend the fol-
lowing session as he had ‘a busy week at work’. I found myself agreeing to this without any
reflection and only when I noticed his withdrawn expression did I realise that we had recre-
ated the same dynamic.

Stan Colleagues
Social level Exchange: Stan: Do I need to come to the meeting?

Manager: No, it’s not necessary.
Ulterior Exchange: Stan: I’m not important, I have nothing to offer

Manager: Yes, I know.
Figure 9.13 Stan’s script-reinforcing interaction with his manager
He experimented with acting differently in his relationships and was heartened by the
results. He reported disagreeing with someone in a meeting and then offering his opinion in
an Adult manner. Others had shown interest and then asked him to give his views on some-
thing else. He had asked a colleague for help with a project and she had responded by sug-
gesting they discuss it over a coffee. Stan looked positively excited as he told me about it.

Almost more important, however, was our continuing exploration of Stan’s Child ego states
in the therapy sessions. Connecting with his body sensations and feelings was linking to
images, emotions and memories (link between Segments C and A). Often he noticed that if
he followed his body he would discover tensions he did not know he had – impulses to push
or to reach, impulses to yell. For example, as he acknowledged his feelings of anger at being
overlooked for promotion, he was fascinated to feel the vitality of that experience, in contrast
to how he ‘depressed’ the impulse to protest, lost energy and, in Passive Behaviour terms ‘did
nothing’ (Schiff et al., 1975). Thoughtfully he also commented on his mother’s Passive
Behaviour, which he accurately recognised as level 4, in terms of escalation to incapacitation.
There were times when Stan experienced me as not interested in him, projecting his Parent
ego state onto me if he thought I looked tired or distracted. I listened carefully to him, some-
times I acknowledged the ‘grain of truth’ in his projections; sometimes I invited him to
experience the fullness of his reactions. Occasionally I might gently point out that, in his
mind, I had become one more person who was not taking the care of him that I should.
Gradually he began to enter a period of what we both recognised as grieving, as he relived

and talked about some of the lonely pain of his childhood, as well as recognising how his
internalised depressed mother and absent father were still influencing him. Releasing some
of his previously intolerable feelings (Segment A) allowed him to see how he was clinging
to his depressed identity from a position of ‘any mother is better than no mother’. Letting go
of that way of being and risking wanting a different sort of relationship required courage.
It also needed support. It was important that Stan structure his life in order that his biopsy-
chological hungers could be met in different ways than the limited ones he was used to. In
other words, while in the past his life had excessive amounts of predictability and structure,
he had been very short of recognition, strokes, incident and the opportunity to have an
impact. Gradually he began to change that. Although it still felt strange, he committed him-
self to joining some clubs, including a dating agency. He continued to meet his friendly col-
league for social occasions and said it was the first time that he felt as if he was really getting
to know a ‘girl’ as a friend. Importantly Stan was experiencing himself as more alive, he felt
embodied in himself and revelled in experiencing his feelings and sensations.
4.1 Developments
As has been described, TA has been taken in many directions. As well as the early schools –
Classical (with two subtypes of psychoanalytic and CBT underpinnings); Redecision,
Cathexis and Radical (a social psychiatry), it has also been developed in many other fields
and cultures. They are described in the international journal of TA, and also a proliferation of
books and articles published all over the world including in France, Italy, Germany, Sweden,
the UK, Australasia and the Americas. In addition to the clinical field, which encompasses
psychotherapy and counselling, TA has recognised applications in the educational field and
organisational fields whose practitioners have also written extensively. As I write, I believe
that the relational approach (including co-creative and constructivist) is probably the most
influential current development in TA, based as it is not only on its humanistic and psycho-
analytic roots, but also supported by psychotherapy outcome research, developmental psy-
chology and neuroscience.
4.1.1 Brief therapy

TA’s very versatility and scope, for working with the intrapsychic and the interpersonal, with
both unconscious and conscious processes, as well as in many fields of application makes it
not only a powerful ‘depth approach’ but also very appropriate for time-conscious therapy
including in primary care, EAPs and counselling agencies. TA’s contractual method means
that the direction and focus of the work can be named in a realistic way. As explained above,
TA’s approach includes several theories and strategies for helping clients change their way of
being in the world through raising awareness, challenging their assumptions and adjusting
their behaviour. This is described in detail in Tudor (2002).


Berne travelled all over the world (see e.g. Mazzetti, 2010) to study psychiatric practice and
to test out his ideas about ego states. He concluded that the theory is applicable and useful to
many different cultures and the popularity of TA world-wide attests to that. However, in
another sense the theory and original practice is a product of its time – its philosophy of
individualism somewhat out of step with ideas of relationality and complexity of recent
years, and the language is unmistakably ‘60s in the USA’ (though interestingly the transla-
tions into other languages have allowed individual countries to amend and adapt the ‘jar-
gon’). What is more, Berne and his colleagues were mainly white, often men – or women
who had been culturally scripted in a male dominated world. In order to be the social psy-
chiatry that it truly wanted to be, TA has had to develop its thinking in a variety of ways from
exploring the notion of cultural scripting (see e.g. Shivanath and Hiremath, 2003). Articles in
the Transactional Analysis Journal demonstrate this work over the years – for example
Drego’s description of the cultural Parent ego state or Noriego’s analysis of transgenerational
scripting to Mazzetti’s work on cross-cultural therapy.
Perhaps most importantly, the relational approach demands that therapist and client take
notice of their interpersonal dynamics and transferences. This includes awareness of cultural
differences and dynamics, their history and expectations (see Figure 9.14, with thanks to
Helena Hargaden).

Recent developments in trauma therapy such as EMDR, somatic experiencing (where work-
ing with ego states is particularly effective) or sensorimotor have been so dramatically
effective that, in my opinion, any TA therapist should be able to inform their work with
P
P
A
A
C
C
Figure 9.14 Who is who? What is going on?

Source: H. Hargaden Relational TA presentation, Amsterdam, 2010, reprinted with thanks.

some or all of these approaches in order to offer a real response to serious trauma. Otherwise
a referral can be made to a specialist.
Another area that has not had much place in TA is the spiritual or transpersonal, which,
with some exceptions is little addressed in the literature. As Tudor and Hobbes say (2007:
280) ‘It may mean … that practitioners miss the important dimension of the need and yearn-
ing for spiritual fulfilment and mistake it for the effect of a social experience such as an
unavailable mother’.
Apart from these limitations, and some of the criticisms in the following paragraphs, there
are no obvious limitations to TA. While in its early days it lacked a depth dimension, recent
developments – especially in psychoanalytic TA and relational TA have filled that gap.

Perhaps the most obvious criticism of TA is that it is over-simple. TA’s language and concepts
make complex and subtle concepts accessible and understandable. The danger in this, of
course, is over-simplification – a sort of reductio ad absurdum of human experience that is
disrespectful of the person and misses the profound. What is worse, some of the language is
somewhat dated and glib. Words like games and rackets can seem at best trivialising and at
worst blaming and cynical – and it may be that this nuance reflects the shadow side of the
founder – perhaps of anyone who spends their lives devoted to the development of others.
Some revision of the original terms is useful.
Another criticism, as already mentioned, is that the volume of easily understood theory and
concepts can lead to over-analysing and intellectualisation at the expense of feeling and sens-
ing, especially when the therapeutic dyad share a similar interest/strength of theorising and
sense making. It can also provide a sort of ‘certainty’ that interferes with the possibility of
previously unformulated meanings.
These first two criticisms do not, in my opinion, need to be a problem to a thoughtful
therapist. However, there are some critiques that may be important for transactional analysts
to respond to. For example, there is much brilliant and laser-sharp theory for understanding
what creates distress in human beings, how problems are formed and how limiting ways of
managing are developed; sometimes transactional analysts are in danger of forgetting or
ignoring the grandness of health, the resilience of people and their capacities to create and
grow. Given the upsurge of research in such approaches as positive psychology, solution
focused therapy, neuro-linguistic programming (NLP), mindfulness and the like, it is a mis-
take to lose the positive ‘can do’ attitude that prevailed in TA in the early days. A predomi-
nance of problem-focused theory might change and shape society in a way that is not helpful.
Despite this ‘medical model’, which, in large part, derives from Berne himself, there is also
a strong strand of positive psychology in TA (see, for instance Summers and Tudor, 2000)
and I would be happy to see that reflected in all our training courses.
There is a tendency to dwell on the family when looking at scripting influences, thereby
sometimes losing the awareness of the social and cultural. This of course has political as well

as personal implications, as it can allow society to ignore its impact. However, there are many
transactional analysts who work to ensure that this does not happen.
4.3.1 The relational approach

I include specifically some criticism/critique of the relational approach, as I have emphasised
it. The first is that it might over-prioritise the relationship between psychotherapist and client
at the expense of the client’s relationship to himself, his body, his soul or indeed his relation-
ships to family, colleagues, community. Sometimes it is important to solve the problem rather
than excavate deep unconscious processes!
The other potential problem is that the therapist’s task of listening to her own responses
and countertransferences might lead her to become too therapist-focused such that the client
is no longer the centre of his own therapy journey. This might include a sort of narcissistic
insistence that the therapist’s feelings represent truth – forgetting that they too have emerged
from and been co-created by the therapeutic relationship itself and will therefore involve the
therapist’s vulnerabilities every bit as much as those of the client. This danger underlines the
importance of ongoing therapy and supervision for practitioners.
4.4. Controversies
The major controversy in the field is doubtless what is and isn’t TA? Those who were drawn
to TA because of its accessibility and simplicity – its call to action (Berne said that we should
change now and analyse it all afterwards) resist the return to TA’s psychoanalytic roots
(Moiso and Novellino, 2000) and the ‘relational turn’ (summarised in Cornell and Hargaden,
2006) as they say that it returns us to the days of arcane theories and impossible interpreta-
tions. Those who embrace a relational approach say that on the contrary, TA has been in
danger of losing the brilliance of Berne and his colleagues who developed this deceptively
simple approach, by excessive simplification and reductionism that comes from paying atten-
tion only to patterns of thinking and behaving that are accessible to conscious thought. They
insist that the findings of developmental psychology, of biology and of neuroscience are
incontrovertible: much of what we do and why we do it is driven by unconscious processes
and we ignore that at our peril. Relational transactional analysts assert that a relational
approach offers the opportunity to harness all that is great about traditional TA – the authen-
tic meeting, the focus on the observable and changeable – and also pay close attention to the
non-conscious and the unconscious processes that underlie every exchange.
5 RESEARCH
As Tudor and Sills (2011) point out, Berne and his colleagues were dedicated to observing
the external manifestations of internal, phenomenological realities and to operationalising the

conclusions. Thus ‘most TA concepts are amenable to research: the life script through ques-
tionnaires; functional modes of ego states through the egogram; passivity and discounting
through the discount matrix; the stroke economy through the stroking profile; and so on’
(2011: 339). (For a detailed description of these concepts, see Lapworth and Sills, 2011.) In
the last 20 years, research articles have appeared in the Transactional Analysis Journal (the
official journal of the international TA world) and the EATA News on for example: self-
esteem in a self-reparenting program; the impact of TA in enhancing adjustment in college
students; ego states; the effects of TA psychotherapy on self-esteem and quality of life stress
amongst high school students; egograms; functional fluency (using the functional modes of
ego states); and the use of TA in treatment centres for addiction and others. In 2010 the online
International Journal of Transactional Analysis Research was launched (www.ijtar.org), the
first issues of which provide a reference list of TA research published in TA journals since the
1960s. Subsequent issues include research into applications of TA with clinical populations
such as with clients with personality disorders by Thunisson and her colleagues and Ohlsson’s
work on addictions as well as Widdowson’s on single case study research and Johnsson’s
doctoral research into different methods of TA group psychotherapy.
There are currently also various research studies into the effectiveness of Transactional
Analysis, using a range of methodologies. The research clinic at Metanoia Institute conducts
ongoing quantitative evaluation of Transactional Analysis Psychotherapy (van Rijn et al.,
2011). Relational TA has been the springboard for some qualitative action research (e.g.
Fowlie and Sills, 2011) and collaborative studies into TA treatment in the NHS are being
established as this volume goes to publication.
6 FURTHER READING
Berne, E. (1961) Transactional Analysis in Psychotherapy. New York: Grove Press.

Berne, E. (1972) What Do You Say After You Say Hello? London: Corgi.
Clarkson, P. (1992) Transactional Analysis Psychotherapy: An Integrated Approach. London: Routledge.
Hargaden, H and Sills, C. (2002) Transactional Analysis: A Relational Perspective. Hove: Brunner-Routledge.
Lapworth, P. and Sills, C. (2011) An Introduction to Transactional Analysis. London: Sage.
7 REFERENCES
Berne, E. (1961) Transactional Analysis in Psychotherapy. New York: Grove Press.

Berne, E. (1966) Principles of Group Treatment. Oxford: OUP (reprinted by Shea Books, California).
Berne, E. (1972) What Do You Say After You Say Hello? London: Corgi.
Clarkson, P. (1992) Transactional Analysis Psychotherapy: An Integrated Approach. London: Routledge.
Cornell, W.F. (1988). Life script theory: A critical review from a developmental perspective. Transactional Analysis
Journal 18: 270–82.
Cornell, W.F. and Hargaden, H. (eds) (2006) From Transactions to Relations. Oxfordshire: Haddon Press.

Erskine, R.G. (1993) Inquiry, attunement and involvement in the psychotherapy of dissociation. Transactional
Analysis Journal 23: 185–90.
Fowlie, H. (2011) Reflective inquiries. In H. Fowlie and C. Sills (eds), Relational Transactional Analysis: Principles in
Practice. London: Karnac, pp. 313–26.
Fowlie, H. and Sills, C. (eds) (2011) Relational Transactional Analysis: Principles in Practice. London: Karnac.
Goulding, M.M. and Goulding, R.L. (1979) Changing Lives through Redecision Therapy. New York: Grove Press.
Horvath, O. and Greenberg, S. (eds) (1994) The Working Alliance: Theory, Research and Practice. New York: Wiley.
Hargaden, H and Sills, C. (2002) Transactional Analysis: A Relational Perspective. Hove: Brunner-Routledge.
Kahler, T. (1974) The miniscript. Transactional Analysis Journal 4(1): 26–42.
Karpman, S. (1968) Fairy tales and script drama analysis. Transactional Analysis Bulletin 7(26): 39–43.
Lapworth, P. and Sills, C. (2011) An Introduction to Transactional Analysis. London: Sage.
Mazzetti, M. (2010) Cross cultural transactional analysis. In C. Sills (ed.), The Psychotherapist – Special Issue:
Transactional Analysis – Eric Berne and His Legacy 46 (Autumn): 23–6.
Moiso, C. and Novellino, M. (2000) An overview of the psychodynamic school of Transactional Analysis and its
epistemological foundations. Transactional Analysis Journal 30(3): 182–7.
Schiff, J.L., with Schiff, A.W., Mellor, K. Schiff, E., Schiff, S., Richman, D., Fishman, J., Wolz, L., Fishman, C.,
Momb, D. (1975) Cathexis Reader: Transactional Analysis Treatment of Psychosis. New York: Harper & Row.
Shivanath, S. and Hiremath, M. (2003) The psychodynamics of race and culture. In C. Sills and H. Hargaden (eds),
Key Concepts in Transactional Analysis – Contemporary Views. London: Worth Publishing, pp. 169–84.
Sills, C. and Mazzetti, M. (2010) The Comparative Script System: a tool for developing supervisors. Transactional
Analysis Journal 39(4): 305–14.
Sills, C. and Salters, D. (1991) The Comparative Script System. ITA News 31: 11–15.
Steiner, C. (1974/1990) Scripts People Live. New York: Grove Press.
Stewart, I. and Joines, V. (1987) TA Today. Nottingham: Life Space.
Summers, G. and Tudor, K. (2000) Cocreative transactional analysis. Transactional Analysis Journal 30(1): 23–40.
Tudor, K. (ed.) (2002) Transactional Analysis Approaches to Brief Therapy. London: Sage.
Tudor, K. and Hobbes, R. (2007) Transactional Analysis. In W. Dryden (ed.), Dryden’s Handbook of Individual
Therapy (5th edn), London: Sage, pp. 256–86.
Tudor, K. and Sills, C. (2011) Transactional Analysis. In C. Feltham and I. Horton (eds), The Sage Handbook of
Counselling and Psychotherapy. London: Sage, pp. 335–40.
van Rijn, B., Wild, C., Moran, P. (2011) Evaluating the outcomes of Transactional Analysis and integrative counsel-
ling psychology within UK primary care settings. International Journal of Transactional Analysis Research 2(2):
34–43.

PART III
The Cognitive-Behavioural
Tradition

10
Cognitive Therapy
Stirling Moorey
During the middle years of this century psychology was dominated by the twin edifices of
behaviourism and psychoanalysis. On the one hand, the individual’s internal world was
unimportant and his or her actions were determined by environmental events. On the other
hand, the internal world was all important but its workings were unconscious and accessible
only with the help of a trained guide. The thoughts which most people regarded as central to
their experience of everyday life were seen by both schools as peripheral. There were, how‑
ever, some lone voices that defended the individual as a conscious agent. George Kelly
emphasised how the person seeks gives meaning to the world, and suggested that each of us
constructs our own reality through a process of experimentation. Albert Ellis drew attention
to the role of irrational beliefs in neurotic disorders and developed rational‑emotive therapy
(RET) to change these beliefs systematically.
The study of the mental processes, which intervene between stimulus and response, is
termed ‘cognitive psychology’. This includes a wide range of activities including thinking,
remembering and perceiving. In the 1970s psychology underwent a ‘cognitive revolution’ as
it moved from the ‘first wave’ of behavioural therapies to a ‘second wave’ of cognitive
behaviourism. Psychologists began to investigate how cognitions could be treated as behav‑
iours in their own right, and so might be conditioned or deconditioned. Bandura showed that
it was possible to understand the phenomenon of modelling from a cognitive rather than
strictly behaviourist perspective, and Mahoney drew attention to the significance of cognitive

244 PART III: THE COGNITIVE-BEHAVIOURAL TRADITION
processes such as expectation and attribution in conditioning. This increasing interest in cog‑
nition led to the development of various cognitive‑behavioural therapies. Although they all
have slightly different theoretical perspectives they share common assumptions and it is often
difficult to distinguish them in terms of the techniques used in clinical practice. Of these the
most influential have been Ellis’s rational‑emotive therapy (now known as rational emotive
behaviour therapy – see Chapter 11) and Beck’s cognitive therapy. Ellis aims to make the
client aware of his or her irrational beliefs and how they lead to maladaptive emotional states.
He emphasises cognitive processes that are ‘evaluative’ rather than ‘inferential’. If, for exam‑
ple, a client reported that she felt depressed when a friend ignored her in the street, rather than
asking her if there were any alternative explanation (e.g. her friend was preoccupied and did
not notice her) Ellis would home in immediately on the evaluative belief underlying her reac‑
tion ‘I must be liked by people’).
Beck, like Ellis, was originally an analyst who became disillusioned with the orthodox
Freudian tradition. His research into depression led him to believe that this condition was
associated with a form of ‘thought disorder’, in which the depressed person distorted incom‑
ing information in a negative way. The therapy derived from Beck’s cognitive model focused
on teaching clients to learn to identify and modify their dysfunctional thought processes.
Underlying these negative thoughts are beliefs that need to be restructured to prevent further
depression. In 1977 Beck’s group published the first outcome study comparing cognitive
therapy with pharmacotherapy in depressed clients. This generated great interest: first,
because previous studies had shown psychotherapy to be less effective than drug treatment
with this group of clients; and second, because psychologists were already becoming inter‑
ested in cognitive approaches. From its origins in the USA cognitive therapy has become
increasingly popular across the world. We now have the emergence of a ‘third wave’ of CBT,
which is challenging the conventional wisdom. However, the fundamentals of the cognitive
approach as outlined many years ago in Beck’s seminal Cognitive Therapy and the Emotional
Disorders (Beck, 1976) remains the cornerstone of most CBT practised today and has the
strongest evidence base. In this chapter the generic model of cognitive therapy will be the
main focus, with particular reference to depression and anxiety disorders.

Cognitive therapy makes a number of assumptions about the nature of the human individual:
1. The person is an active agent who interacts with his or her world.
2. This interaction takes place through the interpretations and evaluations the person makes about his or
her environment.
3. The results of the ‘cognitive’ processes are thought to be accessible to consciousness in the form of
thoughts and images, and so the person has the potential to change them.

COGNITIVE THERAPY 245
Emotions and behaviour are mediated by cognitive processes. This distinguishes cognitive
therapy from the extreme forms of behaviour therapy, which sees the organism as a black
box: what goes on inside the box is of little consequence. It also distinguishes it from psy‑
choanalysis, which gives prime importance to unconscious rather than conscious meanings.
According to Beck:
‘The specific content of the interpretation of an event leads to a specific emotional response ... depending
on the kind of interpretation a person makes, he will feel glad, sad, scared, or angry – or he may have
no particular emotional reaction at all. (Beck, 1976: 51–2)
The behavioural response will also depend upon the interpretation made. An important
concept in Beck’s view of normal and abnormal behaviour is the idea of the ‘personal
domain’. The personal domain is the conglomeration of real and abstract things that are
important to us: our family, possessions, health, status, values and goals. Each of us has
a different set of items in our personal domain; the more an event impinges on our domain
the stronger our emotional reaction is likely to be. The meaning we give to a situation will
be determined by the mental set we bring to it. We need rules or guidelines to allow us to
make educated guesses about what is likely to happen next. If we did not have an inter‑
nalised rule that we should stop at red traffic lights, our insurance bills would be consider‑
ably higher. Some of these assumptions about the world are shared, but others are
intensely personal and idiosyncratic. The hypothetical cognitive structures that guide and
direct our thought processes are called ‘schemata’. A schema is a template which allows
us to filter out unwanted information, attend to important aspects of the environment and
relate new information to previous knowledge and memories (Kovacs and Beck, 1978).
In areas we know well we have well‑developed schemata (e.g. for driving a car, or how
to behave at a social gathering), whereas in new situations schemata will be less well
developed.

In emotional disturbance information‑processing is biased in a negative distorted way:
people revert to more primitive thinking which prevents them functioning as effective
problem‑solvers (Beck et al., 1979: 15). This thinking tends to be global, absolute and
judgmental. A depressed person who is not successful at a job interview would label her‑
self as a total failure, conclude that it was entirely her own fault that she did not get the
job, and ruminate about the interview, focusing on everything that went wrong without
thinking about any of the positive factors. Beck (1976) identifies ‘logical errors’ which
characterise the thinking in psychological disorders. Table 10.1 summarises some of the
common logical errors.
Building on this work on depression, cognitive therapists have been mapping the cognitive
abnormalities seen in the various psychiatric disorders. In depression there is a negative view

Table 10.1 Cognitive distortions
1. Arbitrary inference refers to the process of drawing a conclusion from absent or even contradictory evidence. For instance,
you pass a friend on the other side of the street and she does not wave to you. You think ‘She’s ignoring me. She doesn’t
want to know me.’
2. Selective abstraction occurs when we focus on certain aspects of a situation but ignore others. For instance in health
anxiety the person attends to minor twinges and aches and takes them out of context.
3. Over-generalisation is the tendency to conclude general and global conclusions from a single incident. For instance, a single
failed job interview triggers the thoughts, ‘I’m useless. It’s hopeless. I’ll never get a job.’
4. Magnification and minimisation refers to the tendency to exaggerate the size or importance of negative evidence and
minimise positive. In depression we maximise signs of our inadequacy and minimise and disqualify signs of our competence.
5. Personalisation is the automatic assumption that an event is caused by or relevant to ourselves. For instance, if you hear
your friend’s laughing you assume they are laughing about you.
6. All or nothing thinking is thinking in dichotomous or black and white terms, such as ‘If I’m not a total success I must be a
complete failure; people must be totally loyal or I can’t trust them at all.’
of the self, the world and the future. In anxiety the cognitive distortions involve an overesti‑
mation of major physical or social threat and an underestimation of the individual’s ability to
cope with the threat. Anxious clients selectively attend to threat cues. More specific models
of certain types of anxiety disorder have been proposed. Clark’s model of panic emphasises
the way in which catastrophic misinterpretations of bodily symptoms create a vicious circle
of anxiety leading to more bodily sensations and more panic. Salkovskis and Warwick
adapted this model for hypochondriasis: the hypochondriac misinterprets innocuous bodily
sensations such as headache, twinges, etc. as signs of chronic life‑threatening illness. Each of
these diagnostic groups filters information in a slightly different way.
The conscious products of this biased processing are ‘negative automatic thoughts’. These
are spontaneous thoughts or images which seem plausible, but are in fact unrealistic. In emo‑
tional disorders these become frequent and severe. For instance, an anxious person may think
‘I can’t cope. Something terrible is going to happen.’ A depressed person may ruminate about
his failures, thinking ‘I’m useless, I never do anything right.’ The person’s behaviour will be
consistent with these thoughts.

Psychological health is characterised by the ability to process information in a relatively accurate
and flexible manner. Beck suggests that we are all capable of functioning as rational prob‑
lem‑solvers at least some of the time. Psychological health requires us to be able to use the skills
of reality‑testing to solve personal problems as they occur. Underlying this is a set of rules about
the world that are sufficiently consistent to allow us to predict what will happen in the future, but
also flexible enough to allow changes on the basis of new information. The distinction between
psychological health and disturbance is not a rigid one. The same cognitive processes occur in
both: we tend to interpret reality to support or schemata. This means that in psychological health
we have a slightly positive bias about ourselves, the world and the future.


Beck considers that there are many factors which predispose an individual to emotional distur‑
bance including genetic predisposition, physical disease, developmental traumas suggesting a
much more complex aetiology for emotional disorders than the simplistic notion that cognitions
cause emotions. Maladaptive schemata are the main cognitive vulnerability factors. Early learn‑
ing experiences, traumas and chronic stresses lead to beliefs and attitudes that make a person
vulnerable to psychological disturbance. Someone who has a serious illness as a child and is
overprotected by his parents may develop a core belief that he is frail and vulnerable and needs
to be supported by others to survive. Someone who is continually criticised for making small
mistakes may believe that she must get everything she does completely right. These beliefs are
the way the person makes sense of the world by developing ideas about how the world does, or
should, operate. The more rigid, judgmental and absolute these beliefs become, the more likely
they are to cause problems. Examples of beliefs that predispose to anxiety include:
‘Any strange situation should be regarded as dangerous.’

‘My safety depends on always being prepared for possible danger.’
‘I have to be in control of myself at all times.’
Examples of beliefs that predispose to depression include:
‘I can only he happy if I am totally successful.’

‘I need to be loved in order to be happy.’
‘I must never make a mistake.’
When a relevant event occurs they are activated and become the primary mode of processing.
For instance, because of early childhood experiences a woman may believe that she needs to
be loved in order to survive. While she is in a relationship this belief may not be salient. But
if she is rejected by her lover it acts as a premise to the syllogism:
‘I need to be loved in order to survive.’ ‘X has left me.’ ‘Therefore I cannot survive.’
Cognitive therapy aims not only to correct faulty information‑processing but also to modify
assumptions and so reduce vulnerability to further psychological disturbance.

Biased information‑processing explains how information contrary to the client’s schema is
filtered out or manipulated to make it consistent with her belief system. This is commonly seen
in depression, where positive information (e.g. past achievement) is repeatedly disqualified.

The depressed person will say that past successes were due to luck, or to people helping. In
anxiety there is an underlying bias towards attending to threat cues in the environment and
interpreting benign situations as dangerous.
Behaviour consistent with dysfunctional beliefs also helps to maintain negative emo‑
tions. An example of this can be seen in dog phobia, where avoidance of a feared stimulus
(dogs) prevents the person from learning that not all dogs are dangerous. A more subtle
form of avoidance occurs when we engage in a safety seeking behaviour while in a threat‑
ening situation. The catastrophic misinterpretation of physical symptoms in panic disorder
causes a spiral of anxiety, e.g. breathlessness, triggers the thought ‘I’m suffocating. I’m
going to die’ with consequent focus of attention on breathing, increased anxiety and wors‑
ening symptoms. The safety behaviour might be to take deeper, faster breaths, which leads
to hyperventilation and exacerbation of the panic. After the event one might expect the
person to realise that their fear was misplaced, but two factors can come into play the stop
this new learning occurring: firstly they may avoid situations where they have had a panic
attack, and secondly they may come to the conclusion that the only thing that saved them
from suffocation was taking in deep breaths. It is usually helpful to draw these interactions
of thoughts, feelings, physical sensations and behaviours in a diagram that shows the client
how these vicious circles are set up (see Figure 10.1).

Safety behaviours also occur in an interpersonal context. A client with social anxiety
may believe that he will be judged negatively by others and that he will appear awkward
Feeling stressed in the supermarket
Automatic thought
‘I’m suffocating. I’m going to die’ Anxiety
Breathlessness
Safety behaviour
Over breathe to get more air
Figure 10.1 Perpetuation of panic disorder

and anxious. It makes sense not to look at them because the expression on their faces is
likely to confirm his fears. The client therefore avoids eye contact, which means he
encodes in memory his internal impression of the encounter, rather how people are
really responding to him. The interpersonal safety behaviour not only prevents him
learning what people think of him, but his failure to look at people might actually lead
to them thinking he is awkward and odd creating a self-fulfilling prophecy. People with
personality disorders often use interpersonal strategies like social avoidance, trying to
control others etc. as ways to compensate for negative beliefs about themselves which
act like safety behaviours.

External factors can also help to perpetuate psychological disturbance. From within a
CBT framework these can be understood to trap people either through reinforcing their
negative beliefs, or restricting their opportunities for behavioural change. Certain mala‑
daptive beliefs can be endorsed by the family as a whole or even society, such as the idea
that attractiveness and worth are related to shape and weight. Similarly real‑life problems
such as unemployment make it difficult for depressed people to believe that there is a
future, or to believe that they are of value. The more negative the external environment
the more difficult it is to challenge negative thinking. Poverty or illness can reduce the
range of activities that someone can engage in and so limit their scope for finding positive
reinforcement. Chronic stress or social rejection can contribute to the continuation of
anxiety states, and this is often found in post traumatic stress disorder if the client is still
in an environment where they are at risk, e.g. a traumatised woman still in contact with
her abusive partner.
2.5 Change
The cognitive model assumes that emotional and behavioural change is mediated by
changes in beliefs and interpretations. In therapy, this is achieved through systematic test‑
ing of these thoughts and beliefs, but the same process occurs naturally when we are
exposed to situations that do not fit our assumptions about the world. If information is not
consistent with our schema then we either find ways to incorporate the new information
into our existing belief system, or we have to change our belief. Positive life events can
therefore lift people out of depression. If you think you are unlovable, making a new friend
can make you reconsider this. If you think you are a failure, passing an exam improves
your sense of competence. Because many of our beliefs are tacit rules, these natural
changes often occur gradually and may not be noticed. For instance, someone who has
been abused in childhood may not trust anyone, but over time repeated experience of cer‑
tain people being reliable and honest may lead to revision of this mistrust.

3 PRACTICE

Cognitive therapy has three main goals:
1. to relieve symptoms and to resolve problems;

2. to help the client to acquire coping strategies;
3. to help the client to modify underlying cognitive structures in order to prevent relapse.
Cognitive therapy is problem oriented: whether the complaints are symptoms of psychiatric
illness like anxiety and depression, behavioural problems like addiction or bulimia, or inter‑
personal ones like social anxiety, the primary goal is to help clients solve the problems which
they have targeted for change. The whole course of cognitive therapy can be seen as a learn‑
ing exercise in which the client acquires and practises coping skills, which can be used to deal
with the current episode of distress, but also employed if problems recur. The final goal of
therapy is the modification of maladaptive schemata. The intention is not to restructure all of
a person’s irrational beliefs, but only those that are causing problems.

There are no absolute exclusion criteria for cognitive therapy, but if clients are unable to
engage in a partnership where they explore and report thoughts and feelings and work on
these between sessions they will not be able to sue therapy effectively. This may exclude
clients with substance misuse problems who come to therapy intoxicated, clients with
severe learning difficulties or dementia etc. Similarly, if the client is unwilling to engage in
a structured, problem focused approach and to do homework they should not be taken on.

As with other therapies (including drug treatment) severity and chronicity are associated
with poor outcome in the treatment of depression. The quality of therapeutic alliance has
also been associated with outcome in CBT for depression, but there is some evidence that
the alliance builds as a result of the client making some initial improvements as a result
of intervention, rather than the alliance acting as the sole vehicle for change. Another
factor, which seems to affect outcome is the extent to which the client understands and
accepts the cognitive model. For depression particularly, it may be the case that people
who can easily engage in problem solving might benefit more form CBT. The implica‑
tions are that if the clients do not respond to the idea that their thoughts might have some
relevance to the problem during the initial sessions then cognitive therapy may not be the
right approach.

These factors are usually taken into account when considering clients for cognitive therapy, and a
clinician will often test clients’ suitability by assessing their acceptance of the cognitive model and
their response to cognitive restructuring. Safran and Segal’s Suitability for Short Term Cognitive
Therapy Scale gives a more systematic method for assessing suitability for short term CBT. (Safran
et al., 1993)
Individual or group therapy? Although most cognitive therapists would say that group
therapy is less effective than individual therapy, results from controlled trials are contra‑
dictory. The advantages of group cognitive therapy in a busy health service are obvious
and it can be a very cost-effective approach: group CBT for panic disorder is half the cost
of individual CBT. Some services offer group cognitive therapy as the first intervention
for all clients, and only those who do not make significant gains are then given indi‑
vidual therapy. In other circumstances clients may be offered a group because there are
specific advantages over individual therapy, such as the client being able to see and learn
from interacting with others with similar problems. Some clients may initially require
individual therapy when they are most distressed but can then go on to a group as their
mood improves.

First and foremost, cognitive therapists need to have good general interpersonal skills.
Although the therapy sometimes appears to place a strong emphasis on cognitive and
behavioural techniques these are deemed to be effective only if they are used within the
context of a good therapeutic relationship. In CBT for depression, both the quality of the
therapeutic alliance and the therapist’s competence in using the cognitive behavioural
approach contribute to a good outcome (Trepka et al., 2004). Warmth, genuineness and
empathy are vital components of this relationship. Cognitive therapists need to have
good listening skills, to be able to reflect accurately the cognitive and emotional compo‑
nents of the client’s communication, and to demonstrate an active and warm interest in
the client. If this is not done there is a real danger that attempts to challenge distorted
thinking will be perceived by the client as insensitive or even persecutory. Good thera‑
pists seem to be able to get inside the client’s cognitive world and empathise while at the
same time retaining objectivity.
Many would see the qualities described above as essential to any form of psychotherapy.
It is more difficult to specify qualities that make someone a good cognitive therapist rather
than a good psychotherapist in general. Perhaps one of the most important factors is the
extent to which the therapist can accept the cognitive model. The therapist has to be prepared
to work in a problem‑oriented way without continually looking for unconscious motives in
the client’s self-defeating thinking and behaviour. He or she must be able to blend the inter‑
personal skills described in the last paragraph with a directive approach, which involves a
great deal of structure and focus.


Therapists need to be able to identify problems and set goals with clients and structure ther‑
apy sessions. They need to be able to use questions skilfully so that the client evaluates their
beliefs in a non-threatening relationship. These skills are described in more detail in the sec‑
tion on therapeutic style.

The aim of cognitive therapy is to teach the client to monitor thought processes and to real‑
ity‑test them. Rather than assume that the client’s view of the situation is distorted or correct,
the cognitive therapist treats every statement about the problem as a hypothesis. Therapy is
empirical in the sense that it is continually setting up and testing out hypotheses. Client and
therapist collaborate like scientists testing a theory. For instance, a depressed person may
believe that there is no point in doing anything because there is no pleasure in life any more.
Hypothesis: If I visit my friend tomorrow I will get no pleasure from it.

Experiment: Arrange to visit from 3 p.m. to 4 p.m., and immediately afterwards rate the amount of pleas-
ure I get on a 0‑10 scale.
Most depressed people find they get at least some enjoyment out of activities they used to
find pleasurable.
Experiments like this can gradually erode the belief that it is not worth doing anything by
providing evidence that there is still pleasure open to them and so increase the person’s moti‑
vation. Teaching the client to be a ‘personal scientist’ is done through collaboration rather
than prescription. Wherever possible the therapist will encourage the client to choose prob‑
lems, set priorities and think of experiments. This collaboration is the hallmark of cognitive
therapy and there are a number of reasons for including the client in the problem‑solving
process as much as possible.
• Collaboration gives the client a say in the therapy process and so reduces conflict.
• Collaboration fosters a sense of self‑efficacy by giving the client an active role.
• Collaboration encourages the learning of self‑help techniques, which can be continued when therapy is
ended.
• Collaboration allows an active input from the person who knows most about the problem.
Collaboration also serves to reduce the sorts of misinterpretation that can sometimes affect
the therapeutic relationship. In non‑directive therapies, the impassive stance of the thera‑
pist means that the client has to construct an image of the therapist based on her own pre‑
dictions and rules about people. The resulting misinterpretation (transference) can be used
therapeutically. Cognitive therapy wants to reduce this and does not use the relationship as

the focus of therapy. It sees the therapist and client as partners in the process of prob‑
lem‑solving. This does not prevent the therapist being very active and directive at times,
but it always gives space for the client to contribute and give feedback on what the thera‑
pist is doing. With more severely depressed clients there is often a need for a lot of direc‑
tion at first, but as the mood improves and the client learns the principles of cognitive
therapy the relationship becomes more collaborative. Ideally by the end of therapy the
client is doing most of the work and thinking up his or her own strategies for change. When
the therapist is most directive at the beginning of treatment he or she must also be most
empathic in order to establish rapport.

In the collaborative relationship the client and therapist are co‑investigators trying to uncover
the interpretations and evaluations that might be contributing to the client’s problems. This is
an inductive process of guided discovery. Wherever possible the therapist asks questions to
elicit the idiosyncratic meanings which give rise to the client’s distress and to look for the
evidence supporting or refuting the client’s beliefs. This use of questioning to reveal the
self‑defeating nature of the client’s automatic thoughts has been termed Socratic questioning,
which is a defining feature of the therapeutic style of cognitive therapy.
Another characteristic feature of cognitive therapy is the way in which the session is struc‑
tured. At the beginning of each session an agenda is set, with both client and therapist
contributing to this. Usually the agenda will include a brief review of the last session, devel‑
opments in the last week and the results of homework assignments. The work then goes on
to the major topic for the session. Anyone listening to a cognitive therapy session will also
be struck by two further features: the use of summaries and feedback. Two or three times
during a session the client or therapist will summarise what has been going on so far. This
helps to keep the client on track, which is particularly important if anxiety or depression
impairs concentration. Asking the client to summarise also reveals whether or not the thera‑
pist has got a point across clearly. The therapist regularly asks for feedback about his or her
behaviour, the effects of cognitive interventions, and so on.

3.5.1 Assessment
Unlike many other therapies, cognitive therapy has embraced the diagnostic system in psy‑
chiatry, so a good assessment involves ensuring an accurate diagnosis is made. The reason
for this is that the basic cognitive model is modified for the particular disorder that is being
treated. An illustrative example of this would be anxiety disorders. All anxiety disorders have
in common an exaggerated perception of threat and a reduced perception of the person’s abil‑
ity to cope with that threat. But the exact nature of the threat differs between disorders. In
panic disorder it is the internal body sensations that are misinterpreted in a catastrophic way;

in health anxiety similar body sensations are misinterpreted as a longer term, less immediate
threat. Having a clear understanding of the nature of the disorder helps to orient the assess‑
ment, case formulation and treatment plan.
A cognitive therapy assessment, like the therapy itself, is problem focused. If the problem
is panic attacks the therapist will ask about the frequency and severity of the panics, situa‑
tions that might trigger them, the symptoms (cognitive, behavioural, emotional and physical)
and the consequences. The client’s pressing concerns are identified and explored from a
cognitive behavioural perspective, which is the beginning of the case formulation. In panic,
the therapist will ask detailed questions about what actually happens during an attack, often
focusing on a recent episode as a specific example:
• Where were you when the attack occurred? What were you doing?
• What were the first things you noticed?
• What happened next?
• What were you feeling physically? (looking for symptoms of autonomic nervous system arousal such as
palpitations, chest tightness, breathless, sweating, shaking)
• What went through your mind when you started feeling this way? (looking for catastrophic thoughts of
death, collapse, fainting, loss of control)
• When the attack was at its worst how strongly did you believe you would die/collapse/lose control?
• Did you do anything at the time to try to keep yourself safe and prevent this from happening? (identify-
ing safety seeking behaviours)
• What effect did these have?
• What happened at the end of the attack?
In assessing problems, the therapist will make use of questionnaires and rating scales to
assess the level of depression, anxiety or other problems. There are disorder specific ques‑
tionnaires for disorders such as obsessive compulsive disorder, post traumatic stress disorder
and panic that list common thoughts and behaviours and help the therapist home in on which
ones are relevant for the client in front of them. Having got a picture of nature and severity
of the problems the therapist will also want to look at the impact of these problems on the
client’s life. What can’t they do because of the problem? What is the effect on their family
and friends? In depression the degree of functional impairment, inactivity and withdrawal
needs to be assessed; in anxiety the level of avoidance of particular situations. An essential
component of the assessment will be the degree of hopelessness the client feels about their
problems and the extent to which this might put them at risk of harming themselves. The risk
assessment also needs to evaluate any risk to others directly or indirectly through negligence
etc. At this stage the therapist often asks about protective factors such as supportive relation‑
ships and also the strengths and coping abilities the client can bring to their problems.
The assessment will encompass an understanding of what the clients wants to get out of
therapy. This can help to start the process of problem identification and goal setting which
will be refined once the therapy begins. It also helps the therapist assess if the goals are
achievable and appropriate for this type of therapy. There will be a discussion of the nature
of cognitive therapy and the cognitive model with reference to the symptoms and problems

the client has brought. A brief description of the cognitive model is usually given during the
assessment together with an explanation that this is a structured, problem focused therapy
that is mainly aiming to deal with here and now difficulties; the therapist explains that it is
an active, collaborative partnership in which the client plays an active part and will be
expected to do self-help assignments between sessions. The response of the client to this will
determine whether or not they think they can work in this way. Criteria for selecting clients
for CBT have been described already.
It is good practice to take a developmental history during the assessment, but the depth of
this will depend upon the type of problem. Straightforward focal problems like phobia and
panic may not require a detailed history, apart from enquiries about any specific traumatic
incidents that might have triggered the problem. Clients with depression on the other hand
usually have childhood experiences that have shaped their negative views of themselves that
need to be understood to some degree. People with personality disorder will usually have had
significant experiences of unmet childhood need or abuse that needs to be explored to some
degree in the assessment.

It may sometimes be possible and reasonable to complete a case formulation at assess‑
ment, but the cognitive model emphasises the collaborative and empirical nature of the
therapy and so it is only over time that sufficient information is gathered to have a full
formulation. Cognitive therapists distinguish the maintenance formulation, which focuses
on factors that perpetuate the disturbance from the developmental formulation which
focuses on the acquisition of the disturbance. All CBT cases must have a maintenance
formulation. This will be guided to some degree by the diagnosis, which provides a road
map of the sorts of mechanisms at play for that specific disorder, but this will need to be
modified for the individual client. The maintenance formulation is derived from question‑
ing at assessment, data from questionnaires, but more importantly data the client brings
back from self-monitoring homework during the early stages of therapy. Monitoring
thoughts and behaviours are the best way to gather information that leads to an under‑
standing of how they interact to form what are often vicious circles trapping the person in
their emotional disorder. Figure 10.1 presents a diagrammatic summary of the mainte‑
nance formulation. This sort of diagram is collaboratively developed with the client and
explicitly shared with them.
Some degree of developmental conceptualisation will be done with each client, but as we
have seen, the depth of this can vary. It is less likely to be derived from the initial assessment
and may take time over the whole course of therapy, because the underlying rules for living
will not always be obvious. At its most basic level it will simply describe the history of the
problem and any precipitants identified. At the next level it is more of a problem formulation
that describes the origins of beliefs specific to the target problem, e.g. a client with panic
disorder who has fears of impending madness and losing control, may have had demanding
parents and developed an underlying belief that she has to be in control at all times. The full‑
est level of case conceptualisation includes a detailed account of childhood experience and

how it shaped core beliefs or schemas, together with an understanding of compensatory

beliefs and strategies. This fullest level will be needed for clients with personality disorders
and some more complex depressive and anxiety disorders.

Early on, strategies are aimed at helping to socialise the client into the cognitive model
by identifying how thoughts and feelings are linked, to provide coping strategies for
immediate crises and to help the client get some distance from the constant flow of
maladaptive thinking. In the next phase of therapy the aim is to help the client identify
cognitions and behaviours that might be maintaining their problems and to begin to test
the validity and helpfulness of these thoughts and actions. The last phase of therapy
involves identifying and challenging underlying maladaptive beliefs and developing a
relapse prevention plan.
Conceptualisation: Cognitive therapy is based on a coherent theory of emotional distur‑
bance, and this theory can be used to conceptualise the client’s problems. The clearer the
conceptualisation, the easier it becomes to develop strategies (i.e. general methods for solv‑
ing the client’s problems) and techniques (specific interventions). For instance, a woman
presented with complaints of fatigue and memory problems, but did not have any physical
cause for these symptoms. The initial formulation was that the symptoms were stress related,
and over the course of two assessment interviews the therapist was able to construct a clearer
picture of the problem using the cognitive model. The client had a very poor self‑image and
was in a difficult marriage where her husband was very critical. She described a constant
stream of thoughts criticising herself which occurred whenever she needed to make deci‑
sions. She was also able to identify negative thoughts about the marriage (‘It’s hopeless, I’m
trapped`). The cognitive formulation explained her memory problems as a natural result of
only partly attending to anything: she was distracted by the running commentary she gave on
her actions. Her fatigue probably resulted from the frequent negative thoughts she was having
about herself and her marriage.
Because she had a belief that there was nothing she could do about her marital problems
she tended to put these thoughts to the back of her mind using ‘cognitive avoidance’, and
selectively focused on the physical symptoms. This in turn led to a further set of negative
thoughts – ‘Is there something wrong with my brain? Am I going senile?’ This formulation
allowed the therapist to develop a comprehensive treatment strategy.
Identifying negative automatic thoughts: Early in therapy the therapist teaches the client to
observe and record negative automatic thoughts. Initially the concept of an automatic thought
is explained: it is a thought or image that comes to mind automatically and seems plausible,
but on inspection is often distorted or unrealistic. Thoughts the client has during the session
can be used to illustrate this, e.g. in the first session a depressed client may be thinking ‘I
don’t know why I’ve come, there’s nothing anyone can do for me.’ Written materials are also

used to explain the basic features of therapy. The client is then given the homework task of
collecting and recording negative automatic thoughts. The exact format of this will depend
on the problem. A depressed client will be asked to monitor depressed mood, recording the
situation that triggered a worsening of depression, and the thoughts associated with it.
Someone with an alcohol problem would monitor cravings for drink, and again record the
situations in which they occurred and the thoughts that precipitated them. This phase of iden‑
tifying thoughts help clients to start making the link between an event, their automatic
thoughts and the resulting emotion or behaviour. Identifying thoughts may also be therapeu‑
tic in its own right, since just recording negative thoughts sometimes reduces their frequency.
Clients should try to record their thoughts as soon after the stressful event as possible, when
it is fresh in their mind.
Testing negative automatic thoughts: When the client has learned to identify the maladap‑
tive thinking, the next step is to learn how to challenge the negative thoughts. Through
Socratic questioning the therapist shows the client how to change his or her thinking. This
cognitive restructuring by the therapist usually brings relief in the session, but it takes longer
for the client to practise challenging thoughts outside the therapy session, which becomes a
situation where the therapist models the process of cognitive restructuring and gives the cli‑
ent feedback on his or her success at the task. Clients are encouraged to use a form to record
and challenge their automatic thoughts to help them internalise the process of identifying and
modifying negative automatic thoughts.
There are a number of methods the therapist can use to help a client modify negative
thinking:
Reality testing: This is probably the most common method of cognitive restructuring. The
client is taught to question the evidence for the automatic thoughts. For example, you hear
that your five‑year‑old son has hit another child at school. You immediately think ‘He’s a
bully. I’m a useless parent, and feel depressed.’ But what is the evidence that your son is a
bully? Has he done this sort of thing before? Is this unusual behaviour for a five‑year‑old
child? Bullying implies an unprovoked attack. Could he have been provoked? What is the
evidence that you are a useless parent? Have you been told by anyone in your family that you
are doing a bad job? Is a single instance of bad behaviour in a five‑year‑old child proof that
you are a bad parent?
Looking for alternatives: People who are in emotional crisis, especially if they are
depressed, find it difficult to examine the options that are open to them. They get into a blink‑
ered view of their situation. Looking for alternatives is a way of helping them out of this
mental set. The therapist gently asks for alternative explanations or solutions and continues
until as many as possible are generated. At first these will probably all be negative but after
a while the client will start to come up with more constructive alternatives.
Reattribution: A more specialised form of the search for alternatives involves reattributing
the cause of, or responsibility for, an event. A client who experiences panic attacks may
believe that the physical sensations of dizziness and a pounding heart are signs of an impend‑
ing heart attack. The therapist, through education, questioning and experimentation, helps the
client to reattribute the cause of these experiences to the natural bodily sensations of extreme

anxiety. For example, the client who attributes her son’s behaviour to her failure as a mother
can be taught to change the focus of responsibility; many factors contribute to a child’s
behaviour, and a parent does not have control of all of them.
Decatastrophising: This has been termed the ‘What if’ technique. The client is taught to
ask what would be the worst thing that could happen. In many cases when the fear is con‑
fronted it becomes clear that it is not so terrible after all. For example, you are preparing to
visit a friend for the weekend and do not have much time to pack. You think, ‘I can’t decide
what to pack. I mustn’t forget anything.’ You get into more and more of a panic trying to
remember everything in time. Why would it be so awful if you did forget something? Would
it be the end of the world if you turned up without a toothbrush?
Advantages and disadvantages: This is a very helpful technique to enable clients to get
things into perspective. If a difficult decision has to be made or if it seems difficult to give
up a habitual maladaptive behaviour, the client can list the advantages and disadvantages of
a certain course of action.

Behavioural techniques in cognitive therapy serve two purposes: they work to change
behaviour through a broad range of methods; and they serve as short‑term interventions
in the service of longer‑term cognitive change. This second goal differentiates the behav‑
ioural tasks used in cognitive therapy from those used in more conventional behaviour
therapy. These tasks are set within a cognitive conceptualisation of the problem and are
used to produce cognitive change. Seen in its simplest form, behavioural work changes
cognitions by distracting clients from automatic thoughts early in the process of therapy;
and challenging maladaptive beliefs through experimentation. Behavioural methods are
often used at the beginning of therapy when the client is most distressed and so less able
to use cognitive techniques.
Activity scheduling: This is a technique that is particularly useful with depressed clients
but can be applied with other problems too. The rationale for scheduling time centres on
the proposition that when they are depressed, clients reduce their level of activity and
spend more time ruminating on negative thoughts. The schedule is an hour‑by‑hour plan
of what the client will do. As with all the procedures in cognitive therapy, this needs to be
explained in some detail and a clear rationale given. It is often set up as an experiment to
see if certain activities will improve mood. The therapist stresses that few people accom‑
plish everything they plan, and the aim is not to get all the items done but to find out if
planning and structuring time can be helpful. Initially the aim may just be to monitor tasks
together with the thoughts and feelings that accompany them. The emphasis is usually on
engaging in specific behaviours during a certain period rather than the amount achieved.
For instance, a client would be encouraged to decide to do some decorating between 10 a.m.
and 11 a.m. on a certain day, rather than plan to decorate a whole room over a weekend.
These tasks are set up as homework assignments and the results discussed at the beginning
of the next session.

Mastery and pleasure ratings: This technique can be used in conjunction with activity
scheduling. Clients rate how much mastery (feelings of success, achievement or control) or
pleasure they get out of a task (on a 0–10 scale). Since depressed clients often avoid engaging
in pleasant activities, this method allows the therapist to establish which activities might be
enjoyable for clients and to encourage them to engage in them with greater frequency. It also
challenges all‑or‑nothing thinking, by showing that there is a continuum of pleasure and
mastery rather than experiences that are: (1) totally enjoyable or unenjoyable; and (2) yield
complete success or failure.
Graded task assignments: All‑or‑nothing thinking can also be challenged using graded task
assignments. Many clients think, ‘I have to be able to do everything I set myself, or I have
failed.’ The therapist begins by setting small homework tasks which gradually build up m
complexity and difficulty The client is encouraged to set goals that can realistically be
achieved, so that he or she completes a series of successful assignments.
Behavioural experiments: We have already seen how behavioural experiments are an impor‑
tant component of cognitive therapy. Hypotheses are continually generated and put to the test.
This usually involves a negative prediction of some form. For instance, an anxious client may
state that he is too anxious even to read. An experiment can be set up in the therapy session
where the client reads a short paragraph from a newspaper, thus disproving the absolutism of
this statement. The client can then go on to read articles of increasing length over the follow‑
ing week. Experiments are often set as homework. For instance, a depressed client who firmly
believes that she is unable to go shopping could be asked to go shopping with her husband.
Even if the client is not able to carry out the assignment the experiment is not a failure because
it provides valuable information about what might be the blocks to the activity.
(a) Other behavioural techniques Cognitive therapy employs a variety of other

behavioural techniques where appropriate. Cognitive and behavioural rehearsal is frequently
used during the session in preparation for a difficult homework assignment. Role‑play can be
a very effective cognitive change technique. When clients have practical problems that need
to be solved, behavioural techniques based on a skills training model are especially useful.
This will usually involve forms of assertiveness training or social skills training for people
who have deficits in interpersonal skills.
(b) Schema change methods All the techniques described so far can be applied to help
elicit and change underlying beliefs. In addition some techniques may be specifically applied
to change deeply held core beliefs or schemas. The Historical Review of Schemas involves
testing the evidence for and against the belief across the individual’s lifespan. While many
clients will find evidence for their belief that they are inadequate or doomed to being
abandoned from their recent experience, it is more difficult for them to bias information from
early childhood in the same way. The Continuum Technique is a method where all or nothing
thinking is challenged by plotting it on a continuum and the Positive Data Log involves
collecting daily instances which discount the client’s core beliefs.

(c) Treating clients with personality disorders There is not room in this chapter to
describe the treatment of personality disorders in detail (see Beck et al., 1990; Young et al.,
2003). The schema change techniques just mentioned play an important role in working
with this client group. Because it can be difficult to establish a therapeutic alliance, and
because of the strength with which the dysfunctional beliefs are held, treatment is
usually longer than with emotional disorders. Clients often find it difficult to identify
automatic thoughts and so much of the work has to be done at the schematic level.
Repeated recognition of core beliefs and the behavioural strategies stemming from them
is often necessary before change can occur, and sometimes a much more confrontational
style is needed to overcome schema avoidance (Young et al., 2003). This can include the
use of emotive techniques to activate schemas. For instance, a schema may be activated
by reconstructing a traumatic scene from childhood in role-play. This is often associated
with powerful feelings of fear, hurt and anger. Initially the client is unable to think
rationally and is overwhelmed by the feelings, but a skilful therapist can help the client
get some distance from the affect without getting caught up in it. Cognitive restructuring
can then be used to challenge guilt or blame the person feels for the trauma or abuse, and
to challenge beliefs that the past must always poison the present. More active techniques
like imagery re-scripting can help to change the sense of powerlessness that is often part
of the memory. The conceptualisation is even more important in this work than in
standard cognitive therapy. To guide the interventions the therapist needs a clear picture
of how core beliefs were developed as a result of childhood experiences, how
compensatory beliefs and coping strategies emerged, and how these schemata operate in
the clients’ present to maintain the maladaptive interpersonal patterns. Sharing this
conceptualisation with the client can help give meaning to a seemingly chaotic and
meaningless present.

Cognitive therapy aims to effect change by creating situations where old beliefs can be
tested and updated through the provision of new information. This can occur through
verbal discussion and examination of the evidence for the belief or its logical consistency,
or through behavioural experiments that test the beliefs. At the beginning of therapy the
emphasis is on conceptualising the client’s problems, teaching the cognitive model and
producing early symptom relief. Techniques aimed at symptom relief in the early stages
of therapy tend to be more behavioural. As therapy progresses the client learns to monitor
and challenge automatic thoughts and this forms the major focus in therapy. As the client’s
problems reach some resolution the emphasis shifts to identifying and challenging under‑
lying assumptions, and to work on relapse prevention. The process of change is not
always smooth. The client may come with very different expectations of treatment than
the therapist and it may take longer to help them see for themselves that the model and
methods can be helpful to them.

4 CASE EXAMPLE
4.1 The client

Cindy was a 33-year-old artist who had been troubled by low mood on and off since her
teens. Even when not suffering from depression she had a very poor opinion of herself and
doubted her ability to make anything of her life. She berated herself for not having a part‑
ner or children, criticised herself for not making more of her career, and considered herself
a failure all round. Cindy had problems settling down to mundane tasks or planning her
week because she found it hard to concentrate and stick with humdrum chores. It felt like
there was one side of her that wanted to live a conventional life, but another side that saw
this as boring and ordinary. At weekends she would start drinking with friends in the early
evening and then go out clubbing till the early morning. She often found it hard to remem‑
ber what had happened the night before and feared that she had behaved outrageously. Her
inability to restrict her drinking and the effects of her binges further added to her sense of
shame and failure.
Cindy described an unhappy childhood. She had never really felt loved and valued and
worried that her brother who was two years older was both more able and more appreciated.
Her father was a moderately successful artist, but had an erratic, unpredictable character,
exacerbated by his heavy drinking. He had left him when Cindy was 11 and her contact with
him since then had been fitful. She felt they were similar personalities, so they either got on
really well or were at each other’s throats. Since she had grown up she believed he saw her
artistic efforts as competition: he always wanted to talk about his own work and never
seemed to praise her for her work. Her mother was somewhat morose; she was very hard on
herself but also hard on her daughter, particularly about her heavy drinking. Cindy’s brother
was working abroad as an IT consultant. Their relationship had improved now they were
adults, but she still couldn’t help making comparisons: he seemed to have a successful
career and was planning to return to England to live with his partner.
Cindy had found school difficult. She wondered if she had been dyslexic because she had
always done better at non-verbal subjects. She did not like the rules and regulations of school,
but generally complied and did not get into trouble. She was popular with the others but was
never considered cool. After school she went to Art College and then did various part time
jobs while continuing her art work. Cindy had had a number of relationships, none lasting
more than a year. She tended to go out with men she had met while clubbing. Although they
seemed exciting initially, she later usually found them shallow.
4.2 The therapy

Cindy was eager to take part in therapy and was very motivated. Although she did have
some feelings of shame about her behaviour, the compassionate conceptualisation, which

emphasised how she was acting in this way to cope with unpleasant thoughts and feelings,
helped her to feel understood and not judged. As she monitored her binge drinking and
self-criticism, and then began to find changes in her thoughts and behaviour, the therapeu‑
tic alliance strengthened. When at a later stage in therapy the developmental conceptuali‑
sation was shared with her, she had sufficient trust in the therapist not to feel overwhelmed
by the feelings evoked by this exploration of her underlying beliefs.

The assessment led to an initial maintenance conceptualisation of Cindy’s problems. Her
self-criticism seemed to pervade her life. She attacked herself for what she didn’t do and
for what she did do. There was a vicious circle in which her low self-esteem, low confi‑
dence and belief that she would never be organised and successful led her to avoid dif‑
ficult or onerous tasks, but this avoidance simply confirmed her negative beliefs about
herself. There was also a vicious circle involving her excessive drinking. Through the
week she would either spend her time in a disorganised state escaping from negative
thoughts and feelings, or she would throw herself into her art, sometimes working 12 hours
a day. By the end of the week she began to feel tense and tired and gave herself permis‑
sion to relax and unwind: ‘You’ll feel better if you have a drink. You’ve worked hard,
you deserve to enjoy yourself.’ Her binge drinking made her feel unwell for a couple of
days, so she was then unable to get her work done and she criticised herself even more.
Because she lost her inhibitions when very drunk she often behaved in ways she later
regretted, and this further added to her self-disgust. This conceptualisation is shown in
Figure 10.1. A developmental conceptualisation was developed over the course of ther‑
apy and is described below.

The two main aims of therapy were to help Cindy control her binge drinking and to
improve her self-esteem. The therapist began by helping her to understand the factors
that might be maintaining her low mood and low self-esteem. A cost-benefit analysis of
drinking showed that although she enjoyed it, felt relaxed and felt more socially confi‑
dent, the alcohol tended to make her more depressed and less productive overall. Cindy
agreed it might be worth cutting down on her alcohol intake. She kept a record of her
drinking and a diary of what she did during the week; she rated the activities for pleasure
and mastery.
The activity schedule was used to help her get a balance in her daily routine, between
avoidance and overwork. The therapist helped her to explore what she would like to achieve
and how she might get there, as well as encouraging her to find activities, which could com‑
bat her depressed mood. She felt that avoiding alcohol during the week, exercising and doing
her art were all nurturing activities. The therapist also helped her to rehearse in imagination
how she could leave a club at a reasonable time instead of staying all night. This involved
identifying and challenging some of the permission giving thoughts that encouraged her to

drink more and more. She had variable success with this over the first few weeks of therapy.
She began to recognise some of the risk factors and decided that she would be better off
meeting friends who only drank small amounts and went home early rather than staying with
her old circle. She found that in weeks during which she looked after herself she felt much
better and was much more productive. Her difficulty in doing this every week was a good
source of automatic thoughts.
The habit of berating herself up for failures was very strong and she would easily
think: ‘I’ve done it again. I’m never going to change. I’ve got no self-control.’ She
learned to identify these thoughts in the session and outside the session using the
Dysfunctional Thought Record. Recording and testing these self-critical thoughts
became the main component of the middle phase of therapy. She found that she had
negative thoughts about many things that happened on a day-to-day basis as well as
things that had happened in the past. She noticed that these seemed to be worse when
she was with her mother who was overtly critical of her. Repeatedly using the thought
record helped her to feel stronger and not to fall into believing her mother’s criticism.
Cindy had in the past been quite interested in Buddhism and meditation; the therapist
encouraged her to return to meditating as a means of both nurturing herself and helping
to break the vicious cycle of depressive thoughts. She began to recognise her self-crit‑
ical thoughts as simply thoughts and worked on accepting herself as she was rather than
demanding she be different.
By this time Cindy was bingeing less frequently and had more weeks during which she
achieved the things she wanted to do. Therapy moved on to exploring the underlying
beliefs that made her vulnerable to thinking and feeling so badly about herself. She read‑
ily understood that the origins of this had been in her childhood. She had seen her brother
apparently succeeding effortlessly while everything seemed difficult for her. Her mother
modelled a pessimistic, fatalistic view of the world and criticised her directly, while her
father modelled some of the out-of-control behaviour she later fell into herself. She
therefore developed the core belief that she was a useless failure. This pervaded all she
did and thought, and a number of conditional beliefs arose from this ‘bottom line’. These
included:
‘If I don’t have a successful career, a long term relationship and children, I’m a failure.’
‘If I try to do something I will fail.’
‘If people know the real me they’ll reject me.’
‘If I try to organise my life I’m bound to fail because I’m incompetent.’
Many of the behaviours we had been working on in therapy seemed to arise as compensatory
strategies out of these beliefs:
• Work really hard non-stop, or give up.

• Avoid difficult situations.

• Use alcohol to relax and escape from negative feelings.

• Use alcohol to increase confidence and feel part of the crowd.
• Criticise self in order to do better.
She saw that much of her self criticism was like an internal bully she had inherited from
her mother, who punished herself as well as Cindy in an effort do better (see Figure 10.2).
The therapist helped her to test some of these beliefs for their accuracy and usefulness,
replacing them with alternative more helpful beliefs. She found the self-help book
Overcoming Low Self-Esteem very useful at this stage and was able to create a new ‘bot‑
tom line’: ‘I’m good enough. I can get fulfilment from my work and life for its own sake.’
As therapy came to an end Cindy wrote a blueprint outlining what she needed to do to
maintain the gains she had made.

Cindy attended for 12 weekly sessions and then had two follow-up sessions. At her final fol‑
low up she was still having occasional drinking spells but these were much less frequent and
she was far less critical of herself if they happened. She felt she was more productive in her
work and more constructive in her life in general. She felt that overall she was beginning to
believe her new bottom line.
Self-criticism
‘You’re useless’
‘You’re a failure’
‘You can’t cope’
‘You don’t deserve
good things’
‘Everyone else has
got a life’
Avoid difficult and Work hard at

boring tasks art all day
Act in an embarrassing way
Suffer from hangover the Depressed mood
next day
‘I deserve to enjoy myself’
Binge drink
Figure 10.2 Conceptualisation of factors maintaining Cindy’s problems

5.1 Developments
5.1.1 Brief therapy
Whereas other therapies have often started out as long-term treatments that then developed brief
interventions, cognitive therapy as perhaps done in the other direction: treatments for anxiety and
depression remain as something between 12 and 20 sessions, but the newer treatments like
schema therapy may extend over two or three years. However, there have been briefer CBT
interventions developed for use in primary care and in palliative care (Moorey et al., 2009).

One of the main criticisms of CBT is that it emphasis on rationality may make it difficult for
people from non-Western cultures and people with lower educational attainment to engage in
the therapy. While it may need to be modified the different cultural groups, there is evidence
that this approach can be helpful to people from Asian and other cultures, and there has been
work done with people with learning difficulties. CBT is now being applied across the age
range from children and adolescents to older adults.
Since its initial application to depression, cognitive therapy has been applied to a wide
range of problems. Models and treatments for the subtypes of anxiety disorders have been
developed including panic disorder, obsessive-compulsive disorder, hypochondriasis,
social phobia and post traumatic stress disorder. Using these conceptualisations as a
framework, researchers have developed and tested focused therapies that target the core
cognitive and behavioural elements of each disorder. Britain has been in the forefront of
the development of cognitive behavioural therapies for psychosis (Fowler, Garety and
Kuipers, 1995) and for bipolar affective disorder (Lam et al., 2003), while the adaptation
of CBT for people with personality disorders has developed in the USA (Young et al.,
2003) and Holland (Arntz and Jacob, 2012). Both sides of the Atlantic have contributed
to its application to eating disorders.
The substantial evidence base for CBT has led to its inclusion in the UK’s guidelines from
the National Institute for Health and Clinical Excellence (NICE: www.nice.org.uk) for the
treatment of depression, anxiety, schizophrenia and bulimia: all recommend CBT as one of
the core components of management of these conditions. Building on this, the UK govern‑
ment has invested heavily in the training of cognitive behaviour therapists of the treatment of
common mental disorders. This initiative, termed Improving Access to Psychological
Therapies (IAPT) is delivering evidence-based treatments for anxiety and depression in primary
care settings, and evaluating the outcome is using standardised instruments. The services are
now broadening their scope so that other evidence-based treatments such as interpersonal
therapy are delivered, and there are plans to extend the service to treat long-term conditions
and serious mental illness.
Technical developments in CBT have occurred in a number of areas. These have included
new techniques for working with imagery, ruminations and worry (Harvey et al., 2004).

There is an increasing emphasis on the use of experiential techniques and behavioural exper‑
iments as the most effective way to change cognitions, and less emphasis on verbal cognitive
restructuring techniques (Bennet-Levy et al., 2004).
The third wave cognitive therapies such as Dialectical Behaviour Therapy (DBT: Linehan,
2012), Acceptance and Commitment Therapy (ACT: Hayes, 2004), Behavioural Activation
(BA: Jacobson et al., 2001) are an exciting new direction for the cognitive behavioural
approach. These therapies share a foundation in radical behaviourism and an interest in the
function of problematic behaviours, thoughts, emotions and physical sensations rather than
their content (Hayes, 2004). According to Hayes they emphasise ‘contextual and experien‑
tial change strategies rather than direct and didactic ones’. They approach thoughts very
differently from traditional ‘second wave’ CBT. Instead of being taught to challenge nega‑
tive thoughts, clients are helped to acknowledge the thoughts without engaging with them.
This is done through experiential exercises (ACT) or mindfulness practice (DBT). The
behavioural component of therapy may involve a functional analysis of unhelpful behav‑
iours or identifying behaviours that help you work towards your life values (ACT). An
important new development in these approaches is the idea of directly experiencing negative
emotions without engaging in ruminations or avoidance behaviour. Mindfulness Based
Cognitive Therapy (MBCT: Segal et al., 2002) uses this as one of its main components. It
helps people learn to accept whatever we are experiencing in the moment without trying to
fix or change it.

Many of the limitations of cognitive therapy are the same as those that apply to any form of
psychotherapy. Motivation to change is an important construct that is not always assessable
until therapy is under way. The emphasis placed on homework and self‑help can be a limita‑
tion for some clients. As we have seen, the question of acceptance of the theoretical model,
and the ability and willingness to carry out self‑help assignments, must be taken into account
when considering clients for therapy. The more clearly difficulties can be defined as problems
the easier it is to do cognitive therapy. With vague characterological flaws, which manifest
themselves as problems in interpersonal relationships, it is sometimes very hard to find a
focus. With such clients the form of therapy described here may not be adequate and the
longer-term schema approach may be necessary.

Many criticisms have been made of CBT since it first appeared. These include the claim that
it is too superficial, does not acknowledge emotions, interpersonal factors or developmental
origins of the client’s problems. Some of these criticisms are based on a misunderstanding of
the approach, but others have some substance, and have led to modifications in the therapy.
Schema therapy has been developed in response to the difficulty in using straightforward

cognitive techniques with people with personality disorders. Its emphasis on a longer-term
process with the use of experiential change techniques and therapeutic relationship make it
much more than integrity of therapy. Third-wave therapies have developed in response to
findings that some clients become caught up in the debate between negative thoughts and
rational responses. They offer a way of escaping from this dilemma.
5.4 Controversies
Therapists from other schools are very critical of the precedents that CBT now has in govern‑
ment funded programmes. This is because it has strongest evidence base, but evidence that it
is more effective than other therapies is difficult to find. It is also difficult to demonstrate that
cognitive therapy works through changing underlying cognitive structures. This has led some
to conclude that all therapies are equal and should therefore be treated equally. However, this
criticism breaks down when we focus on specific disorders: there is good evidence that CBT
is more effective for phobias, panic disorder, PTSD and OCD than other therapies.
6 RESEARCH
CBT has the strongest evidence base of all the psychological therapies. It lends itself well to
the research design of the randomised controlled trial (RCT) because it has specific protocols
for different disorders, can be manualised, and has overt targets for change that can be rela‑
tively easily measured. It has also been committed to the empirical method from the outset.
Beck’s cognitive therapy for depression has been shown to be as effective as anti-depressant
medication and has a relapse prevention effect equivalent to that of maintenance medication
(Beck and Dozois, 2011). Its effectiveness in severe depression is currently under scrutiny
since one of the new third wave therapies (behavioural activation) may actually produce
superior results (Dimidjian et al., 2006). In anxiety disorders, the specific cognitive models
for panic, social phobia, obsessive compulsive disorder and post traumatic stress disorder
have all been shown to be effective treatments, and these disorder specific protocols appear
to be more effective than general CBT approaches such as stress management. The UK
National Institute for Health and Clinical Excellence (NICE) guidelines recommend CBT as
the psychological treatment of choice for anxiety and depression (e.g. NICE, 2011) as well
as for eating disorders and chronic fatigue syndrome.
Beck’s cognitive approach to personality disorders has not been extensively researched,
but Young’s schema therapy has been found to be superior to transference focused psy‑
chotherapy in the treatment of borderline personality disorder (Giesen-Bloo et al., 2006).
Some recent trials of CBT for serious mental illness have raised questions about how
many clients with these conditions might actually benefit (Scott et al., 2006; Lynch et al.,
2010). Evidence for the third-wave therapies is growing: a recent review found that all
now had at least two positive randomised controlled trials (Kahl et al., 2012). Their

equivalence or superiority to standard CBT has not yet been investigated. The empirical
standing of cognitive behaviour therapy is strong and its commitment to evaluation means
that as more effective forms of the therapy are developed it will be able to continue to
adapt and change in a truly scientific way.
7 FURTHER READING
Beck, A.T. (1976) Cognitive Therapy and the Emotional Disorders. New York: International Universities Press.
Beck, JS. (2011) Cognitive Therapy. Basics and Beyond. New York: Guilford Press.
Bennet-Levy, J., Butler, G., Fennel, M., Hackmann, A., Mueller, M., Westbrook, D. (eds) (2004) Oxford Guide to
Behavioural Experiments in Cognitive Therapy. Oxford University Press.
Westbrook, D., Kennerley, H., Kirk, J. (2007) An Introduction to CBT: Skills and Applications. London: Sage.
Young, J.E., Klosko, J.S., Weishaar, M.E. (2003) Schema Therapy: A Practitioner’s Guide. New York: Guilford Press.
8 REFERENCES
Arntz, A. and Jacob, G. (2012) Schema Therapy in Practice: An Introductory Guide to the Schema Mode
Approach. Oxford: Wiley-Blackwell.
Beck, A.T. (1976) Cognitive Therapy and the Emotional Disorders. New York. International Universities Press.
Beck, A.T., Rush, J.L., Shaw, B.E., Emery, G. (1979) The Cognitive Therapy of Depression. New York: Guilford Press.
Beck, A.T., Freeman, A. and Associates (1990) Cognitive Therapy of Personality Disorders. New York: Guilford
Press.
Beck, A.T. and Dozois, D.J. (2011) Cognitive therapy: current status and future directions. Annual Review of
Medicine 62: 397–409.
Bennet-Levy, J., Butler, G., Fennel, M., Hackmann, A., Mueller, M., Westbrook, D. (eds) (2004) Oxford Guide to
Behavioural Experiments in Cognitive Therapy. Oxford University Press.
Dimidjian, S., Hollon, S.D., Dobson, K.S., Schmaling, K.B. et al. (2006) Journal of Consulting and Clinical
Psychology 74: 658–70.
Fowler, D., Garety, P., Kuipers, E. (1995) Cognitive Behaviour Therapy for Psychosis: Theory and Practice.
Chichester: John Wiley & Sons Ltd.
Giesen-Bloo, J., Van Duck, R., Spinhoven, P. et al. (2006) Outpatient psychotherapy for borderline personality
disorder: a randomized trial of schema-focused therapy v transference-focused psychotherapy. Archives of
General Psychiatry 63: 649–58.
Harvey, A., Watkins, E., Mansell, W., Shafran, R. (2004) Cognitive Behavioural Processes across Psychological
Disorders: A Transdiagnostic Approach. Oxford: Oxford University Press.
Hayes, S.C. (2004) Acceptance and Commitment Therapy and the new behavior therapies: Mindfulness, accept-
ance and relationship. In S.C. Hayes, V.M. Follette and M. Linehan (eds), Mindfulness and Acceptance:
Expanding the Cognitive Behavioral Tradition. New York: Guilford, pp. 1–29.
Jacobson, N.S., Martell, C.R., Dimidjian, S. (2001) Behavioral activation therapy for depression: returning to con-
textual roots. Clinical Psychology: Science and Practice 8 (3): 255–70.
Kahl, K.G., Winter, L., Schweiger, U. (2012) The third wave of cognitive behavioural therapies: what is new and
what is effective? Current Opinion in Psychiatry 25: 522–8.

Kovacs, M. and Beck, A.T. (1978) Maladaptive cognitive structures in depressions. American Journal of Psychiatry
135: 525–7.
Lam, D.H., Watkins, E.R., Hayward, P., Bright, J., Wright, K., Kerr, N., Parr-Davis, G., Sham, P. (2003) A randomized
controlled study of cognitive therapy for relapse prevention for bipolar affective disorder: outcome of the first
year. Archives of General Psychiatry 60: 145–52.
Linehan, M.M. and Koerner, K. (2012) Doing Dialectical Behavior Therapy. New York: Guilford Press.
Moorey, S., Cort, E., Kapari, M., et al. (2009) A cluster randomised controlled trial of cognitive behaviour therapy
for common mental disorders in patients with advanced cancer. Psychological Medicine 39: 713–23.
Lynch, D., Laws, K.R., McKenna, P.J. (2010) Cognitive behavioural therapy for major psychiatric disorder: does it
really work? A meta-analytical review of well-controlled studies. Psychological Medicine 40: 9–24.
National Institute for Health and Clinical Excellence (2011) Generalised Anxiety Disorder and Panic Disorder (with
or without Agoraphobia) in Adults (CG113) London: National Institute for Health and Clinical Excellence.
Safran, J.D. Segal, Z.V., Vallis, T.M., Shaw, B.F. et al. (1993) Assessing patient suitability for short-term cognitive
therapy with an interpersonal focus. Cognitive Therapy and Research 17: 23–38.
Scott, J., Paykel, E., Morriss, R. et al. (2006) Cognitive-behaviour therapy for severe and recurrent bipolar disorders:
randomized controlled trial. British Journal of Psychiatry 188: 313–20.
Segal, Z.V., Williams, J.M.G., Teasdale, J.D. (2002) Mindfulness-Based Cognitive Therapy for Depression: A New
Approach to Preventing Relapse. New York: Guilford Press.
Trepka, C., Rees, A., Shapiro, D.A., Hardy, G.E., Barkham, M. (2004) Therapist competence and outcome of cog-
nitive therapy for depression. Cognitive Therapy and Research 28: 143–57.
Young, J.E., Klosko, J.S., Weishaar, M.E. (2003) Schema Therapy: A Practitioner’s Guide. New York: Guilford Press.

11
Rational Emotive Behaviour
Therapy
Windy Dryden
Rational emotive behaviour therapy (REBT) was established in 1955 by Albert Ellis, a clinical
psychologist in New York, who originally called the approach rational therapy. In the late
1940s, Ellis trained in psychoanalytically oriented psychotherapy, but he became increas-
ingly disenchanted with psychoanalytic theory, claiming that it tended to be unscientific,
devout and dogmatic. He had always maintained an interest in philosophy and how it could
be applied to the realm of human happiness. The writings of Stoic philosophers (especially
Epictetus and Marcus Aurelius) were particularly influential in stressing that people are dis-
turbed not by things, but by their view of things. Ellis began to realise that he had made the
error of stressing a psychodynamic causation of psychological problems and began instead
to emphasise the philosophic causation of psychological problems.
From this point he began to stress the role of cognition in the creation and maintenance of
psychological disturbance. In his early presentations and writings, Ellis (1958) tended to
overemphasise this role and critics wrongly thought that he neglected emotional factors. To
correct this misconception Ellis, in 1962, changed the name of the approach to rational-
emotive therapy or (RET). In 1993, Ellis decided to change its the name once more to rational
emotive behaviour therapy (REBT) in response to critics who claimed, again wrongly, that
RET neglected behaviour and was purely cognitive and emotive in nature.

In addition to owing a debt to philosophers, Ellis acknowledged that he was also influenced
by theorists and practitioners who advocated the role of action in helping clients to overcome
their problems (e.g. Herzberg, 1945). Indeed, Ellis employed a number of in vivo behavioural
methods to overcome his own fears of speaking in public and approaching women. Initially,
REBT received unfavourable and even hostile responses from the field of American psycho-
therapy. Despite this, Ellis persisted to make his ideas more widely known and its popularity
in the United States increased markedly in the 1970s, when behaviour therapists became
interested in cognitive factors. The present high status of the cognitive-behavioural therapy
tradition has helped REBT to maintain its popularity. Currently, REBT is practised by thou-
sands of mental health professionals throughout the world and, as such, the legacy of Albert
Ells, who died in 2007, will be carried forward.
Until the early 1990s, training in REBT was available in Britain only on an ad hoc basis
from myself or Dr Al Raitt (now deceased). Now, two Centres of REBT offer training
courses, one under the auspices of Stephen Palmer in London and the other under the aus-
pices of Peter Trower and Jason Jones in Birmingham.
In September 1995, I established what is now called the MSc in Rational-Emotive and
Cognitive Behaviour Therapy at Goldsmiths, University of London, which is the world’s
only Masters course in this subject. This course closes in 2014.
Over the years the number of REBT therapists has steadily increased in Britain; most
belong to the Association for Rational Emotive Behaviour Therapy (AREBT), which was
formed in 1993.

REBT holds that humans are essentially hedonistic (Ellis, 1976): their major goals are both
to stay alive and to pursue happiness efficiently, that is, in a non-compulsive, but self-
interested manner – enlightened by the fact that they live in a social world. It is stressed that
people differ enormously in terms of what will bring them happiness; rational emotive behav-
iour therapists show clients not what will lead to their happiness but how they prevent them-
selves from pursuing it and how they can overcome these obstacles. Other basic concepts
implicit in REBT’s image of the person include those listed below.
2.1.1 Rationality
In REBT, ‘rational’ means primarily that which helps people to achieve their basic goals and
purposes; ‘irrational’ means primarily that which prevents them from achieving these goals and
purposes. However, ‘rational’ also means that which is flexible, non-extreme, logical and con-
sistent with reality, whereas ‘irrational’ also means that which is rigid, extreme, illogical and
inconsistent with reality. REBT holds that humans easily tend to think irrationally about matters
that are important to them, but also have the capacity to think rationally about such matters.

RATIONAL EMOTIVE BEHAVIOUR THERAPY 273
2.1.2 Human fallibility

Humans are deemed to be by nature fallible and not perfectible. They naturally make errors
and defeat themselves in the pursuit of their basic goals and purposes. However, they also
have the capacity to learn from their errors.
2.1.3 Human complexity and fluidity

Humans are seen as both enormously complex organisms who cannot legitimately be given
a single defining rating and are constantly in flux, and are encouraged to view themselves as
such.
2.1.4 Biological emphasis

Ellis (1976) argues that humans have two basic biological tendencies. First, they have a tendency
towards irrationality; they naturally tend to make themselves disturbed. Ellis (1976) makes a
number of points in support of his ‘biological hypothesis’. These include the following:
(a) Virtually all humans show evidence of major human irrationalities.

(b) Many human irrationalities actually go counter to the teachings of parents, peers and the mass media
(for example, people are rarely taught that it is good to procrastinate, yet countless do so).
(c) Humans often adopt other irrationalities after giving up former ones.
(d) Humans often go back to irrational activity even though they may have worked hard to overcome it
(Ellis, 1976).
Second, and more optimistically, humans are considered to have great potential to work to
change their biologically based irrationalities, as noted above.
2.1.5 Human activity

Humans can best achieve their basic goals by pursuing them actively. They are less likely to
be successful if they are passive or half-hearted in their endeavours.
2.1.6 Cognitive emphasis

Although emotions overlap with other psychological processes such as cognitions, sensations
and behaviours, cognitions are given special emphasis in REBT theory. The most efficient way
of effecting lasting emotional and behaviour change is for humans to change their philoso-
phies. Two types of cognition are distinguished in Ellis’s (1962) ‘ABC’ model of the emo-
tional/behavioural episode. The first type refers to the person’s inferences about events, and
includes such cognitive activities as making forecasts and guessing the intentions of others.
Inferences are hunches about reality and need to be tested out. As such they may be accurate
or inaccurate. They are placed under ‘A’ of the ABC of REBT1 since they do not fully account
1
Where ‘A’ stands for Activating event, ‘B’ for Belief and ‘C’ for the emotional/behavioural/thinking
Consequences of holding that belief.

for the person’s emotions and/or behaviours at ‘C’. The second type of cognition – beliefs – is
attitudinal in nature; such cognitions, which are placed under ‘B’ of the ABC of REBT, do
account for the person’s emotions and/or behaviours at ‘C’.
2.1.7 Constructivistic focus

Ellis (1994) argued that REBT is best seen as one of the constructivistic cognitive therapies.
In REBT, the constructivistic focus is seen in the emphasis that REBT places on the active
role that humans play in constructing their irrational beliefs and the distorted inferences,
which they frequently bring to emotional episodes.

Early on, Ellis (1962) distinguished between two types of beliefs: irrational and rational.
According to REBT theory, irrational beliefs are rigid, extreme, illogical, inconsistent with
reality and self-and other-defeating. By contrast, rational beliefs are non-absolute and non-
extreme in nature, logical, consistent with reality and self- and other-enhancing. Table 11.1
provides a summary of irrational beliefs and their rational alternatives.

According to Ellis, irrational beliefs underpin psychologically disturbed responses to life’s
actual or perceived adversities. The most common of these disturbed responses that appear
in the clinic are: anxiety, depression, guilt, shame, hurt, unhealthy anger, unhealthy jealousy
Table 11.1 Irrational and rational beliefs in REBT theory
Irrational belief Rational belief
Rigid belief Flexible belief

X must (or must not happen) I would like X to happen (or not happen), but it does not have to be
the way I want it to be
Awfulising belief Non-awfulising belief
It would be terrible if X happens (or does not It would be bad, but not terrible if X happens (or does not happen)
happen)
Discomfort intolerance belief Discomfort tolerance belief
I could not bear it if X happens (or does not happen) It would be difficult to bear if X happens (or does not happen), but I
could bear it and it would be worth it to me to do so
Depreciation belief Acceptance belief
If X happens (or does not happen) If X happens (or does not happen), it does not prove that I am no
I am no good/you are no good/life is no good good/, you are no good/life is no good.
Rather, I am a FHB1/you are a FHB, life is a complex/mixture of good
bad and neutral
1
FHB = Fallible human being

and unhealthy envy. These emotions are known in REBT theory as unhealthy negative emo-
tions in that they are negative in feeling tone and discourage people from changing adversi-
ties that can be changed and from adjusting constructively to adversities that cannot be
changed.
Ellis (1994) also argued that irrational beliefs underpin dysfunctional behaviours such as
withdrawal, procrastination, alcoholism, substance abuse and so on.
Of the four irrational beliefs listed to the left of Table 11.1, Ellis (1994) held that rigid
demands are at the very core of human disturbance and the other three irrational beliefs are
derived from these demands.

According to Ellis, rational beliefs underpin psychologically healthy responses to life’s actual
or perceived adversities. Healthy alternatives to the eight unhealthy negative emotions listed
above are: concern, sadness, remorse, disappointment, sorrow, healthy anger, healthy jeal-
ousy and healthy envy. These emotions are known in REBT theory as healthy negative emo-
tions in that they are negative in feeling tone, but encourage people to change adversities that
can be changed and to adjust constructively to adversities that cannot be changed.
Ellis (1994) also argues that rational beliefs underpin functional behaviours, such as con-
fronting life’s adversities, self-disciplined action and sensible use of alcohol.
Of the four rational beliefs listed to the right of Table 11.1, Ellis (1994) holds that flexible
beliefs (or non-dogmatic preferences) are at the very core of psychological health and the
other three rational beliefs are derived from these flexible beliefs.

REBT does not posit an elaborate theory concerning how psychological disturbance is
acquired. This follows logically from Ellis’s (1976) hypothesis that humans have a strong
biological tendency to think and act irrationally. While Ellis is clear that humans’ tendency
to make absolute demands on themselves, others and the world is biologically rooted, he
does acknowledge that environmental factors contribute to emotional disturbance and thus
encourage humans to make their biologically-based demands (Ellis, 1976). He argues that
because humans are particularly open to influence as young children, they tend to let them-
selves be over-influenced by societal teachings such as those offered by parents, peers,
teachers and the mass media (Ellis, 1994). One major reason why environmental control
continues to wield a powerful influence over most people most of the time is because they
tend not to be critical of the socialisation messages they receive. Individual differences also
play a part here. Humans vary in their suggestibility: while some humans emerge relatively
unscathed emotionally from harsh and severe childhood regimes, others emerge emotion-
ally damaged from more benign regimes. Ellis strongly believes that we, as humans, are
not disturbed simply by our experiences, rather we bring our ability to disturb ourselves to
our experiences.


While REBT does not put forward elaborate theories to explain the acquisition of psycho-
logical disturbance, it does deal more extensively with how such disturbance is perpetuated.
2.4.1 Intrapersonal factors

First, most people perpetuate their psychological disturbance precisely because of their own
theories concerning the ‘cause’ of their problems. They do not have what Ellis (1994) calls
‘REBT Insight 1’: that psychological disturbance is largely determined by the irrational
beliefs that people hold about the negative events in their lives. They tend to attribute the
‘cause’ of their problems to situations, rather than to their beliefs about these situations.
Lacking ‘Insight 1’, people are ignorant of the major determinants of their disturbance; con-
sequently they do not know what to change in order to overcome their difficulties.
Second, even when individuals see clearly that their beliefs determine their disturbance,
they may lack ‘REBT Insight 2’: that they remain upset by re-indoctrinating themselves in
the present with these beliefs. People who do see that their irrational beliefs largely determine
their disturbance tend to perpetuate such disturbance by devoting their energy to attempting
to find out why and how they first adopted such beliefs instead of using such energy to
change the currently held irrational beliefs.
Thirdly, some people who have both insights still perpetuate their disturbance because they
lack ‘REBT Insight 3’: only if we consistently work and practise in the present as well as in the
future to think, feel and act against these irrational beliefs are we likely to surrender them and
make ourselves significantly less disturbed (Ellis, 1994). People who have all three insights see
clearly that just acknowledging that a belief is irrational is insufficient for change to take place.
Ellis (1994) stressed that perhaps the major reason why people fail to change is due to their
philosophy of ‘discomfort disturbance’ (or low frustration tolerance – LFT). By believing
that they must be comfortable, people will tend to avoid the discomfort that working to effect
psychological change very often involves, even though facing and enduring such short-term
discomfort will probably result in long-term benefit. Such people are operating hedonistically
from within their own frames of reference. They evaluate the tasks associated with change as
‘too uncomfortable to bear’ – certainly more painful than the psychological disturbance to
which they have achieved a fair measure of habituation. They prefer to opt for the comfort-
able but disturbance-perpetuating discomfort of their problems rather than face the ‘change-
related’ discomfort, which they rate as ‘awful’.
Ellis (1994) also noted that people often make themselves disturbed about their distur-
bances and this leads them to maintain their original disturbance. Thus, they block them-
selves from working to overcome their original psychological disturbance because they upset
themselves about having the original disturbance. Humans are often inventive in this respect –
they can make themselves anxious about their anxiety, depressed about being depressed,
guilty concerning their anger, and so on. Consequently, people often have to overcome their
meta-emotional problems (as these secondary disturbances are now called – Dryden and
Branch, 2008) before embarking on effecting change in their original problems.

Ellis (1994) observed that people sometimes experience a perceived pay-off for their psy-
chological disturbance other than the gaining of immediate obvious ease. Here such distur-
bance may be perpetuated until the perceived pay-off is dealt with, in order to minimise its
impact. However, REBT therapists stress that it is the person’s view of the pay-off that is
important in determining its impact, not the events delineated in the person’s description.
Another important way in which people perpetuate their disturbance is that their behaviour
and thinking do not support their developing rational beliefs. Thus, I may believe that I do
not have to have your approval, but if I behave towards you as if I do and if I think that very
bad things will happen if you do not approve of me then this behaviour and thinking will tend
to nullify my developing rational belief and reinforce my well established irrational belief
(i.e. ‘I must have your approval’).
2.4.2 Interpersonal and environmental mechanisms

As shown in the section of acquisition of psychological disturbance, REBT theory privileges
intrapersonal mechanisms in this arena. The same is true in the perpetuation of psychological
disturbance. Here, both interpersonal and environmental factors are deemed to be ‘A’ which
are evaluated at ‘B’ and the combined effect of this ‘A’ x ‘B’ interaction leads to the person’s
emotional/behavioural/response at ‘C’. Thus, interpersonal and environmental factors are
deemed to contribute to how the person perpetuates his/her psychological disturbance.
Basically, the more aversive these factors are the more likely it is that the person will hold
irrational beliefs about them which leads to the continuation of disturbance.
Having said this, one interpersonal mechanism worth detailing in the perpetuation process
is the ‘self-fulfilling prophecy’ (Jones, 1977). By acting according to their predictions, people
often elicit from others’ reactions, which they then interpret in such a way as to confirm their
initial self-defeating forecasts. They then disturb themselves about the resulting ‘A’s.
In conclusion, Ellis (1994) believes that humans tend naturally to perpetuate their prob-
lems and have a strong innate tendency to cling to self-defeating, habitual patterns, thereby
resisting basic change.
2.5 Change
REBT theory argues that humans can and do change without psychotherapy. First, people can
change their disturbance-creating philosophies by reading rational self-help material or talking
to people who teach them sound rational principles. I personally derived much benefit in the
1970s from reading and acting on the principles of REBT and helped myself to overcome feel-
ings of inferiority, which I experienced from my early teens. Well before that time, I heard
Michael Bentine talk on the radio about how he overcame his fear of talking in public due in
large part to his stammer. He said that he helped himself by telling himself: ‘If I stammer, I
stammer. Too bad!’ I thought this was excellent advice and because I was scared in my teens to
speak in public since I had a stammer, I undertook a similar programme of speaking in public
(behavioural exposure) while telling myself, ‘If I stammer, I stammer. Fuck it!’ (cognitive

restructuring with a strong emotive component). The conjoint use of behavioural and cognitive
techniques is frequently the hallmark of change when people (whether they are in therapy or
not) alter their disturbance-creating philosophies.
People can help themselves overcome or gain relief from their problems in a number of ways
other than changing the philosophies that underpin their psychological problems. They may
succeed at changing their distorted inferences about negative events at ‘A’ or they may put their
situation into a more positive frame. They may help themselves by learning new skills like
assertion or study skills and thereby improve their relationships with people and their perfor-
mance at college. They may leave a situation in which they experience their psychological
problems and find a new, much more favourable situation. Similarly, they may find a job or a
relationship that may help them to transform their problems into strengths. Thus, a very obses-
sive person may flourish in a job environment that values his obsessiveness.
Finally, people may help themselves by telling themselves obvious irrationalities. I might
help myself enormously if I tell myself and believe that I have a fairy godmother who will
protect me from trouble and strife or if I think that I am a wonderful person because I write
books and articles on REBT!
As this chapter shows, the most enduring psychological changes are deemed to occur when
someone changes their irrational beliefs to rational beliefs. All the other changes mentioned
tend to be more transient and dependent on the existence of favourable life conditions.
3 PRACTICE

In trying to help clients overcome their emotional difficulties and achieve their self-enhancing
goals, REBT therapists have clear and well-defined aims. In this discussion I will distinguish
between outcome goals and process goals. Outcome goals are those benefits that clients hope to
derive from the therapeutic process. Ideally, REBT therapists try to assist clients to make profound
philosophic change. These would involve clients: (a) giving up their demands on themselves, others
and the world, while sticking with their flexible beliefs; (b) refusing to rate themselves, a process
which would help them to accept themselves unconditionally; (c) refusing to give others and life
conditions a global negative evaluation; (d) refusing to rate anything as ‘awful’; and (e) increasing
their tolerance of frustration while striving to achieve their basic goals and purposes.
If therapists are successful in this basic objective, clients will be minimally prone to future
ego disturbance or discomfort disturbance. They will still experience healthy negative emo-
tions in the face of life’s adversities such as sadness, healthy anger, concern and disappoint-
ment, since they would clearly retain their desires, wishes and wants; however, they will rarely
experience unhealthy negative emotions such as depression, unhealthy anger, anxiety and guilt
since they would have largely surrendered the absolutistic ‘musts’, ‘shoulds’ and ‘oughts’
which underlie such dysfunctional emotional experiences. In achieving such profound philo-
sophic changes, clients would be well along the road towards self-actualisation.

If such ideal client goals are not possible, REBT therapists settle for less pervasive changes
in their clients. Here clients may well achieve considerable symptomatic relief and overcome
the psychological disturbance that brought them to therapy, but they will not have achieved
such profound philosophic change as to prevent the development of future psychological
disturbance. In this case, clients benefit from therapy either: (a) by making productive behav-
ioural changes which lead to improved environmental circumstances at ‘A’ in Ellis’s ‘ABC’
model; or (b) by correcting distorted inferences at ‘A’. In reality most clients achieve some
measure of philosophic change, while only a few achieve a profound philosophic change.
Process goals involve therapists engaging clients effectively in the process of therapy so
that they can be helped to achieve their outcome goals. Here Bordin’s (1979) concept of the
therapeutic alliance is helpful. There are three major components of the therapeutic alliance:
bonds, goals and tasks.
3.1.1 Effective bonds

These refer to the quality of the relationship between therapist and client that is necessary to
help clients achieve their outcome goals. REBT therapists consider that there is no one way
of developing effective bonds with clients: flexibility is the key concept here.
3.1.2 Agreement on goals

Effective REBT is usually characterised by therapists and clients working together towards
clients’ realistic and self-enhancing outcome goals. The role of therapists in this process is to
help clients distinguish between: (a) realistic and unrealistic goals; and (b) self-enhancing and
self-defeating goals. Moreover, REBT therapists help clients see that they can usually achieve
their ultimate outcome goals only by means of reaching a series of mediating goals. In addi-
tion, some REBT therapists like to set goals for each therapy session, although Ellis (1994) is
against this practice because, he argues, it forces clients to identify goals that they do not really
have. Client goals can be negotiated at three levels: ultimate outcome goals; mediating goals;
and session goals. Effective REBT therapists help their clients explicitly to see the links
between these different goals and thus help to demystify the process of therapy.
3.1.3 Agreement on tasks

REBT is most effective when therapist and client clearly acknowledge that each has tasks to
carry out in the process of therapy, clearly understand the nature of these tasks and agree to
execute their own tasks. The major tasks of REBT are: (a) to help clients see that their emo-
tional and behavioural problems have cognitive antecedents; (b) to train clients to identify
and change their irrational beliefs and distorted inferences; and (c) to teach clients that such
change is best effected by the persistent application of cognitive, imagery, emotive and
behavioural methods. The major tasks of clients are: (a) to observe their emotional and
behavioural disturbances; (b) to relate these to their cognitive determinants; and (c) to work
continually at changing their irrational beliefs and distorted inferences by employing cogni-
tive, imagery, emotive and behavioural methods.


In response to a question that I once asked Albert Ellis concerning selection criteria, he said
the following:
In regard to your question about placing people in individual, marital, family or group therapy, I usually let them
select the form of therapy they personally want to begin with. If one tries to push clients into a form of therapy
they do not want or are afraid of, this frequently will not work out. So I generally start them where they want
to start. If they begin in individual therapy and they are the kind of individuals who I think would benefit from
group, I recommend this either quickly after we begin or sometime later. People who benefit most from group
are generally those who are shy, retiring and afraid to take risks. And if I can induce them to go into a group,
they will likely benefit more from that than the less risky situation of individual therapy. On the other hand, a
few people who want to start with group but seem to be too disorganized or too disruptive, are recommended
for individual sessions until they become sufficiently organized to benefit from a group.
Most people who come for marital or family therapy actually come alone and I frequently have a few
sessions with them and then strongly recommend their mates also be included. On the other hand, some
people who come together are not able to benefit from joint sessions, since they mainly argue during
these sessions and we get nowhere. Therefore sometimes I recommend that they have individual sessions
in addition to or instead of the conjoint sessions. There are many factors, some of them unique, which
would induce me to recommend that people have individual rather than joint sessions. For example, one
of the partners in a marriage may seem to be having an affair on the side and will not be able to talk
about this in conjoint sessions and therefore I would try and see this partner individually. Or one of the
partners may very much want to continue with the marriage while the other very much wants to stop it.
Again, I would then recommend they be seen individually. I usually try to see the people I see in conjoint
sessions at least for one or a few individual sessions to discover if there are things they will say during the
individual sessions that they would refuse to bring out during the conjoint sessions.
On the whole, however, I am usually able to go along with the basic desire of any clients who want
individual, marital, family or group psychotherapy. It is only in relatively few cases that I talk them into
taking a form of therapy they are at first loath to try. (Ellis in Dryden, 1984: 14–15)
While I cannot say whether or not other REBT therapists would agree with Ellis on these
points, his views do indicate the importance that REBT theory places on individual choice.
Within individual therapy, it is important to distinguish between those who may benefit from
brief REBT and those who may require a longer period of therapy. In 1995, I published an
11-session protocol for the practice of brief REBT (Dryden, 1995). In it I outline the follow-
ing indications that a person seeking help might and might not benefit from brief REBT.
1. The person is antagonistic to the REBT view of psychological disturbance and its remediation.
2. The person disagrees with the therapeutic tasks that REBT outlines for both therapist and client. (These two
points are contra-indications for REBT (whether brief or longer-term) as a treatment modality and the person
should be referred to a different therapeutic approach that matches her views on these two issues.)
3. The person is unable to carry out the tasks of a client in brief REBT.

4. The person is at present seriously disturbed and has a long history of such disturbance. (The above two
points do not mean that the person is not a good candidate for longer-term REBT.)
5. The person seeking help and the therapist are clearly a poor therapeutic match. (In this case referral to a
different REBT therapist is in order. Brief REBT cannot yet be ruled out.)
6. The person’s problems are vague and cannot be specified even with therapist’s help. (While in this case
the person is clearly not suitable for brief REBT, she may be suitable for longer-term REBT if she can be
helped to be more concrete. If she cannot, then REBT may not be helpful for her.)
The more the person meets these criteria the less the person is suitable for brief REBT.
3.2.2 Suitability criteria
1. The person is able and willing to present her problems in a specific form and set goals that are concrete
and achievable.
2. The person’s problems are of the type that can be dealt with in 11 sessions.
3. The person is able and willing to target two problems that she wants to work on during therapy.
4. The person has understood the ABCDEs2 of REBT and has indicated that this way of conceptualising and
dealing with her problems makes sense and is potentially helpful to her.
5. The person has understood the therapist’s tasks and her own tasks in brief REBT, has indicated that REBT
seems potentially useful to her and is willing to carry out her tasks.
6. The person’s level of functioning in her everyday life is sufficiently high to enable her to carry out her tasks
both inside and outside therapy sessions.
7. There is early evidence that a good working bond can be developed between the therapist and the person
seeking help.
The more a person meets such inclusive criteria, the more suitable she or he is for brief
REBT.
It should be stressed that Ellis’s and my views on selection criteria are only suggestions
and need to be tested empirically before firm guidelines can be issued on selection criteria
for REBT in general, and as an approach to individual therapy in particular.

Unfortunately, no research studies have been carried out to determine the personal qualities
of effective REBT therapists. REBT theory does, however, put forward a number of hypoth-
eses on this topic (Ellis, 1978), but it is important to regard these as both tentative and await-
ing empirical study.
2
Where ‘A’ stands for Activating event, ‘B’ for Belief and ‘C’ for the emotional/behavioural/ thinking
Consequences of holding that belief, ‘D’ for Disputing irrational beliefs and ‘E’ for the Effects of
disputing.

3.3.1 The personal characteristics of effective REBT therapists

Effective REBT therapists tend to have little fear of failure themselves. Their personal
worth is not invested in their clients’ improvement. They do not need their clients’ love
and/or approval and are so not afraid of taking calculated risks if therapeutic impasses
occur. They tend to accept both themselves and their clients as fallible human beings
and are tolerant of their own mistakes and the irresponsible acts of their clients. They
tend to have, or persistently work towards, acquiring a philosophy of high frustration
tolerance and do not get discouraged when clients improve at a slower rate than they
desire. Effective practitioners tend to score highly on most of the criteria of positive
mental health outlined earlier in this chapter and serve as healthy role models for their
clients.
REBT strives to be scientific, empirical, anti-absolutistic and undevout in its approach to
people’s selecting and achieving their own goals (Ellis, 1978). Effective practitioners of
REBT tend to show similar traits and are definitely not mystical, anti-intellectual and
magical in their beliefs.
3.3.2 The skills shown by effective REBT therapists

Since REBT is a fairly structured form of therapy, its effective practitioners are usually com-
fortable with structure, but flexible enough to work in a less structured manner when the
situation arises. REBT practitioners tend to be intellectually, cognitively or philosophically
inclined and are attracted to REBT because the approach provides them with opportunities to
fully express this tendency.
Ellis argues that REBT should often be conducted in a strong active-directive manner;
thus, effective REBT practitioners are usually comfortable operating in this mode.
Nevertheless, they have the flexibility to modify their interpersonal style with clients so that
they provide the optimum conditions to facilitate client change.
REBT emphasises that it is important for clients to put their therapy-derived insights
into practice in their everyday lives. As a result, effective practitioners of REBT are
usually comfortable with behavioural instruction and teaching and with providing the
active prompting that clients often require if they are to follow through on homework
assignments.
REBT advocates the use of techniques in a number of different modalities (cognitive,
imagery, emotive, behavioural and interpersonal). Its effective practitioners are comfortable
with a multi-modal approach to treatment and tend not to be people who like to stick rigidly
to any one modality.
Finally, Ellis (1978) notes that some REBT therapists often modify the preferred practice
of REBT according to their own natural personality characteristics. For example, some
practise REBT in a slow-moving passive manner, do little disputing and focus therapy on
the relationship between them and their clients. Whether such modification of the preferred
practice of REBT is effective is a question awaiting empirical enquiry.


REBT practitioners strive to establish the same ‘core conditions’ as their person-centred col-
leagues, albeit in a different style (see Chapter 6, by Worrall). They, however, do not regard
such ‘core conditions’ as necessary and sufficient for therapeutic change to occur. Rather,
they regard them as often desirable for the presence of such change. While research in the
more relationship-oriented aspects of REBT is sparse, DiGiuseppe et al. (1993) did find in
one study that their clients rated REBT therapists highly on the core conditions.
Ellis (1994) has argued that it is important for REBT therapists not to be unduly warm
towards their clients, since he believes that this is counterproductive from a long-term per-
spective in that it may inappropriately reinforce clients’ approval and dependency needs.
However, other REBT therapists do try to develop a warm relationship with their clients.
Consistent with this, DiGiuseppe et al. (1993) found that Ellis was rated as being less warm
than other REBT therapists in their study.

Taking their lead from Ellis (1994), most REBT therapists tend to adopt an active-directive
style in therapy. They are active in directing their clients’ attention to the cognitive determi-
nants of their emotional and behavioural problems. While they often adopt a collaborative
style of interaction with clients who are relatively non-disturbed and non-resistant to the
therapeutic process, Ellis (2002) advocates that they be forceful and persuasive with more
disturbed and highly resistant clients. Whichever style they adopt, they strive to show that
they unconditionally accept their clients as fallible human beings and to be empathic and
genuine in the therapeutic encounter.
While an active-directive style of interaction is often preferred, this is not absolutely
favoured. What is important is for therapists to convey to clients that they are trustworthy
and knowledgeable individuals who are prepared to commit themselves fully to the task of
helping clients reach their goals. Therapists must develop the kind of relationship with
clients that the latter will, according to their idiosyncratic positions, find helpful. This
might mean that, with some clients, therapists emphasise their expertise and portray them-
selves as well-qualified individuals whose knowledge and expertise form the basis of what
social psychologists call communicator credibility. Such credibility is important to the
extent that certain clients will be more likely to listen to therapists if they stress these char-
acteristics. Other clients, however, will be more likely to listen to therapists who portray
themselves as likeable individuals. In such cases, therapists might de-emphasise their
expertise but emphasise their humanity by being prepared to disclose certain aspects of
their lives which are both relevant to clients’ problems and which stress liking as a power-
ful source of communicator credibility.
Many years ago, I saw two clients on the same day with whom I emphasised different
aspects of communicator credibility. I decided to interact with Jim, a 30-year-old bricklayer,

in a casual, ‘laid-back’ style. I encouraged him to use my first name and was prepared to
disclose some personal details because I believed, from what he had told me in an assessment
interview, that he strongly disliked ‘stuffy mind doctors who treat me as another case rather
than as a human being’. However, in the next hour with Jane, a 42-year-old unmarried fash-
ion editor, I portrayed myself as ‘Dr Dryden’ and stressed my long training and qualifications
because she had indicated, again in an assessment interview, that she strongly disliked thera-
pists who were too warm and friendly towards her; she wanted a therapist who ‘knew what
he was doing’. REBT therapists should ideally be flexible with regard to changing their style
of interaction with different clients. They should preferably come to a therapeutic decision
about which style of interaction is going to be helpful in both the short and long term with a
particular client. Furthermore, they need to recognise that the style of interaction that they
adopt may in fact be counterproductive; for instance, they should be wary of adopting an
overly friendly style of interaction with ‘histrionic’ clients, or an overly directive style with
clients whose sense of autonomy is easily threatened. No matter which style of interaction
REBT therapists may adopt with individual clients, they should be concerned, genuine and
empathic in the therapeutic encounter.

3.5.1 Assessment
Clients often begin to talk in therapy about the troublesome events in their lives (‘A’) or their
dysfunctional emotional and/or behavioural reactions (‘C’) to these events. REBT therapists
use concrete examples of ‘A’ and ‘C’ to help clients identify their irrational beliefs at ‘B’ in
the ABC model. In the assessment stage therapists particularly look to assess whether clients
are making themselves disturbed about their original disturbances as described earlier in this
chapter.
Box 11.1 Case formulation
Following Ellis’s lead, most REBT therapists don’t do a full case formulation before intervening. I have per-
haps put forward the most developed approach to using case formulation in REBT (Dryden, 1998) which I
call UPCP (‘Understanding the Person in the Context of his or her Problems’) because I dislike referring to
a person as a ‘case’. I argue that there are several factors that need to be identified when conducting a
UPCP:
•• basic information on the client and any striking initial impressions;

•• a list of the client’s problems;
•• the client’s goals for change;
•• a list of the client’s problem emotions (UNEs);

•• a list of the client’s problem critical ‘A’s (e.g. disapproval, uncertainty, failure, injustice);
•• the client’s core irrational (rigid and extreme) beliefs;
•• a list of the client’s dysfunctional behaviours;
•• the purposive nature of dysfunctional behaviours;
•• a list of the ways in which the client prevents or cuts short the experience of their problems;
•• a list of the ways in which the client compensates for problems;
•• a list of meta-emotional problems;
•• a list of the cognitive consequences of core IBs;
•• how the client expresses problems and the interpersonal responses to these expressions;
•• the client’s health and medication status;
•• a list of relevant predisposing factors;
•• predicting the client’s likely responses to therapy.
As the above shows, developing a UPCP takes time, which may be better spent helping the
client to address their problems. Thus, I do not recommend that REBT therapists carry out a
full UPCP with every client. But it should be conducted:
• when it is clear that the person has many complex problems;

• when resistance occurs in clients who have at first sight non-complex problems and where usual ways
of addressing such resistance have proven unsuccessful;
• when clients have had several unsuccessful previous attempts at therapy, particularly REBT.

The primary purpose of the major therapeutic strategies and techniques of REBT is to help clients
give up their rigid beliefs and adhere to more flexible ones. However, before change procedures
can be used, REBT therapists need to make an adequate assessment of clients’ problems.

Ellis (1994) pointed out that there are two forms of REBT – specific and general. General
REBT is synonymous with other approaches within the CBT tradition, while specific REBT
is unique in a number of important respects. As pointed out above, the major goal of specific
REBT is an ambitious one: to encourage clients to make a profound philosophic change. This
involves helping clients, as far as humanly possible, to give up their irrational beliefs and
replace them with rational (i.e. beliefs when they face adversities at ‘A’).
In specific REBT the major therapeutic strategies are designed to help clients pursue their
long-range basic goals and purposes and help them do so as effectively as possible by fully
accepting themselves and tolerating unchangeable uncomfortable life conditions. Practitioners
of specific REBT further strive to help clients obtain the skills, which they can use to prevent
the development of future disturbance.

With the majority of clients, from the first session onwards, REBT therapists are likely to
use strategies designed to effect profound philosophic change. The therapist begins therapy
with the hypothesis that this particular client may be able to achieve such change and thus
begins specific REBT, which he or she will abandon when and if he/she collects sufficient
data to reject the initial hypothesis. Ellis regularly implemented this viewpoint, based on the
notion that the client’s response to therapy is the best indicator of his/her prognosis. What
proportion of REBT therapists share and regularly implement this position is unknown.
When it is clear that the client is unable, or doesn’t wish, to achieve philosophic change,
whether on a particular issue or in general, the therapist often switches to general REBT,
using methods to effect inferential and behavioural-based change. It is worth stressing that
some clients are more receptive to re-evaluating their irrational beliefs (IBs) having been
helped to correct distorted inferences.
It is important to note that REBT therapists, if they follow Ellis’s lead, show REBT’s dis-
tinctiveness in helping clients question their IBs much earlier in the therapeutic process than
do other CBT therapists (Dryden and Branch, 2008).

(a) Cognitive change techniques Here both verbal and imagery methods are used to dis-
pute clients’ irrational beliefs. Verbal disputing involves three sub-categories. First, therapists
can help clients to discriminate clearly between their rational and irrational beliefs. Then,
while debating, therapists can ask clients a number of Socratic-type questions about their
irrational beliefs: for example, ‘Is there evidence that you must …?’ Finally, defining helps
clients to make increasingly accurate definitions in their private and public language. These
verbal disputing methods can also be used to help correct their faulty inferences.
To reinforce the rational philosophy clients can be given books to read (bibliotherapy).
They can also employ written rational self-statements, which they can refer to at various
times, and they can use REBT with others – a technique which gives clients practice at think-
ing through arguments in favour of rational beliefs.
Written homework, in forms such as those presented in Dryden (1995), is another major
cognitive technique used in REBT, as is rational-emotive imagery (REI). REI is the major
imagery technique used in REBT. Here clients get practice at changing their unhealthy nega-
tive emotions to healthy ones (‘C’) while keenly imagining the negative event at ‘A’; what
they are in fact doing is getting practice at changing their underlying philosophy at ‘B’. Some
cognitive techniques (like REI) are particularly designed to help clients move from ‘intel-
lectual’ insight (i.e. a weak conviction that their irrational beliefs are irrational and their
rational beliefs are rational) to ‘emotional’ insight (a strong conviction in those same points)
(Ellis, 1994). Others included in this category are a range of rational-irrational dialogue tech-
niques described in Dryden (1995).
(b) Emotive-evocative change techniques Such techniques are quite vivid and evocative in
nature, but are still designed to dispute clients’ irrational beliefs. REBT therapists unconditionally

accept their clients as fallible human beings even when they act poorly or obnoxiously: they thus
act as a good role model for clients. In this they judiciously employ self-disclosure, openly admit-
ting that they make errors, act badly, etc., but that they can nevertheless accept themselves.
Therapists employ humour at times in the therapeutic process, believing that clients can be helped
by not taking themselves and their problems too seriously; such humour is directed at aspects of
clients’ behaviour, never at clients themselves.
Clients are sometimes encouraged to do shame-attacking exercises in which they practise
their new philosophies of discomfort tolerance and self-acceptance while doing something
‘shameful’ but not harmful to themselves or others: examples might include asking for
chocolate in a hardware shop, and wearing odd shoes for a day. Repeating rational self-
statements in a passionate manner is often employed in conjunction with shame-attacking
exercises and also at other times.
(c) Behaviour change techniques REBT therapists can employ the whole range of cur-
rently used behavioural techniques (see Chapter 13); however, they prefer in vivo (in the
situation) rather than imaginal desensitisation. Ellis (1994) favours the use of in vivo desen-
sitisation in its ‘full exposure’ rather than its gradual form, because it offers clients greater
opportunities to change profoundly their ego and discomfort disturbance-creating philoso-
phies. This highlights the fact that behavioural methods are used primarily to effect cognitive
changes. Careful negotiation concerning homework assignments, where clients aim to put
into practice what they have learned in therapy, is advocated, and it should be realised that
clients will not always opt for full-exposure, in vivo homework. Other behavioural methods
often used in REBT include: (a) ‘stay-in-there’ activities which help clients to remain in an
uncomfortable situation for a period while tolerating feelings of chronic discomfort; (b) anti-
procrastination exercises which are designed to help clients start tasks earlier rather than
later, thus behaviourally disputing their dire need for comfort; (c) skill-training methods,
which equip clients with certain key skills in which they are lacking (social skills and asser-
tiveness training are often employed, but usually after important cognitive changes have been
effected); (d) self-reward and self-penalisation (but not, of course, self-depreciation!) which
can also be used to encourage clients to use behaviour change methods.
These are the major treatment techniques, but REBT therapists are flexible and creative
in the methods they employ, tailoring therapy to meet the client’s idiosyncratic position. A
fuller description of these and other REBT treatment techniques is to be found in Dryden
and Neenan (1995).

REBT therapists are quite ambitious in setting as their major therapeutic goal helping clients
to affect what Ellis often calls a ‘profound philosophic change’. This primarily involves cli-
ents surrendering their ‘demanding’ philosophy and replacing it with a ‘desiring’ philosophy.
In striving to achieve these changes in philosophy, such clients are helped in therapy to:

1. adhere to the idea that they manufacture and continue to manufacture their own psychological disturbance;
2. acknowledge fully that they have the ability to change such disturbance to a significant degree;
3. understand that their psychological disturbance is determined mainly by irrational beliefs;
4. identify such irrational beliefs when they disturb themselves and distinguish these from rational beliefs;
5. dispute such beliefs using the logico-empirical methods of science and replace these with their rational
alternatives (more specifically, such clients work towards unconditional self-acceptance and raising their
frustration tolerance);
6. reinforce such cognitive learning by persistently working hard in employing emotive and behavioural
methods; such clients choose to tolerate the discomfort that this may well involve because they recognise
that without acting on newly acquired insights, change will probably not be maintained;
7. acknowledge that as humans they will probably have difficulty in effecting a profound philosophic change
and will tend to backslide. Taking such factors into account, such clients re-employ and continually prac-
tise REBT’s multi-modal methods for the rest of their lives. In doing so, they learn to experiment and find
the methods that work especially well for them. They specifically recognise that forceful and dramatic
methods are powerful ways of facilitating philosophic change and readily implement these, particularly
at times when they experience difficulty in changing. (Ellis, 1994)
In helping clients achieve such profound change, effective REBT therapists are unswerving in
their unconditional acceptance of clients. They realise that the achievement of profound philo-
sophic change is an extraordinarily difficult task, and one that frequently involves many set-
backs. Consequently, while tolerating their own feelings of discomfort they dedicate themselves
to becoming a persistent and effective change agent. They: (a) identify and work to overcome
their clients’ resistances (Ellis, 2002); (b) interpret and challenge the many defences that their
clients erect against such change; (c) continually encourage, persuade and cajole their clients to
keep persisting at the hard work of changing themselves; and (d) generally experiment with a
wide variety of methods and styles to determine which work best for individual clients.
REBT therapists acknowledge that not all clients can achieve such far-reaching philosophic
change. This knowledge is usually gained from clients’ responses to the therapeutic process.
When deciding to settle for less ambitious outcome goals, REBT practitioners limit themselves
to helping clients effect: situationally based philosophic change; correct distorted inferences; and
effect behavioural changes so that they can improve negatively perceived life events. Profound
philosophic change would, of course, incorporate these three modes of change.
4 CASE EXAMPLE
4.1 The client3

Agnes, a 32-year-old single woman, referred herself to my private practice suffering from
depression. She had not found her previous two years of twice-weekly psychodynamic
therapy helpful but was reluctant to end the process because, she said, ‘I didn’t want to upset
3
To protect the client’s confidentiality, I have changed all identifying information.

my therapist.’ Agnes worked as a PA to a demanding male boss and was reluctant to leave
because he felt very reliant on her. She lived with her parents and although she wanted to get
a flat on her own, she had never managed to leave home. She had had a series of short rela-
tionships with men who, after using her sexually, left her.
4.2 The therapy

From the outset, it was clear that Agnes experienced great difficulty in caring for herself in
her relationships with men, at work and with her parents. Given her tendency to acquiesce, I
sought to develop an egalitarian therapeutic relationship by offering her choices so she could
experience doing things that were in her interests rather than mine – for example, I offered
her appointment times to suit her rather than me. Later in the process, I encouraged her to
identify aspects of the therapy that were not helpful to her to counter her effusive praise for
the work we were doing. Aware that she might become dependent on therapy, I worked with
her to have decreasing contact with me as she made progress outside therapy.

(a) Assessment At the outset, Agnes was moderately depressed according to her DASS4
scores. To focus therapy and encourage collaboration, I asked her which problem she
wanted to start with and she chose her work problem. She worked long hours in the office
and was reluctant to leave at 5.30 because she would feel guilty if her boss needed her and
she was not there. Her goal was to leave at 5.30 to socialise with friends and attend cul-
tural events on her own. I did the following ‘ABC’ assessment of a specific example of
this problem:
‘A’ = My boss will be upset with me if I leave early

‘B’ = I mustn’t upset my boss; if I do I’m a bad person
‘C’ (emotional) = Anxiety
(behavioural) = Staying late
This type of assessment was also applied to specific examples of her other problems.
(b) Formulation: core irrational beliefs and their effects As we worked on this and
Agnes’s other problems, it became clear that she held the following core irrational
beliefs:5
4
Depression Anxiety Stress Scales (Lovibond and Lovibond, 1995)
5
Irrational beliefs held across the board in relevant settings.

‘I mustn’t upset significant others; if I do then I’m bad.’

‘I need the approval of people close to me; I’m worthless if I don’t have this approval.’
Holding these core irrational beliefs had a number of effects on Agnes.
1. Behavioural effects of core irrational beliefs.
The above core irrational beliefs led Agnes to:
do what others wanted rather than what she wanted;

go out of her way to please others at the expense of her own mental and physical health;
stay silent when others used her and broke her unspoken personal boundaries.
2. Cognitive effects of core irrational beliefs.
The above core irrational beliefs impacted on Agnes’s thinking, as she tended to think that:
when she is involved and others are upset it is her fault;

she is responsible for making others happy;
putting herself first is selfish;
selflessness is a virtue.

My main strategy with Agnes was to help her develop a set of specific core rational
beliefs and encourage her to act consistently with them. This would help her get more
out of life and be more in control of her destiny with resulting beneficial effects on her
feelings.
I first helped her set goals with respect to her target problem, i.e. to leave work at 5.30
without feeling anxious or guilty. Using the above ABC assessment I then helped her ques-
tion her irrational belief: ‘I mustn’t upset my boss; if I do, I’m a bad person’ and to develop
the following alternative rational belief: ‘I would prefer it if I don’t upset my boss, but I’m
not immune from doing so, nor do I have to be immune. I’m not a bad person if I upset my
boss. Rather, I’m a fallible human being.’ I helped her consolidate this belief by acting on it,
encouraging her to leave work at 5.30 (her stipulated leaving time) twice a week at first, but
without giving her boss what she thought was an acceptable but manufactured excuse (such
as going home to look after a sick parent). After a few false starts when Agnes backed out at
the last minute – because she thought she couldn’t bear the discomfort of leaving work on
time without making an ‘acceptable’ excuse – Agnes managed to do this twice and learned:
(a) she did not need her boss’s permission; and (b) she had overestimated how badly he would
react to her leaving at 5.30.

Once Agnes had made progress about asserting herself and laying down healthy
boundaries at work, she wanted to deal with similar issues with her relationships with
men. Rather than dealing with issues from scratch, I encouraged Agnes to see how she
could generalise her work-related rational belief to the relationship context. Agnes devel-
oped her own rational belief in this arena to the effect that while it was nice to have a
man’s approval, this wasn’t all that mattered and she could accept herself in the face of
male disapproval. To strengthen her conviction in this rational belief, Agnes acted on it,
refusing to sleep with a man until ready to do so rather than when he wanted to. She
found that when she did this, she was treated with greater respect by men and was rarely
abused by them.
Buoyed by success in this area, Agnes then wanted to deal with her relationship with
her parents, which was characterised by her self-sacrifice. We first discussed the concept
of norms and I helped Agnes see that a norm of her self-sacrifice had been established and
that her parents might pressurise her to conform to the norm if she tried to break it.
Consequently, we identified a number of scenarios where Agnes’s parents would try to
make her feel guilty as a way of getting her to continue to put their interests before her
own. Having helped Agnes identify, question and change the irrational beliefs underpin-
ning her guilt feelings and related behaviour, we used rational role-play where I played
her parents and tried to make her feel guilty. She responded first internally with the
rational beliefs that she developed to counter her guilt feelings and then externally with
assertive statements. The result of this work was that after weathering difficult times with
her parents, she felt more able to live independently from them. When she ended therapy
she was actively looking to buy a flat and leave home.

I saw Agnes for 19 sessions over eight months with space between sessions increasing over
time. As noted above, during therapy Agnes became increasingly assertive with her boss, with
men she dated and subsequently with her parents. The changes she made were as follows.
(a) Core rational beliefs and their effects Agnes developed the following core rational
beliefs:6
‘I don’t want to upset significant others, but I’m not immune from doing so, nor do I have to be immune.
It’s unfortunate when this happens, but I’m not a bad person. I’m an ordinary, fallible person strug-
gling to pursue interests while helping others meet theirs.’
‘I like having the approval of people close to me, but I don’t need it. If they disapprove, I’m not worthless,
but an ordinary fallible person with good, neutral and bad points.’
Holding these core rational beliefs had a number of effects on Agnes.
6
Rational beliefs held across the board in relevant settings.

3. Behavioural effects of core rational beliefs
The above core rational beliefs led Agnes to:
do what she wanted to do as well as helping others do what they wanted, but to shift the balance to
self-care rather than other-care unless the needs of others were truly greater than her own at that
time;
please herself as well as please others whenever possible, but to look after herself more than hitherto;
speak up and assert herself when others tried to use her and break her expressed personal boundaries.
4. Cognitive effects of core rational beliefs.
The above core rational beliefs impacted on Agnes’s thinking, as she tended to think that:
when she is involved and others are upset it may be her fault, but there are a host of other factors to be
taken into consideration;
she is responsible for how she treats others, but they are largely responsible for their own happiness;
putting herself first is healthy but doesn’t preclude her putting others first at times;
self-care is a virtue.
5.1 Developments
5.1.1 Brief therapy
REBT can be practised briefly with clients with specific problems or over time with clients
experiencing more pervasive problems. A number of leading REBT therapists have written
texts on brief REBT. For example, I devised an 11 session protocol for brief REBT for which
I specified above a set of suitability and unsuitability criteria (see Dryden, 1995).

REBT theory argues that while people disturb themselves in similar ways (i.e. by holding a
set of rigid and extreme beliefs) the content of what they disturb themselves about varies
enormously by culture, gender, ethnicity and religious affiliation. While the practice of REBT
has emerged with a Western culture emphasising self-determination and autonomy, there is
no reason why it cannot be modified for use with other diverse groups that emphasise differ-
ent values. At the heart of REBT theory and practice and effective REBT therapist are flex-
ible in their use of REBT with diverse groups.


I have been practising REBT now for almost 30 years in a variety of settings and I have seen
a wide range of moderately to severely disturbed individuals who were deemed to be able to
benefit from weekly counselling or psychotherapy. While I do not have any hard data to
substantiate the point, I have found REBT to be a highly effective method of individual psy-
chotherapy with a wide range of client problems.
However, I have of course had my therapeutic failures, and I would like to outline some of
the factors that in my opinion have accounted for these. I will use Bordin’s (1979) useful
concept of the therapeutic working alliance as a framework.
5.2.1 Goals
I have generally been unsuccessful with clients who have devoutly clung to goals where
changes in other people were desired. (I have also failed to involve these others in therapy.)
I have not been able to show or to persuade these clients that they make themselves emotion-
ally disturbed and that they are advised to work to change themselves before attempting to
negotiate changes in their relationships with others. It is the devoutness of their beliefs that
seems to me to be the problem here.
5.2.2 Bonds
Unlike the majority of therapists of my acquaintance, I do not regard the relationship between
therapist and client to be the sine qua non of effective therapy. I strive to accept my clients
as fallible human beings and am prepared to work concertedly to help them overcome their
problems, but do not endeavour to form very close, warm relationships with them. In the
main, my clients do not appear to want such a relationship with me (preferring to become
close and intimate with their significant others). However, occasionally I get clients who do
wish to become (non-sexually) intimate with me. Some of these clients (who devoutly
believe they need my love) leave therapy disappointed after I have failed either to get them
to give up their dire need for love or to give them what they think they need.
5.2.3 Tasks
As Bordin (1979) has noted, every therapeutic method requires clients to fulfil various tasks
if therapy is to be successful. I outlined what these tasks are with respect to REBT earlier in
this chapter. In my experience, clients who are diligent in performing these tasks generally
have a positive therapeutic outcome with REBT, while those who steadfastly refuse to help
themselves outside therapy generally do less well or are therapeutic failures.
It may of course be that I am practising REBT ineptly and that these failures are due to my
poor skills rather than any other factor. Ellis (1983), however, published some interesting
data that tends to corroborate my own therapeutic experiences. He chose 50 of his clients who
were seen in individual and/or group REBT and were rated by him, and where appropriate

by his associate group therapist, as ‘failures’. In some ways, this group consisted of fairly
ideal REBT clients in that they were individuals of:
(1) above average or of superior intelligence (in my judgement and that of their other group therapist);
(2) who seemed really to understand RET and who were often effective (especially in group therapy) in
helping others to learn and use it; (3) who in some ways made therapeutic progress and felt that they
benefited by having RET but who still retained one or more serious presenting symptoms, such as
severe depression, acute anxiety, overwhelming hostility, or extreme lack of self-discipline; and (4) who
had at least one year of individual and/or group RET sessions, and sometimes considerably more. (Ellis,
1983: 160)
This group was compared to clients who were selected on the same four criteria but who
seemed to benefit greatly from REBT. While a complete account of this study – which, of
course, has its methodological flaws – can be found in Ellis (1983), the following results are
most pertinent:
(a) In its cognitive aspects, RET ... emphasises the persistent use of reason, logic, and the scientific method
to uproot clients’ irrational beliefs. Consequently, it ideally requires intelligence, concentration, and high-
level, consistent cognitive self-disputation and self-persuasion. These therapeutic behaviours would tend
to be disrupted or blocked by extreme disturbance, by lack of organisation, by grandiosity, by organic
disruption, and by refusal to do RET-type disputing of irrational ideas. All these characteristics proved to
be present in significantly more failures than in those clients who responded favourably to RET.
(b) RET also, to be quite successful, involves clients forcefully and emotively changing their beliefs and
actions, and their being stubbornly determined to accept responsibility for their own inappropriate feel-
ings and to vigorously work at changing these feelings. But the failure clients in this study were signifi-
cantly more angry than those who responded well to RET; more of them were severely depressed and
inactive, they were more often grandiose, and they were more frequently stubbornly resistant and rebel-
lious. All these characteristics would presumably tend to interfere with the kind of emotive processes and
changes that RET espouses.
(c) RET strongly advocates that clients, in order to improve, do in vivo activity homework assignments, delib-
erately force themselves to engage in many painful activities until they become familiar and unpainful,
and notably work and practice its multi-modal techniques. But the group of clients who signally failed in
this study showed abysmally low frustration tolerance, had serious behavioural addictions, led disorgan-
ised lives, refrained from doing their activity homework assignments, were more frequently psychotic and
generally refused to work at therapy. All these characteristics, which were found significantly more fre-
quently than were found in the clients who responded quite well to RET, would tend to interfere with the
behavioural methods of RET. (Ellis, 1983: 165)
It appears from the above analysis that the old adage of psychotherapy applies to REBT: that
clients who could most use therapy are precisely those individuals whose disturbance interferes
with their benefiting from it. At present, it is not known whether clients who ‘fail’ with REBT
are likely to benefit more from other therapies. Finally, as discussed by other contributors to this
book, the practice of REBT is limited by the poor skills of the REBT practitioner.
As I have often said: ‘REBT is easy to practise poorly.’ There is no substitute then, for
proper training and rigorous ongoing supervision in the approach.


REBT has received much criticism over the years. Originally, it was wrongly criticised for
neglecting the emotions. This was never the case, but to make this point Ellis changed the
name from Rational Therapy (RT) to Rational-Emotive Therapy (RET). Then, it was wrongly
criticised for neglecting behaviour. Again, this was never the case but again to clarify matters,
Ellis again changed the name from RET to Rational Emotive Behaviour Therapy (REBT). It
has also been criticised for advocating arguing with patients, trivialising their emotional
problems by getting them to do fatuous shame-attacking exercises and reducing all distur-
bance to the effects of rigid, absolutistic thinking. Space does not permit a full discussion of
these criticisms, which while having a grain of truth are largely based on misconceptions of
REBT and I refer the reader to Dryden and Branch (2008) for a full discussion.
5.4 Controversies
A few years before the death of Albert Ellis in 2007, the world of REBT was split asunder
following the Albert Ellis Institute’s decision to prevent Ellis from engaging in various
activities due to possible infractions of the rules pertaining to the Institute being a not for
profit organisation and concerns about him being fit to engage in his regular Institute duties.
The rifts that developed over this issue have not been healed and the development of REBT
has been hampered by this unfortunate state of affairs. It is to be hoped that both sides of the
divide will eventually come together to heal the wounds, but at present this is unlikely.
6 RESEARCH
In this section, I consider the evidence-based status of REBT in terms of REBT theory and
clinical strategies derived from the theory. For a discussion on what we still don’t know, see
Dryden et al. (2009).
6.1 The evidence-based status of REBT theory

As a specific type of cognitive appraisal, whether primary and/or secondary, irrational beliefs
(IBs) are regarded as key causal mechanisms in a number of clinical conditions such as low
frustration tolerance (involved in anger), awfulising (involved in anxiety and pain), and self-
downing, a basic element of depressed mood (e.g. David et al., 2002).
(a) A major irrational belief is demandingness, in which the impact of an activating event, such as a trau-
matic episode, on the affective and/or behavioural consequences is mediated by rigid beliefs as a pri-
mary irrational appraisal mechanism, and awfulising beliefs, discomfort intolerance beliefs and
depreciation beliefs as secondary irrational appraisal mechanisms (see David et al., 2002). In 2007

DiLorenzo et al. published a study on this issue. They researched the interrelations between IBs in engen-
dering distress among students, at the start of term and before a midterm exam. Ninety-nine students
completed the Attitudes and Beliefs Scale II (measuring IBs) and the Profile of Mood States-Short Version
(measuring distress) at the start of term (Time 1), and prior to the exam (Time 2). The four IBs above were
directly related to distress levels at both times (p <.05). However, mediation analyses revealed that the
effect of rigid beliefs on distress was mediated by awfulising beliefs, discomfort intolerance beliefs and
depreciation beliefs. Rigid beliefs might, of course, follow the other three IBs, in being endemic to the
process of re-appraisal. For instance, rigid beliefs can be endemic to the re-appraisal process (that is,
meta-cognition); as described above, the other three IBs can be secondary appraisal mechanisms
involved in the appraisal process.
(b) Irrational beliefs are regarded as cognitive vulnerability factors, i.e. they will only engender a clinical
condition in conjunction with specific stressful activating events. One can therefore hold IBs, but unless
activated by stressful activating events, one will experience no distress or maladaptive behaviours.
(c) Irrational beliefs about particular activating events generate distorted inferences and descriptions (for exam-
ple automatic thoughts, intermediate and core beliefs) about that event. Szentagotai and Freeman (2007), for
instance, showed that IBs influence the automatic thoughts, which exacerbate the depressed mood of
patients with major depression. They studied the relationship between IBs and automatic thoughts in predict-
ing distress (that is, depression in 170 patients with major depressive disorder). Although both constructs
have been hypothesised before and found to engender emotional distress in stressful situations, the relation-
ships between these two types of cognitions in predicting distress have not been properly considered in
empirical studies. Results indicate that IBs and automatic thoughts both relate to distress (specifically
depressed mood/depression), and that automatic thoughts partially mediate IBs’ impact on distress.
(d) Irrational beliefs have a particular pattern in relation to a number of clinical mood states: rigid beliefs
and discomfort intolerance beliefs for unhealthy anger; rigid beliefs and awfulising beliefs for anxiety;
rigid beliefs and depreciation beliefs (especially self-depreciation or depressed mood – see for example,
David et al., 2002).
6.2 The empirical status of REBT clinical strategies

A number of qualitative reviews to date (for example, David et al., 2005) have explored
REBT’s effectiveness and efficacy. These qualitative reviews, although mainly positive, have
also highlighted various methodological problems that need to be corrected to strengthen the
conclusion that REBT is an effective treatment.
Outcome research has become the foundation for a quantitative approach in examining
REBT’s efficacy, and for enabling meta-analyses to address a majority of the criticisms advanced
in previous REBT qualitative reviews (e.g. Lyons and Woods, 1991). Regarding outcome
research, there are two types of quantitative reviews: general – concerned with cognitive behav-
ioural psychotherapy in general; and specific – concerned specifically with REBT efficacy.
6.3 General quantitative reviews

REBT has generally rated highly in quantitative reviews of psychotherapy. For instance,
Smith and Glass (1977), one of the first psychotherapy meta-analyses, cited REBT as

establishing the second highest average effect size among ten major forms of psychother-
apy. The proportion of REBT outcome studies included in psychotherapy meta-analyses is,
however, small, and authors tend to consign all forms of cognitive-behavioural therapy into
a single category (e.g. Wampold et al., 1997). While psychotherapy meta-analyses usually
indicate that cognitive-behavioural therapy has the highest overall effect size, as REBT is
included in the general CBT category, the extent to which REBT independently contributes
to these results is unclear.
6.4 Specific quantitative reviews

REBT’s efficacy and effectiveness have been evaluated by two significant meta-analyses (Engels
et al., 1993; Lyons and Woods, 1991), which form the basis for the following summary:
(a) REBT is effective in a broad spectrum of clinical diagnoses and outcomes. Interestingly, REBT appears to
have a much stronger impact on ‘untargeted variables’, which do not seem to relate to the treatment
directly (for example physiological measures like blood pressure), than on ‘targeted variables’, which
have a direct relationship with the treatment (e.g. IBs). This implies that REBT’s effect is not due to
compliance or task-demand characteristics.
(b) Individual and group REBT are broadly similar in efficacy.
(c) REBT is as useful for clinical populations as for non-clinical, for males and females and for a broad age
range (9–70 years).
(d) More REBT sessions produce better results.
(e) The higher the level of training of the therapist generally, the better the results of the REBT intervention.
This is interesting, as most psychotherapy meta-analyses find no relationship between treatment out-
come and therapist training, and requires further study.
(f) Greater REBT effectiveness is indicated by higher-quality outcome studies.
Continuing high-quality research into REBT’s theoretical hypotheses and into the effec-
tiveness of the approach is needed if REBT is going to keep pace with the developments
of other approaches within the cognitive-behavioural tradition. For REBT is at an impor-
tant point in its history. Its development rests on the contributions of the upcoming gen-
eration who need to take over from those of the old guard who have either died or have
retired. It is my hope that they will respond with the same vibrancy and intellectual pas-
sion that REBT’s founder showed in the mid-1950s and over the course of his professional
life. If they do, then REBT will merit its inclusion in future editions of this Handbook. If
they do not, then it will not.
7 FURTHER READING
Dryden, W. (2009) Rational Emotive Behaviour Therapy: Distinctive Features. Hove, East Sussex: Routledge.
Dryden, W. and Branch, R. (2008) Fundamentals of Rational Emotive Behaviour Therapy: A Training Handbook
(2nd edn). Chichester: Wiley.

Dryden, W. and Neenan, M. (1995) Dictionary of Rational Emotive Behaviour Therapy. London: Whurr.
Ellis, A. (1994) Reason and Emotion in Psychotherapy. Revised and updated edition. New York: Birch Lane Press.
Yankura, J. and Dryden, W. (1994) Albert Ellis. London: Sage.
8 REFERENCES
Bordin, E.S. (1979) The generalizability of the psychoanalytic concept of the working alliance, Psychotherapy
Theory, Research and Practice 16: 252–60.
David, D., Schnur, J., Belloiu, A. (2002) Another search for the ‘hot’ cognition: Appraisal irrational beliefs,
attribution, and their relation to emotion. Journal of Rational-Emotive and Cognitive-Behavior Therapy 20:
93–131.
David, D., Szentagotai, A., Kallay, E., Macavei, B. (2005) A synopsis of rational-emotive behavior therapy
(REBT): Fundamental and applied research. Journal of Rational-Emotive and Cognitive-Behavior Therapy 23:
175–221.
DiGiuseppe, R., Leaf, R., Lipscott, L. (1993) The therapeutic relationship in rational-emotive therapy: some pre-
liminary data. Journal of Rational-Emotive and Cognitive-Behavior Therapy 11(4): 223–33.
DiLorenzo T.A., David, D., Montgomery, G. (2007) The interrelations between irrational cognitive processes and
distress in stressful academic settings. Personality and Individual Differences 42: 765, 776.
Dryden, W. (ed.) (1984) Individual Therapy in Britain. London. Harper & Row.
Dryden, W. (1995) Brief Rational Emotive Behaviour Therapy. Chichester: John Wiley & Sons Ltd.
Dryden, W. (1998) Understanding persons in the context of their problems: A rational emotive behaviour therapy
perspective. In M. Bruch and F.W. Bond (eds), Beyond Diagnosis: Case Formulation Approaches in CBT.
Chichester: John Wiley & Sons Ltd, pp. 43–64.
Dryden, W. and Branch, R. (2008) Fundamentals of Rational Emotive Behaviour Therapy: A Training Handbook
(2nd edn). Chichester: John Wiley & Sons Ltd.
Dryden, W. and Neenan, M. (1995) Dictionary of Rational Emotive Behaviour Therapy. London: Whurr.
Dryden, W., David, D., Ellis, A. (2009) Rational emotive behavior therapy. In K.S. Dobson (ed.), Handbook of
Cognitive-Behavioral Therapies (3rd edn). New York: Guilford, pp. 226–76.
Ellis, A. (1958) Rational psychotherapy. Journal of General Psychology 59: 35–49.
Ellis, A. (1962) Reason and Emotion in Psychotherapy. Secaucus, NJ: Lyle Stuart.
Ellis, A. (1976) The biological basis of human irrationality. Journal of Individual Psychology 32: 145–68.
Ellis, A. (1978) Personality characteristics of rational-emotive therapists and other kinds of therapists. Psychotherapy
Theory, Research and Practice 15: 329–32.
Ellis, A. (1983) Failures in rational-emotive therapy. In E.B. Foa and P.M.G. Emmelkamp (eds), Failures in Behavior
Therapy. New York: John Wiley & Sons Inc.
Ellis, A. (1994) Reason and Emotion in Psychotherapy. Revised and updated edition. New York: Birch Lane
Press.
Ellis, A. (2002) Overcoming Resistance: A Rational Emotive Behavior Therapy Integrative Approach (2nd edn). New
York: Springer.
Engels, G.I., Garnefsky, N., Diekstra, F.W. (1993) Efficacy of rational-emotive therapy: A quantitative analysis.
Journal of Consulting and Clinical Psychology 6: 1083–90.
Herzberg, A. (1945) Active Psychotherapy. New York: Grune and Stratton.
Jones, R.A. (1977) Self-fulfilling Prophecies: Social, Psychological and Physiological Effects of Expectancies.
Hillsdale, NJ: Lawrence Erlbaum.

Lovibond, S.H. and Lovibond, P.F. (1995) Manual for the Depression Anxiety Stress Scales (2nd
edn). Sydney: Psychology Foundation.
Lyons, L.C. and Woods, P.J. (1991) The efficacy of rational-emotive therapy: A quantitative review of the outcome
research. Clinical Psychology Review 11: 357–69.
Smith, M.L. and Glass, G.V. (1977) Meta-analysis of psychotherapy outcome studies. American Psychologist 32:
752–60.
Szentagotai, A. and Freeman, A. (2007) An analysis of the relationship between irrational beliefs and automatic
thoughts in predicting distress. Journal of Cognitive and Behavioral Psychotherapies 7: 1–11.
Wampold, B.E., Mondin, G.W., Moody, M., Stich, F., Benson, K., Ahn, H. (1997) A meta-analysis of outcome stud-
ies comparing bona fide psychotherapies: Empirically, ‘all must have prizes’. Psychological Bulletin 122: 203–15.

12
Compassion-Focused Therapy
Paul Gilbert and Chris Irons
Compassion Focused Therapy (CFT) was developed with and for people with chronic and
complex mental health problems associated with high levels of shame and self-criticism.
Many of these people had experienced difficult early relationships, often characterised by
abuse, neglect and a lack of emotional warmth, care and affection. Working primarily
within a CBT model, clients would say: ‘I can look at the evidence and understand logi-
cally that I’m not worthless, but I still feel like I am’, or ‘I know as a child and I was not
to blame for being abused, but I still feel like it’s my fault and I am bad.’ This phenomenon
of what we think/know versus what we feel has been described as a cognitive–emotion
mismatch, or rational emotional dissociation, and is recognised as an important difficulty
for many therapies (Stott, 2007). A key problem for many clients experiencing this is that
the emotional texture and tone of their alternative thoughts is often laced with coldness,
disappointment or anger/aggression. For example, a depressed person may generate
thoughts about the value of getting out of bed and think: ‘Lying here doesn’t really help
me, I just ruminate and feel worse. If I get up and try and do things maybe I will feel bet-
ter.’ But imagine hearing these thoughts in your mind in an angry way (a ‘get out of bed
you lazy toad, you are only making yourself worse’ sort of tone) in contrast to a genuinely
caring, supportive and encouraging tone.
CFT began with exploring the capacity to generate not only evidence based thinking and
engage in behavioural experiments and exposure, but also the ability to generate emotionally

textured self-focused feelings of support, understanding, encouragement and kindness. This

is why we call our approach ‘compassion focused therapy’, not ‘compassion therapy’,
because the elements of the therapy can be various but require attention to the emotional
textures of the interventions. So, CFT developed as a focus on:
1. understanding how the generation and experience of compassion has major impacts on threat-based
emotions, moods and traits such as depression, anxiety and paranoia;
2. understanding the blocks, fears and resistances to developing compassionate and affiliative feelings
when approaching life difficulties and relating to oneself. It turned out that affiliative emotion could be
experienced as very threatening.

CFT routes itself in scientific research (e.g. psychological, social and neurophysiologi-
cal) rather than in any single school of therapy, although is most closely associated with
cognitive behavioural therapies and the importance of generating particular kinds of
emotional experience. The image of the person in CFT is derived from evolutionary
psychology and social contextualism (Gilbert, 1989: 2012). As part of the flow of life,
humans evolved from earlier primate species with particular functional emotion systems,
motivations and mentalities. Similar to other primates, these systems orientate us to seek
out resources that are important to our survival, opportunities for reproduction and pros-
perity. Among our primary social motives are: forming attachments to close others,
group membership, seeking status, and sexual partners. Our sense of self is created from
a combination of genes we inherit plus the social circumstances that choreographed and
shaped our minds. Indeed, we now know that our phenotypes are highly plastic (Belsky
and Pluess, 2009).
We often use the example that if the therapist had been kidnapped as a three-day-old
baby into a violent drug gang, the kind of person they would have become, and the values
they would endorse, are likely to be very different to the ones they are expressing as a
therapist. One would even invite clients to think about what the therapist might be like in
terms of potential for violence and lack of compassion in this scenario. This leads to the
recognition that so much of our sense of ourselves and what goes on in our minds is not
designed by us and is not our fault; our minds are designed for us, but not by us. If we
have a depression, anxiety or personality disorder – these are not things we would ever
choose. They arise involuntarily because of the complexities of our biological mind and
the socially shaped self and are therefore examples of phenotypic variability. So, the
therapist starts with what we have in common with each other, our common humanity,
rather than trying to assess some pathological process in the patient. The patient is a
socially shaped version of whole potential of possible selves. Therapists who convey this

COMPASSION-FOCUSED THERAPY 303
often help to build a therapeutic relationship that is by nature de-shaming and collabora-
tive based on this common humanity understanding – a sense of being in the same boat as
the client.
The not your fault approach can catch a naive therapist out if they have a rather sim-
plistic view about moral process. CFT avoids moral judgements about what patients
should and should not do. So when we talk about this is ‘not your fault’ we are seeking to
create a form of enlightenment that undermines shaming and blaming (which is what CFT
was originally designed for). CFT makes clear that it may not be your fault that you have
genetic tendencies for lung cancer but if you don’t stop smoking you will get it; it may
not be your fault that you have tendencies towards violence but if you act them out people
might hit you back, you are unlikely to be loved or you will go to prison. It may not be
your fault that you have a tendency for ruminating and depression but if you keep rumi-
nating then you will stay depressed.
Our minds are very tricky with many evolved glitches in them, and operate frequently
on non-rational heuristics (Gilbert, 1998). It’s rare for people to recognise that evolution
can actually build in all kinds of disadvantages as well as advantages. This is particularly
true with the human brain. For example, about two million years ago our human ancestors
began to evolve along a line that would lead to rapid expansion of cognitive competen-
cies, and ultimately, our ability to imagine, use language and symbols to aid thinking and
reasoning. We can plan, anticipate and ruminate, communicate and share complex ideas.
We can run complex simulations in our minds and even create imaginary worlds that
could possibly exist. These cognitive competencies provide fantastic advantages in the
struggle for survival and of course give rise to science, art and many other things. But they
have a very serious disadvantage in that they can distort motivation and emotional pro-
cesses. For example, animals can be aggressive with each other but don’t build nuclear
bombs to do it.
The example we often give is: imagine a zebra running away from a lion. If they are suc-
cessful they will quickly calm down and go back to grazing. Humans, however, may spend
the rest of the day fantasising what could have happened if they had got caught; intrusive
images of being eaten alive may pass through their minds and in the middle of the night they
might wake up in a cold sweat worrying about what to do tomorrow. So the human brain can
create loops between threat-based emotions and thinking that people get stuck in and can find
very difficult to get out of. Much of cognitive therapy is, of course, based on this principle of
emotion cognition looping, but this is often linked to specific, acquired core beliefs rather
than being part of brain design itself. Helping people understand this ‘your brain is designed
to loop’ (and can easily drive us loopy!) is another step in the de-shaming and normalising
process – ‘It’s not your fault your mind goes into loops like this.’ The therapist may offer
examples of how anger drives violence and how many social groups sadly get caught up in
this because of the lack of insight into how our mind naturally creates thinking-motivation-
feeling loops. In fact this is a message we give when training people in mindfulness too. From
a CFT perspective, understanding is part of the first psychology of compassion – that of
engagement and the approach of suffering and distress, whereas taking responsibility for this

Driven, excited, vitality Content, safe, connected
Incentive/resource- Non-wanting/
focused Affiliative-focused
Wanting, pursuing,
Safeness-kindness
achieving, consuming
Activating Soothing
Threat-focused
Protection and
safety-seeking
Activating/inhibiting
Anger, anxiety, disgust
Figure 12.1 Three types of affect regulation system

Source: From P. Gilbert, The Compassionate Mind (2009), reprinted with permission from Constable & Robinson Ltd.
suffering and attempting to alleviate it – to do something different – is part of the second

psychology of compassion. We will return to this below.
The third CFT image of human beings is concerned with our basic, evolved, functional
emotional systems. Evolutionary approaches always focus on function before structure
because function is what is selected for. Panksepp (1988) posits a number of different, func-
tional emotional systems whereas CFT follows a simpler three-system model based on the
work of Depue and Morrone-Strupinsky (2005) and LeDoux (1998), and one which patients
find easy to understand. Basically, although clearly a simplified model of functional emo-
tions, we suggest three basic forms of emotion regulation system:
The threat and self-protection system: this system evolved to detect, process and respond
to threats to ourselves, our family, friends or groups we belong to. It has a variety of threat
based emotions (anger, anxiety, disgust) and behaviours (freeze, flight, fight, submission).
Cognitive systems linked to the threat system commonly work on a better safe than sorry
principle. The threat system is often easy to activate, and is highly conditionable.
The drive-seeking system: this system evolved to detect, seek and acquire advanta-
geous resources. Obvious ones are food and sexual opportunities, but for humans it can
be any number of rewards and reinforcers – especially social ones like approval and
affection. When a very major resource is acquired there can be extreme levels of activa-
tion. For example, winning £100 million on the lottery would probably cause a minor
hypomania making it difficult to sleep for a few days. So this is an energy giving and
activating system. In depression, deactivation of this system gives rise to feelings of
fatigue, low energy, lack of interest and anhedonia.

The contentment and soothing-affiliative system: organisms need to rest and recuperate, to
be in states of calmness. This is a particular state linked to an affect regulation system that
evolved in the context of non-threat satisfaction where animals are not seeking out resources
nor avoiding threats. It is linked to the parasympathetic nervous system, which is sometimes
called a ‘rest and digest’ system. The affect quality is one of calming and peaceful well-being.
Importantly, this system was adapted during the evolution of attachment so that affiliative
relationships can stimulate this system, giving a sense of calming and soothing. The attach-
ment and affiliative qualities of soothing and peaceful well-being are linked to hormones
such as oxytocin and the neurotransmitter endorphin, although the neurophysiological
mediators of all these systems are complex and interactive.
The fourth image of a human being emerges from the above. This is that human beings
have evolved into the species most in need of affiliative relationships (Cacioppo and
Patrick, 2008). Caring and affiliative relationships have become salient as physiological
and psychological regulators. It is now well known that the basic reproductive strategy of
mammals is of few offspring and high parental investment (caring behaviour). The infant
is orientated to stay close to the mother, and the mother is motivated to provide sources of
food and warmth but also comfort and affect regulation. There is good evidence that the
quality of this relationship in early in life has a significant impact on a whole range of
processes including genetic expression (Belsky and Pluess, 2009) and neurophysiological
maturation (Cozolino, 2007). When we are distressed particularly when young we turn to
the kindness, comfort and support of others to calm down. In adult life too, when we are
stressed we turn to somebody we think loves us and their listening, empathising and emo-
tional support is often key in calming us. Feeling valued and cared about has very impor-
tant regulating effects on threat.

CFT suggests there are many routes to psychological disturbance. The first relates to an
overly active, powerful or sensitive threat system (see Figure 12.1). As discussed above, the
human threat system evolved over millions of years with the purpose of keeping us ‘safe’
from a variety of different harms. This system is built upon a ‘better safe than sorry’ princi-
ple, in which the brain functions on a rule akin to ‘we can have lunch many times, but we
can only be lunch once’. But this principle relates to many threats. For example in pre-
modern times individuals who made mistakes in their balance, fell and broke bones and
became incapacitated, were vulnerable to predation and could get infections and die quite
quickly. Individuals who got shunned, rejected or attacked didn’t last long. Thus, the system
is designed to prioritise safety, and therefore is biased to process threat signals and react to
them as quickly as possible.
But like all systems there are adaptive ranges linked to the triggers, frequency, intensity
and duration of threat-based responses. Individuals can have threat detection systems ‘set’ too

high or low, and may experience panic level anxiety rather than apprehension. For some
people, this system is triggered too frequently (e.g. in worry), can be activated for a pro-
longed period (general anxiety disorder), can be at high detection and response to things
linked to the conditioning and body memory of threats (PTSD), and can respond too power-
fully (e.g. panic attacks). Whilst the threat system has particular emotional (anger, anxiety,
disgust) and behavioural (fight, flight, submission) responses, it also impacts on our cogni-
tions. Thus, whilst CBT may refer to certain thinking styles (e.g. black and white, overgen-
eralising) as ‘errors’ or ‘distortions’, CFT views these as manifestations of better safe than
sorry processing, in which our thoughts become understandably biased to quickly, crudely
and automatically prioritise threat detection and safety seeking. Once again because CFT is
also focused on problems of shame and self-criticism, it is essential to avoid any language
could be seen as blaming and shaming.
CFT also highlights that from a young age the threat system has priority in developing
safety strategies for living. For example, children who grow up in abusive homes may
develop safety strategies of avoidance of conflict, inhibited assertive behaviour, suppres-
sion of anger and excessive appeasing behaviour. These are submissive strategies that can
be adaptive in the context of hostile environments – but if they are carried through into
later life they can cause serious problems particularly in developing genuinely affiliative
relationships. However, it’s important that the client recognises the protective adaptive
value of safety strategies – this is called function analysis of early safety strategies -and
again, CFT doesn’t just see these as maladaptive because that’s a language that is not
helpful to shame prone patients. Function analysis is crucial – which in this case is of
threat-based processing.
In contrast to the anxiety and anger-based difficulties, the depressions involve threat
processing but in addition there is a change in positive affect. Typically depressed people
lose feelings of drive and motivation (drive system) but also feelings of affiliation and con-
nectedness (soothing/affiliative system). There are a range of models explaining the evolu-
tionary context in which downgrading of positive affect could be adaptive (Gilbert, 2009).
In CFT these models will be explained to the client with the focus on why ‘depression is
not your fault’. We would also discuss biology and how depression also involves physio-
logical changes, not just a change in your thoughts – this is why it feels so bad in the body.
However, there are certain behaviours and patterns of thinking/feeling that can constantly
stimulate and down regulate positive affect (e.g. rumination, self-criticism, worry). So we
share with the patient the importance of trying to stimulate positive affect systems and get
them back online.
Another way in which the positive affect systems can become problematic is with their
over-development and functional misuse. There are a range of difficulties in which people
are highly achievement oriented and become depressed and anxious if they fail. Again,
functional analysis helps the therapist to look at how drive motives and emotions are operat-
ing to protect the patient from some kind of fear – such as loss of value in the eyes of others
or feeling meaninglessness or disconnectedness. In fact, we have termed this ‘striving to

avoid inferiority’, and research has shown that this can be associated with higher levels of
fears of rejection, hypercompetitive attitudes, feeling inferior to others, submissive behav-
iour, and symptoms of anxiety and depression. This type of insecure striving may be a com-
mon source of psychological disturbance for many people. Often, people can strive to
achieve things for what is called secondary gains – so it’s not the thing in itself but what it
is associated with. For example, striving to be seen as a ‘nice’ person, or achieve things
because then you think people will love you. In this scenario, being kind to others is not a
goal in itself, it’s what it brings you. The problem is that people may succeed in one part of
the strategy but not the other. They may indeed behave ‘nicely’ and suppress their anger and
always try to be what other people want of them – but then people still don’t like them or
treat them like a doormat. Whilst common, striving for secondary gains can often leave
people feeling defeated.
Psychological disturbances may also result from the underdevelopment or blocks to the
soothing/affiliative system. In CFT, we are keen to understand why, for some people, the
affiliative/soothing system is underdeveloped or blocked. Research has suggested that the lack
of certain early experiences (e.g. of warmth, love, kindness, appropriate, attuned and consist-
ent care), or the presence of certain experiences that have contaminated this system (e.g. the
conditioning of care with abuse or ideas of weakness) may leave this system stunted and
unable to assert it’s innate, evolved capacity to regulate threat. If this system – almost like a
muscle that has not been used much – is underdeveloped, then it may easily get fatigued when
trying to regulate threat system, or buckle under the strain of a particular distressing experi-
ence, feeling or memory.

Psychological health and well-being is found in the organisation of motivational, emo-
tional and cognitive systems. In regard to motivational systems, the ability to enjoy goals
and achievements for their own pleasures (e.g., passing an exam is a pleasure in itself
not because you think your parents are now going to love you), to be able to take joy and
interest in the world as it is, and have genuine interest in the well-being of others. There
is a lot of evidence now that a genuine caring for others is conducive to well-being. In
addition we require the flexibility and openness of the three affect systems so that no one
emotion regulation system dominates out of context. We can be fearful or angry appro-
priately, or we can take joy and pleasure in achieving things, but importantly, we can also
regulate our emotions with kindness and social affiliation. We develop increasing appre-
ciation of just how interdependent we all are and how evolution has built into our brains
a whole range of systems that respond kindness and create positive affect. In CFT we
would contextualise psychological well-being in the research that shows that feeling
loved, valued and wanted (in contrast to feeling unloved unvalued or rejected) and being
loving, valuing contributing and caring (in contrast to feeling indifferent, anger or
hatred) is conducive to well-being.


CFT is embedded within a biopsychosocial understanding of the development of pheno-
types and their psychological disturbance (Gilbert, 1995). For example, in a major review
of environmental factors linked to parenting style and social anxiety, Brook and Schmidt
point out that ‘practices of control, overprotection, rejection, neglect, lack of warmth or
affection, anxious parenting, insensitivity, restrictiveness, social isolation, criticism, shame
tactics, behavioral rigidity and concern with the opinions of others’ (2008: 126) are all asso-
ciated with social anxiety. However of course, they are with many other conditions (Ingram
and Price, 2010). In addition, they note other key early influences such as traumas and
abuse, cultural factors and variations in gender sensitivities to such influences. Again, all of
these are not specific to social anxiety, but are general vulnerability factors. They are back-
grounds that are shaping and developing strategies for coping with potentially socially
hostile environments.

Perpetuation of psychological disturbance occurs because of various ‘loops’ that people can’t
get out of, and these can operate at different levels.

Interpersonal fears are linked to the emergence of things within us, such as overwhelming
affect, distressing memories or feeling disconnected/alone. Safety strategies here focus on
attempts to manage these inner states by rumination, worry, drug/alcohol use or even self-harm.
Many of these could also be seen as forms of experiential avoidance (Hayes, 2004). Whilst often
partially helpful in reducing distress (especially in the short term), they tend to create a set of
unintended consequences, including shame (from the use of drugs or self-harm) exhaustion
(from continually focusing on these threats via ruination and worry) and self-criticism.
Fundamentally, the initial threat one was attempting to manage does not reduce, and instead,
often becomes more pronounced.

External (interpersonal) fears focus upon concerns in the outside world, and often with how we
feel people might think, feel or behave towards us; thus, external safety strategies are commonly
linked to attempts to avoid people, or finding ways to reduce the perceived threat of others (e.g.
by ingratiating them, behaving submissively or responding with an ‘aggression first, find out
second’ policy). Again, whilst these strategies are sometimes helpful and successful (especially
in the short term), their extended use often leads to unintended consequences such as feeling like
a fraud (ingratiation), rejection (aggression) or feeling weak (submission).
In CFT, it is important to validate and normalise why both intra- and interpersonal mecha-
nisms have developed, and whilst they might be associated with unintended (perpetuating)

consequences, they were not consciously initiated knowing this. Rather, people just do the
best they can with their fears and threats, and thus, it is important to emphasise a message of
‘not your fault’ when exploring these associations.

The environments to which we are exposed have a significant impact on how psychological
processes function. There is clear evidence that increased risk of mental health problems are
linked to environments with high crime, unemployment, poverty, violence and pollution.
Environmental factors can of course be on multiple levels, from the atmosphere in a home in
which there is domestic violence, to overcrowding and poor conditions in the home (e.g. lack
of heating, place to sleep or food), sense of threat in the local area (e.g. gang culture or
prevalence of drugs), how our community or society suggests we should be or act (e.g.
heterosexual, academically successful, having many possessions) or moving more broadly to
the type of societal philosophy or economic system prevailing (e.g. meritocracies and forms
of capitalism) that can have a significant impact upon us. CFT argues strongly that we should
not de-contextualise people and believe that psychological disturbance only arises from pro-
cesses ‘inside’ people. Understanding the powerful impact of social context is a salient aspect
of this approach, and can contribute to the understanding of why current suffering and dis-
tress is ‘not their fault’, and then allow movement towards what might be helpful.
2.5 Change
In CFT we try to understand the natural process by which change occurs in environments
and ecologies. For the most part change occurs when there are opportunities to change,
where there is support and reward for change, where there is information on how to
change, opportunities to practise and develop, modelling, and commonly social support
and encouragement from valued others. This is a rather general model change but is appli-
cable to most approaches to therapy.
3 PRACTICE
3.1 Evolution and nature of compassion in CFT

Humans became a successful species because of our capacity to support and care for each other
(primarily) within small kin networks. Evolution of caring and sharing both within the parent–
child relationship and wider groups of people led to a range of competencies for caring and
affiliation that can now be seen as part of compassion. Hence, today compassion can be seen as
part of a complex set of psychological process which can loosely be defined as ‘a sensitivity to
the suffering of self and others, with a deep commitment to try to relieve it’. From a CFT per-
spective then compassion needs to be understood in terms of different psychologies: (i) the

Warmth
Warmth
SKILLS -TRAINING
Imagery
ATTRIBUTES
Attention Reasoning
Sensitivity Sympathy
Distress
Care for Compassion tolerance
well-being
Feeling Behaviour
Non-judgement Empathy
Sensory
Warmth Warmth
Figure 12.2 Attributes and skills of compassion

Source: From P. Gilbert (2009) The Compassionate Mind. With kind permission Constable & Robinson Ltd.
psychology of being sensitive to, and engaging with distress and suffering – called engagement
psychology, and (ii) the psychology of being motivated and skilled to try and alleviate and
prevent suffering. CFT distinguishes between compassion attributes that enable us to notice,
turn towards and engage with suffering rather than block out or avoid it, and compassion skills
that enable us to begin to soften, alleviate and prevent suffering. These can be represented as
interacting circles of competencies in Figure 12.2.
These circles can be used for understanding compassion that operates between people – how
we feel compassion coming into us and how we are compassionate to others – and may be an
important lens for understanding the ‘flow’ of the therapeutic relationship. The inner circle
represents the interdependent competencies and attributes for noticing and engaging with suf-
fering. We start with an underlying motivation to be caring of our well-being and to address
issues of pain and difficulty or suffering. So we can take this orientation to ourselves and to
others and we can also experience other people taking this orientation to us – that is to say we
experience them as being motivated to help us. Clearly, in clinical work, if people are in pre-
contemplation or are blocked on motivation this can be the first point of work – even encourag-
ing them to come to therapy.
Sensitivity is learning to turn towards and notice suffering and distress rather than being in
denial and avoidance. When we turn towards painful things then of course we are going to feel
them more, so as we engage with people’s suffering we may have a sympathetic reaction and
similarly when we open up to our own. As we begin to get in touch with painful memories, situ-
ations and feelings then of course we need to be able to tolerate those. This is true of the therapist
as well, otherwise they just turn into rescuers in an effort to turn off distress and may not allow
the exposure necessary for working through distress (e.g. exposure and tolerance of anxiety,

anger or sadness). As we begin to experience the distress in ourselves and others, or we begin to
experience others as being interested in our distress, then empathy becomes important. This
involves us seeking to understand and making sense of distress, rather than it just remaining
perplexing, meaningless suffering or overwhelming. There is both an intuitive and also imagi-
nary component to empathy. At the intuitive level we can simply feel into the world of the other.
However, therapeutic empathy requires us to create space in our minds and actually imagine
walking in the shoes other – as Rogers might say.
Core to a lot of CFT is the way in which we respond to our reactions. If we become anxious
or angry with something, then we might become anxious and angry with being anxious and
angry. Non-judgement therefore is about how we allow ourselves to accept, without criticis-
ing or condemning. However, non-judgement is not non-preference; it is about allowing
things to be as they are in this moment but we might work to change these in the future and
this is where alleviation and prevention (outer circle) psychology becomes important.
In CFT these attributes are extremely important for building the therapeutic relationship
and enabling the patient to approach and navigate working with what is causing them to suf-
fer. Whilst being able to engage and make sense of distress and suffering, it’s important that
there are things that can be done about it and this is where the multi-model (outer circle)
aspects of CFT skills interventions become important.
Understanding the power and regulation of attention is a central aspect of CFT. This is
because when our attention is moved on purpose it can act as a powerful activator of physi-
ological systems. Think of how an intentional focus on a sexual fantasy can stimulate the
body in a particular way. So attention to suffering (sensitivity on the inner circle) and atten-
tion to what can be helpful alleviate it (engagement in outer circle skills) helps us to focus on
what is helpful to alleviate our distress (both now and in long-term) but which is genuinely
healing rather than avoiding. Attention is important as it links to mindfulness, and we teach
people to become aware of the loops going on in our minds and to begin to stand back from
them. Sometimes we need to build capacity to experience affiliative emotion and sometimes
people are very frightened of that. Imagery (see below) can be used to help people experi-
ment and practise generating affiliative and compassionate feelings for themselves and others
and being open to compassion from others no matter how small it might be. There is increas-
ing evidence that imagery has a great impact on affect generation and change than verbal
engagement alone. Compassionate thinking can look very similar to cognitive interventions
where individuals are encouraged to stand back and observe the process of the thinking and
consider alternatives. The only difference is that we focus less on particular core beliefs or
schemas (but may still do) and much more on emotional memories, in the moment experi-
ences, and sense of self. Moreover, cognitive change must be coordinated with genuine feel-
ings that will stimulate the soothing affiliative system so that individuals actually ‘feel’ what
they are thinking. In addition, the reasoning and ‘thinking’ aspects of compassion involve
what we have discussed above which is insight into the very nature of our human minds, why
they are so tricky, and that they can get into loops which are ‘not our fault’.
Compassionate behaviour is not necessarily just doing nice or soothing things to oneself,
though it can be. Compassionate behaviour means recognising that at times we have to do things

that are difficult for us, and focusing on how we build the courage to do that. So for example
somebody with agoraphobia builds the courage to go out a little further each day; somebody with
traumatic memories builds the courage to begin to face and work on healing those memories;
someone in an abusive relationship develops the courage to leave. The concept of courage is very
important in CFT and our main suggestion is that courage will be much easier if you are able to
feel supportive, encouraging and caring voices in your head (or from others) than if you feel
isolated or are very critical and bullying to try to produce change.
Sensory focusing means that we have to pay attention to the body and there are certain
things that we can do which enable us to put ourselves into a calmer state, which will
facilitate courage and engagement. This involves breathing and various postural trainings.
Last but not least is of course a major focus on generating affiliative feelings – sometimes
this is with loving kindness meditations but not always. So if we practise learning to pay
attention to what is helpful to us, learning to think in particular ways, learning to try to engage
with things we find difficult rather than avoid them, develop courage and learning how to treat
ourselves and others with kindness – this can go a long way to the process of alleviating suf-
fering and distress. So bringing the two together, CFT involves – engagement with suffering
and distress (inner circle) and alleviation/prevention of suffering and distress (outer circle)
through multi-model skills interventions.

The aims of CFT are:
1. To develop a therapeutic relationship which facilitates guided discovery and guided practice.
2. To provide psycho-education on the core principles of CFT: the flow of life principle (gene built, functional
brains); the principle that life involves coping with tragedies, difficulties and suffering; the principle that
we are all socially created and contextualised; the nature of the different affect regulation systems and
the role that affiliative emotion has played in mammalian evolution, particularly in regard to threat regu-
lation; and the true nature of compassion.
3. To provide insight into the concept of ‘not your fault’ with psycho-education, but also through the formu-
lation that demonstrates many people’s difficulties are linked to carrying over fears from childhood that
give rise to safety strategies that embed or maintain the problem.
4. Teaching the basis of the compassionate model and how compassion becomes an agent of change.
5. Teaching the basis of compassion refocusing as a way of developing and balancing motives and emotion
regulation systems, which has an impact on self identity and a range of intentional behavioural, affective and
cognitive systems.

Whilst CFT emerged from a context of working with people with high levels self-criticism and
shame, the approach has been extended to work with a variety of mental health diagnoses,

including anxiety disorders (including PTSD), eating disorders, bipolar affective disorder,
schizophrenia, and borderline personality disorder. CFT is therefore a transdiagnostic model,
with a particular focus on threat system and problems with the soothing/affiliative system, and
therefore there are no specific disorders or symptom severity exclusion criteria. Suitability
should be assessed on an individual basis, assessing general criteria such as motivation to
engage, ability to utilise a talking approach and so forth. As with other psychological therapies,
individuals who have high levels of passive aggressiveness, are in pre-contemplation stages,
and have psychopathic or schizoid traits may be difficult to engage with in therapy, and require
careful modification of the therapy to fit their abilities.

As with other therapies, the format that therapy takes (i.e. individual, couples, group) is
linked to a thorough assessment of presenting difficulties. However, particular focus is
placed on understanding the idiosyncratic functioning of an individual’s affect regulation
systems, with a particular understanding of the types of threat/self-protection processes
occurring (forms, functions and level of activation) and functioning of the affiliative
system. It may be that for some presenting issues (e.g. eating disorders, personality dis-
order), the utility of a group based CFT intervention – even if this follows individual
sessions – may be quite important and helpful to consider. Regardless of an individual,
couple or group format, key here is to use the other people in the room (the therapist/
partner/group members) as a conduit for the client to receive compassion from and
express compassion to.

There are some key personal characteristics that are likely to make an effective CF thera-
pist, and these involve the same compassion attributes that are displayed in the inner
circle in Figure 12.2 above.
• Care for well-being: the CF therapist is orientated by the suffering of the client, with a desire to nurture,
care and help alleviate and prevent suffering. Motivated concern is an important quality here.
• Distress sensitivity: involves the therapist being attentive to the distress of their clients. Whilst this
may be obvious at some times, in fact it involves a variety of therapeutic micro-skills that tune into
what the client is saying (the actual words, but also voice tone etc.), how they are doing this (e.g.
body language, facial expressions), and what they are not saying (which may reflect the presence
of shame or affect intolerance). However, it may be that the therapists’ own difficulties (threat
system activation e.g. high anxiety or shame) that prevent distress sensitivity. Learning how to track
emotions is a skill that some therapists struggle with.
• Sympathy: the capacity to connect to the suffering of the other with feelings in oneself. These feelings may
or may not be the same that the client is experiencing, and often occur without clear or conscious attempts
at empathy.

• Distress tolerance: all of the above attributes may take a therapist powerfully into the client’s emotional
world, which may lead to a great deal of emotion and distress in the therapist themselves. Key here is for
the therapist to have distress tolerance – an ability to be with strong and distressing experiences and be
able to tolerate these feelings in themselves.
• Empathy : this involves an emotional resonance but also the ability to step back and think about, reflect
upon and understand the client’s perspective. We talk about ‘empathically bridging’ using a Rogerian
concept of imagining being in the shoes of the other. This requires the therapist to spend time imagining
being the patient and what is sitting behind their distress – not just listening to the patient.
• Non-judgement : involves the ability to stand back from and ‘hold’ one’s immediate reactions to what a
client is saying or doing in a non-judgemental and benign manner.
3.4.2 The skills shown by effective therapists.

Many of these skills overlap with the core counselling skills discussed by Rogers (1973) and
others, including accurate empathy, congruence (genuineness), positive regard and valida-
tion. The therapist will also be mindful of their therapeutic micro skills – non-verbal behav-
iour, reflection, paraphrasing/summarising, type of questions (e.g. Socratic, open/closed),
and use of pace/silence (allowing feelings space to breathe). In addition, the CF therapist will
be skilled in a range of interventions that will involve: Socratic dialoguing, guided discovery,
inference chaining, behavioural experiments, exposure, re-scripting, use of imagery use of
breathing and body postures, method acting techniques, development of personal practice
and more besides. These are part of the outer circle of compassion as shown in Figure 12.2.
As noted above, the therapist is encouraged to hold in mind the attributes and skills depicted
in Figure 12.2 in their interactions and approach to the patient.
They will also be particularly attentive and mindful of the presence, function and conse-
quence of shame and self-criticism (both in the client, but also in the therapist themselves),
and engage skills to deshame and depathologise.

CF therapists will seek to create a safe, secure and containing therapeutic relationship in
which the client can feel able to engage with their pain and suffering. The therapist seeks
to be ‘compassionately alongside’ their clients, promoting a sense of togetherness and
working as a team (the idea that ‘two minds are better than one’). Having an awareness
of their own and their clients idiosyncratic threat system profile (e.g. of shame, anxiety),
the therapist is mindful and attentive to how the therapeutic relationship itself can run into
problems (via issues of transference and countertransference), and the embracing of dif-
ficulties in the TA as opportunities to reconnect and repair ruptures. However, the CF
therapist is also aware of how their responses can become submissive, anxiety based or
rescuing in the face of a threatening client presentation, and respond with a benign author-
ity and care that helps to provide useful containing boundaries.


In CFT, the therapist adopts a flexible approach, in which the use of direction, silence, collabora-
tion and boundary setting is dependent upon understanding what might be most helpful for this
client, given their current level of threat/drive/soothing system activation. At times, it is impor-
tant to slow the pace down, allowing room for emotions, feelings and memories to ‘breathe’
through the use of compassionate voice tones, facial expressions and body posture. Key themes
in the therapeutic style are: sharing appropriate information especially what we all have in com-
mon (the nature of the tricky human brain; common humanity), thinking with patients not for
them, creating a safe environment which at times can be playful, but also focusing on the central
processes which are often about exposure to avoided emotions or situations.

3.6.1 Assessment
Assessment in CFT entails standard practices of investigating the nature of the presenting
problem, and involves assessing symptomatology, identification of risk, and appropriate-
ness for therapy. In contrast the formulation is nearly always based on a particular model.
So where assessment might be very similar for psychodynamic, CBT or CFT, the formula-
tion will be quite different.

Formulation in CFT has many similarities with formulation in CBT, in that the therapist
seeks to understand how early life experiences are related to the development of current
threats and attempts to manage these (safety strategies). It follows the model outlined in
the section on the acquisition of psychological disturbance. In particular, the CFT therapist
is interested in understanding the experiences that have shaped the threat, drive and sooth-
ing/affiliative systems. Thus, CFT formulation covers four key areas (diagrammatically
drawn out typically as four columns):
Background: This relates to key emotional experiences particularly with caregivers/par-
ents, siblings, teachers and peers that gave rise to emotional memories. So these could
include things like a critical mother, an emotionally detached and distant father, various
forms of abuse or neglect, sibling rivalry, and/or peer bullying. These experiences shape the
emotional memories of self and others, and how they orientate themselves in relationships.
Early experiences can affect people’s external fears and worries (what others will think of
them or how they will accept or reject them) and internal fears and worries (how one would
deal with the arising of certain emotions or feelings about oneself).
Current threat focused processing: The threats that people carry forward from their back-
grounds are externally focused and/or internally focused. An example of external threats might
be that others can abandon, criticise or reject you. Internal threats are linked to one’s internal
experiences, and often involve emotions and feelings (of a particular emotion or feeling, like

anger or loneliness, but also in the experience or expression of emotions in general), but some-
times memories and fantasies. For example abused people might be fearful of flashbacks of
trauma memory; depressed people can be anxious of getting depressed again or of their anger.
In CFT shame-based emotions and memories are a central focus.
Safety strategies: As a result of background influences and current threat sensitivities,
individuals will have (automatically) developed a variety of safety strategies to ‘defend’ and
protect against feared situations and threats. So for example, children from frightening or
critical backgrounds might be highly sensitive to negative evaluation from others and adopt
a very appeasing or submissive interpersonal style. Alternatively, they may adopt an aggres-
sive and threatening style.
Unintended consequences: The problems with safety strategies (e.g. being overly appeas-
ing or submissive, or avoidant, or overly aggressive) is that they usually don’t address the
core fear or difficulty. This creates unintended consequences whereby problems can get
worse, and may often result in the individual becoming very self-critical, ‘churning over’
events from the past (rumination) or becoming overly preoccupied with potential threatening
things in the future (worry). For example, submissive individuals tend to avoid conflicts and
feelings of anger, but can then struggle to create supportive relationships around them can be
critical for their ‘weakness and lack of assertion’; or they might not really develop a sense of
themselves or their own values and goals other than appeasing others.

The major therapeutic strategy in CFT is the development of a compassionate mind (mental-
ity) and building compassionate capacity via a number of steps:
• Encouraging an empathetic and compassionate understanding of the development and subsequent

strategies used to deal with key threats, and the unintended consequences that have arisen. This, coupled
with an increasing understanding of how our brains develop and function, may be the starting place for
an appreciation that ‘this is not my fault’.
• Developing the internal capacity to become more aware of and able to engage with unhelpful threat and
drive system processes.
• Developing greater capacity to experience positive emotions, in particular those linked with affiliation
(e.g. contentment, safeness) but also to experience drive based positive affect in a more regulated way.
Recent research has shown that the experience of positive emotions can be very difficult for many people,
and in particular, that people can feel fearful of compassion and positive affect (Gilbert et al., 2011).
• Building the desire and commitment (motivation) to alleviate distress by using a variety of trans-therapeutic,
multi-modal interventions (see Figure 12.2). These will be discussed further below.

Attention training and mindfulness: attention can be understood to be like a spotlight, illuminating what
it focuses on, so if we attend to a happy memory or unhappy memory, specific positive or negative

feelings and bodily sensations are elicited. Training people in the power of attention, the importance of
attention and awareness, and attention training including mindfulness are key skills in CFT.
Soothing breathing rhythm: practising specific forms of breathing (usually slower and
deeper than normal) have therapeutic benefits and have been used in many therapeutic
approaches both recent and old (Brown and Gerbarg, 2012). These breathing techniques are
linked to body posture techniques that focus on the sense of grounding and inner stillness.
These are different to those of relaxation, and have more in common with Tai Chi and yoga
techniques. For example the diver on the high board who stops, centres themselves, and then
dives would be an example of focusing, centring and slowing before ‘going’. The body is
alert not in a floppy relaxed state.
Imagery: imagery is used in many ways. Clients are taught what imagery is and isn’t. For
example, to those who feel they don’t experience imagery you can ask ‘What’s a bicycle?’ or
‘What did you have for breakfast?’. We explain that the way we get that information to
answer the question is through imagery. Imagery is not about trying to create Polaroid pic-
tures in the mind; rather, it is the sensory aspects that are important. Imagery can be used for
guided discovery where individuals describe images from memory. Imagery also stimulates
specific physiological systems. For example, a purposeful focus on sexual image will stimu-
late the pituitary to release hormones – here the image is acting as a prompt. Compassionate
imagery simply utilises this basic process of physiological stimulation. Imagery can be a lot
more effective in change process than verbal engagement.
Compassionate imagery: CFT teaches a variety of key compassionate imagery exercises
and can involve the idea of compassion as flow, with compassion being directed/experienced
in three directions:
• from others to self;

• from self to others;
• from self to self.
Developing an ideal compassionate other: in order to start practising the experience

(exposure to) of feelings associated with receiving compassion, this exercise involves
individuals first reflecting upon the key qualities of their personal, ideal compassionate
image (e.g. warmth, acceptance, wisdom, a deep care about the self). They then imagine
these characteristics as being personified or objectified in some way. One’s ideal com-
passionate image does not have to be human, and in fact, many people who have been
abused prefer to have an animal or inanimate object – like a tree – as their compassionate
image. During early development of the image in sessions, the therapist helps the client
to direct attention to different characteristics of the image, for example, its voice tone or
facial expressions. The person can practise bringing this image to mind when they need
to, or use the image to reflect upon themselves, others or a specific situation e.g. ‘What
would your compassionate image think and feel about this?’
Developing a compassionate self: there is increasing evidence that forming images of
the ‘self we would like to be’ and practising that is beneficial. A range of meditations and

method acting techniques are used to help people think about the value of, goals of, and
ways of developing a sense of a compassionate self. This self is rooted in the sense of
stillness, wisdom and authority with a commitment to be helpful to self and others. So,
for example, when engaging with difficult emotions or conflicts, one might first spend a
moment slowing the breath, focusing on the posture and giving space to look at the dif-
ficulty from a compassionate point of view. This imagery may be focused in two key
directions:
• Compassion flowing out (compassion to others): Here, the individual spends a short time slowing the
breath and engaging with the qualities of the compassionate self and then directs compassionate
desires and feelings towards a person or animal that they care for, with a desire and wish for them to
be happy and free of suffering. We can imagine how we would be with this person; for example, what
caring or compassionate words we would say, what the voice tone would be like (e.g. warm, gentle),
what we would like to do for the person (e.g. hug, touch, or help out in some way), or just directing
particular types of feelings (kindness, warmth) towards the person.
• Compassion flowing in (self-compassion): In this exercise, the individual engages the compassionate
self, and then directs thoughts and feelings of care, kindness and warmth, to themselves with a desire
for the self to be happy and free of suffering. This can be done in a variety of ways (e.g. expressing
it to a picture of oneself, or into the mirror) but commonly, people create an image of themselves that
can be ‘seen’ through the eyes of the compassionate self. Of all the ‘flow’ exercises, clients often find
directing compassion to themselves the most difficult one, and it is important for the therapist to be
mindful of the type of fears, blocks and resistances (FBRs) that might emerge. These will be discussed
in more detail later.
These experiential practices are designed to stimulate the soothing/affiliative system, but the
purpose is not to ‘sooth away’ unpleasant or threatening thoughts, emotions or memories, but
rather, to create affiliative affect to engage with them. CFT is not about feeling ‘nice’ or
‘warm’ (although these can be helpful in themselves). For example, if you suffer agoraphobia
it is not compassionate to stay indoors and try and soothe oneself, but rather to try and find
the strength and courage to confront the anxiety and go out. Compassionate parenting does
not involve saying yes to everything your child desires, and wrapping them up from the
potential difficulties of the world; rather, it is to have the strength to say ‘no’ and help your
child learn to experience, face and manage distress and difficulties as they emerge in the
world.
Developing compassionate skills: Once an individual has begun to develop a compas-
sionate part of themselves, a variety of skills can be used to practise, strengthen and ‘bring
compassion to the here and now’. The CF therapist can then utilise some of the following
interventions to help clients to develop skills in using their compassionate mind to cope
with their threat systems.
Working with emotions: There are many standard cognitive behavioural ways of working
with emotions that are utilised in CFT. In addition, however, we see emotions as often being
in conflict. For example, individuals can be fearful of their anger, or angry of their fear, or
struggle with allowing sadness because they think it will overwhelm them. CFT works with

ways of identifying different emotions (e.g. angry self, anxious self, sad self), exploring their
thoughts, bodily feelings, actions and memories and then helping the person explore the
relationship between these emotions. The same is done for motives. The point here is helping
people recognise that multiple processing systems are operating and can conflict with each
other. We then take the person to a compassionate self position and invite them to reflect on
the process. This enables individuals to gain insight into the multiple natures of their emo-
tions, the conflicts between their emotions, and how they can resolve them.
Working with memories: Recent developments in the use of rescripting of memories in
PTSD highlight the benefit of creating new emotional feelings to difficult, distressing mem-
ories. CFT uses this principle, and seeks to develop an alternative emotional experience by
utilising the brain’s evolved, innate capacity for regulating distress – that is, the soothing/
affiliative system. There is emerging evidence that rescripting traumatic memories via the
generation of a compassionate mind (e.g. attention, images, feelings, thoughts, behaviours)
can lead to significant improvements in levels of distress (Lee and James, 2012).
Chair work: A variety of emotion focused therapies invite participants to take up different
chairs reflecting different parts of themselves and different emotions. This is used to good
effect when working with self-criticism. In CFT we can have three (or more) chairs, such as:
the person sitting in the chair and being critical, shifting to the chair where they experience
and respond to the criticism, and then having a third chair where they take up the compas-
sionate self position and reflect on the internal argument and how to change and soften
(Gilbert and Irons, 2005).
Compassionate letter writing: CFT utilises expressive writing interventions by teaching
people how to write compassionate letters about their difficulties and struggles. These
include a variety of aspects, including empathy and understanding for one’s struggle/distress
(‘not your fault’ and an understanding of how attempts to cope may have led to unintended
consequences), a focus on what might be helpful to cope with the difficulty, and finally, what
might help to deal with these difficulties differently (alleviation) in the future. Clients, espe-
cially to start with, can feel like they have written compassionate letters, but upon reading it
with the therapist, it becomes clear that there is an undercurrent of blame, criticism, recrimi-
nations or even anger/hostility to the self for the difficulty. When first practising in session,
it can be helpful for the therapist to leave the room for five or ten minutes, to allow the client
space to write their first compassionate letter.

Broadly, the change process in CFT involves a series of steps whereby the client has:
• a greater understanding of the nature and functioning of mind, that suffering is unintended and ‘not my
fault’, and an ability to spot ‘loops’ of the mind;
• an increased capacity to engage and approach distress and suffering;
• an increased ability to use a variety of skills to alleviate that suffering.

Lack of progress in CFT: Many of the difficulties faced in CFT relate to the experience
of ‘not being able to do’ compassion. At the root of this are fears, blocks and resistances
(FBRs) to compassion. Whilst the exploration of fears around negative emotion have
been the mainstay of many psychotherapies, fewer have explored how some people can
be fearful of positive emotions. However it’s not just emotions. People can be fearful of
motivation to develop compassion, or fearful of the attention or behaviours required to
be compassionate. Not all compassionate behaviours require positive emotion. Further
exploration of fears of compassion often identifies some of the following beliefs or
experiences:
• feelings of not deserving compassion;

• feeling that if one became compassionate, this would mean ‘giving up’ their self-criticism, leaving them
lazy/selfish/arrogant/making more mistakes/weak;
• fear that becoming more compassionate would lead to feeling overwhelmed with grief or loss.
Some therapists can take resistances and fears of compassion as evidence that it is not helpful
for this client. However, working with the FBRs is often the work in CFT. This involves
exploring, using guided discovery, a function analysis of fears of compassion, and clarifica-
tion on the nature of compassion and addressing negative metacognitive beliefs (e.g. compas-
sion is soft and weak). Following this, we explore ways to help people begin to experience
and engage these fears.
4 CASE EXAMPLE
4.1 The client

David was a 49-year-old man of mixed ethnic heritage (White British and Black Caribbean)
who presented with persistent depression. He reported that ‘things were worse’ in the past six
months following the loss of his job as a technician in a laboratory. He described a sense of
being trapped and feeling lost in life; he was critical about his lack of progress, success or
happiness, and often found himself dwelling on past failures and mistakes.
4.2 The therapy

Upon meeting David, the treating therapist (C.I.) was struck by his politeness and
attempts to answer questions, but by his slow responses that involved much reflection,
but little reference to emotions or feelings (verbally or non-verbally). In terms of the
compassion circle (Figure 12.2), I felt motivated to help him (care for his well-being),
felt I was trying hard to be sensitive to signs of his distress (sensitivity) and was able to
do this with kindness and non-blame (non-judgement) and tolerate what he was sharing

with me (distress tolerance). However, I realised quickly that I was not being emotion-
ally moved by his presentation (sympathy) or feel able to imagine what his life was actu-
ally like for him or understand well the impact of events upon his current life (empathy).
I worked hard to slow down my questioning, focusing in particular on helping David to
connect with his emotions via the use of evocative imagery, bodily focus and the use of
purposeful silence to allow space for feelings to emerge. I also spent time actively imag-
ining what it would be like to be David, with his background, current distress and inter-
personal history. Over time, I began to find it easier to ‘feel’ with David, and to get a
better understanding of his perspective. So here, ‘being with’ and making specific
attempts for empathic bridging, rather than ‘doing to’, was crucial for emotional thera-
peutic connecting.

David found it difficult to recall many early memories. When he was able to, he found
it difficult to describe any specific emotions or feelings. His typical responses included
‘I can’t actually remember much’, ‘I don’t know’ or ‘Growing up was okay.’ He was
brought up predominantly by his mother, as his father was often away for long periods
with work. He described his mother as available but unresponsive, seemingly unable to
notice whether he was in distress or happy, or modify her responses to him (a ‘one size
fits all’ response to him). Moreover, she showed little enthusiasm towards him, was
rarely affectionate or warm, and he could not recall knowing how she felt about him. As
we explored his mother’s personality, it emerged that it was likely she had been
depressed herself. In contrast to his mother’s numb affect, his father could often react
in emotionally unpredictable ways, and at times with intense anger. Although he found
it difficult to describe emotions associated with his father, slowly he was able to locate
physical sensations he experienced in his body (tightness in the chest and arms, clammy
palms), which we were able to label as anxiety and fear. Subsequently, he realised this
was a feeling that he often felt in his adult life when around other people, particularly
men, and we linked this to a fear of other people’s responses being unpredictable and
(potentially) aggressive and violent.
In terms of school, David initially described this as ‘fine’, and that he had been an aca-
demically able student, but with few friends. Due to his father’s job, he had to move
schools on a number of occasions, and we postulated this might have added to his sense
of dislocation from others. Following one move to a more rural area of the country, David
was bullied and experienced racial abuse (shame and rejection), to which he recalled
attempting to stay further away from people. He described feeling ashamed about his
identity, but having no one to turn to for help or support. After a while, he stopped trying
to connect with people, and whilst his anxiety reduced somewhat, he was left feeling a
deep sense of aloneness and isolation. As we discussed these experiences, we began to
make notes together on a form like the one below, which eventually led to our formulation
of his difficulties.

Table 12.1 David’s threat-based CFT formulation
Key background Safety/protective

experiences Key fears/threats strategies Unintended consequences
Physically unwell (in pain) External: External: External:

as child, parents unaware. • Being shamed/put down by Hypervigilant – try to spot Feel exhausted always being on
Mother depressed, others. threats asap; avoid others alert. Feeling lonely and
present but not • Others’ anger/hurting if possible; submit to detached. Not getting own
emotionally; Father often physically. others and people-please needs met – ‘walked all over’
absent, unpredictably • Rejection
angry and violent. Internal: Internal:
Mixed ethnic heritage – Internal: Keep feelings and distress Emotions confusing, frightening
racism, bullied, isolated • Feeling alone. to self; Detach from and at times, explosive – can’t
by peers • Feeling worthless and feelings; blame self for keep them all in. Feel more
inadequate. perceived flaws before isolated. Starts another cycle of
• Being overwhelmed by feelings others do self-blaming and self-attacking
(esp. anger and sadness) for ‘not coping or being assertive’

I introduced the evolutionary model with a focus on ‘not your fault’ which is important for
beginning the process of opening and undermining shame. I then outlined the three basic
affect regulation systems, and explored how these systems could be ‘out of balance’. David
responded to this psycho-education well, connecting with the examples given. He was able
to see for himself that he had an overactive threat system focused on fear of being inferior
for vulnerable to attack/rejection, and would then strive to be successful or achieve things to
avoid those outcomes. He described feeling there was a ‘hole’ where he felt the soothing
system should be. David took quickly to attention training, mindfulness and soothing breath-
ing rhythm, and felt these all helped him to observe the processes of his mind and body. He
realised how tense his muscles were, and shallow his breathing was, and we equated this with
his body’s protective ‘always be on alert for threat’ mode. This understanding and gentle
experiential practice helped him to find ways of slowing down and grounding himself in his
body.
However, this initial progress quickly ran into a significant roadblock – as we began to
explore ‘compassion as flow’ and practise developing David’s ‘compassionate self’, he became
noticeably disengaged and emotionally withdrawn in sessions, and began to respond to ques-
tions with a lot of ‘I don’t know’ and failed to complete homework tasks. We formulated this
in terms of Fears, Blocks and Resistances (FBRs) to compassion. With guided discovery and
sensitive, predictive empathy, we began to understand that for David, the experiential practice
of compassion had triggered feelings of rejection, shame and ‘aloneness’. At first David was
confused about why he would feel like this in response to compassion practice. However, on
asking him to focus on these feelings and on any memories that came to mind of times in the
past he might have felt similarly, he sat, for some time with a distant look but then with sadness
and tears, and responded that he remembered feeling similar powerful sensations with his

mother as a child. This was a significant moment in our therapy; whilst it did not reduce the
fears experienced with experiential compassion practice, it did open David to having a more
empathetic, compassionate stance to his own difficulties. We were then able to approach prac-
tice in an agreed way – slowly, gradually, with ‘small steps’ and in an exposure based way. We
used multiple skills interventions here (see outer circle in Figure 12.2), with a particular focus
on behavioural experiments, letter writing and chair work to help him to learn how to be with
and alleviate his distress.

David made significant progress in therapy, and no longer met diagnostic criteria for a
depression. He still experienced short periods of feeling low, but was able to use his compas-
sionate mind to help understand and accept these feelings but also focus on what would be
helpful to him rather than ruminating. On these occasions he would use a variety of strategies
to engage with his soothing/affiliative system (his particular favourite was using Compassionate
Self, and then writing compassionate letters to himself to explore and understand the diffi-
culty). This helped him to resist the urge to engage in many of his old safety behaviours,
although if he did fall into old habits, he tried his best not to blame or criticise himself.
Crucially for David, he had begun to make changes in the way he related to his parents, and
although in the early stages, described feeling that he was ‘making up for lost time’ with them
5.1 Developments
5.1.1 Brief therapy
CFT was designed for more complex cases. To modify the therapy requires the therapist
to have a good understanding of the model and of the process of therapy, from which they
are able to tailor therapy for the individual patient. For example, for individuals who have
less disruptive or dysfunctional backgrounds the educational components can be fairly
brief and easily connected with. Explaining the basic principles of compassion as an affect
regulating process and clarifying what compassion is and isn’t is often more straightfor-
ward. Moreover, there are far less resistances to the practice of compassion and the feeling
of affiliative emotion.

CFT is a transdiagnotic model, incorporating ideas and approaches that have been influenced
by both Western and Eastern psychological, philosophical, spiritual and scientific traditions.
Moreover, it is embedded in a biopsychosocial framework, in which biological, psychologi-
cal and social factors are seen as interacting factors in leading to psychological distress and
well-being. From a CFT perspective the important point is to understand how underlying

physiological mechanisms shared across people of all backgrounds (e.g. the presence of a
threat system, the important role of affiliative positive emotions) is textured by cultural and
social experiences. At the heart of this is the need for psychotherapies to understand the link
between genotypic and phenotypic variations via learning and experience (Gilbert, 1998).
Our research in how shame operates in women from South Asian backgrounds has high-
lighted how, whilst the experience of shame is similar to that of white Western women, there
are differences (particularly related to the concept of ‘Izzat’, or reflected shame, in which
shame can be brought to another by one’s own behaviour).

As for many therapies, some people do better than others. There is no clear research evidence
yet on who does well and who does poorly in CFT but it is likely that people who are caught
in very aversive environments (e.g. those stuck in a violent, abusive relationship or environ-
ment) will struggle unless they get out of those environments. In terms of personal factors,
motivation for change is important and processes that interfere with motivation may limit the
approach. Personality factors may play a role particularly in the dimension of psychopathic.
And of course for all of us, therapy skill and timing may limit the approach.
CFT seems deceptively straightforward but in fact our experience teaching and supervising
is that it’s a lot more complicated than it seems. This is partly because it’s easy to get a sim-
plified idea of CFT that it’s just teaching people to be nice to themselves or do some ‘kind
imagery work’ and not understand that the core is cultivating the courage and strength to be
able to engage with very painful things.

An obvious limitation of this approach is a lack of evidence of effectiveness, although there
are increasing numbers of studies in the areas of eating disorders, psychosis and depression
showing promising results. However, as of yet there are no appropriate randomised con-
trolled trial (RCT). CFT is a process based therapy and like dialectical behavioural therapy
(DBT), it faces difficulties, in manualising the therapeutic process to fit criteria for RCT.
Another criticism of the approach has been the simplification of complex, multi-level neu-
rophysiological processes into the heuristic of the three affect regulation model of threat,
drive and soothing/affiliation. Whilst there is validity to this criticism, the three-circle model
was always described as a heuristic of highly complex brain systems.
5.4 Controversies
CFT focuses on all aspects of functioning such as motivation, emotion, behaviour, and cogni-
tive processes. A key controversy though is the degree to which these qualities are particularly

focused on and developed. In contrast while mindfulness may often involve loving kindness
meditation (metta), compassion is typically not viewed as a set of integrated but different pro-
cesses and abilities but rather, as something that will arise by itself as part of mindful practice.
Mindfulness was not originally developed as psychotherapy whereas CFT was. CFT argues
therefore that many of the elements of compassion need to be individually understood, deliber-
ately cultivated and FBRs identified and worked with.
There are controversies around the way in which compassion is defined and there are
controversies around the way in which compassion should be measured. For example, the
Self Compassion Scale (Neff, 2003) conflates positive and negative items into a single
score making it difficult to know whether it’s negative self-evaluation or genuine feelings
of kindness that are linked to psychopathology and change.
6 RESEARCH
In the last ten years a number of studies have shown the benefits of practising and culti-
vating compassion in self and others on a range of processes, including physiological
change, and health and well-being (Hoffmann, Grossman, and Hinton, 2011). In regard to
CFT, Gilbert and Procter (2006) reported data on a 12-week CFT group for people at a
day hospital with chronic, complex mental health problems. CFT achieved significant
reductions in depression and anxiety symptoms, two types of self criticism (self-persecution
and self-hatred), submissive behaviour, and significant increases in the ability to self-
reassure. Mayhew and Gilbert (2008) utilised elements of CFT with three people with
psychosis and voice hearing, and found a reduction in pre to post levels of interpersonal
sensitivity, depression, psychoticism, anxiety and paranoia scores.
Laithwaite et al. (2009) evaluated a pilot, CFT recovery group for people with psychosis in a
maximum security hospital in Scotland. Eighteen male participants, with diagnoses of schizo-
phrenia and bipolar affective disorder, completed the programme (in three separate groups). CFT
produced significant reductions in negative (inferior) social comparisons, shame and depression,
and improvements in self-esteem. They also found a significant reduction in the general psycho-
pathology subscale of The Positive and Negative Syndrome Scale (PANSS), and change that
approached significance for the PANSS subscales of negative symptoms and depression.
Interestingly, they found a non-significant rise in scores on the self-compassion scale.
Gale et al. (2012) explored the effects of introducing CFT into a CBT programme for people
with eating disorders, and found significant improvements on all measures, particularly for people
with bulimia. Lucre and Corten (2012) reported a pilot study looking at the feasibility, acceptabil-
ity and potential value of a 16 week, CFT group for people with personality disorder. They found
a significant reduction in shame, social comparison, self-hatred, depression symptoms, problem
behaviours, and a significant increase in self-reassurance (a measure highly associated with self-
compassion), well-being, and social functioning. Moreover, these benefits were maintained at a
one-year follow up, with non-significant trend for continued improvement.

7 FURTHER READING
Gilbert, P. (2005) Compassion: Conceptualisations, Research and Use in Psychotherapy. London: Routledge.
Gilbert, P. (2009) The Compassionate Mind. London: Constable and Robinson.
Gilbert, P. (2010) Compassion Focused Therapy: The CBT Distinctive Features Series. Hove: Routledge.
Cacioppo, J.T. and Patrick, B. 2008) Loneliness: Human Nature and the Need for Social Connection. W.W. Norton:
New York.
Cozolino, L. (2007) The Neuroscience of Human Relationships: Attachment and the Developing Brain. New York:
W.W. Norton.
8 REFERENCES
Belsky, J. and Pluess, M. (2009) Beyond diathesis stress: Differential susceptibility to environmental influences.
Psychological Bulletin 135: 885–908.
Bowlby, J. (1969) Attachment: Attachment and Loss, Vol. 1. London: Hogarth Press.
Brown, P.P. and Gerbarg, P.L. (2012) The Healing Power of the Breath. Simple Techniques to Reduce Stress and
Anxiety, Enhance Concentration, and Balance Your Emotions. Boston, MA: Shambhala Publications, Inc.
Brook, C.A. and Schmidt, L.A. (2008) Social anxiety disorder: A review of environmental risk factors,
Neuropsychiatric Disease and Treatment 4: 123–43.
Cacioppo, J.T. and Patrick, B. (2008) Loneliness: Human Nature and the Need for Social Connection. W.W. Norton:
New York.
Cozolino, L. (2007) The Neuroscience of Human Relationships: Attachment and the Developing Brain. New York:
W.W. Norton.
Depue, R.A. and Morrone-Strupinsky, J.V. (2005) A neurobehavioural model of affiliative bonding. Behavioural and
Brain Sciences 28: 313–95.
Gale, C., Gilbert, P., Read, N., Goss, K. (2012) An evaluation of the impact of introducing compassion focused
therapy to a standard treatment programme for people with eating disorders. Clinical Psychology and
Psychotherapy advance online publication DOI: 10.1002/cpp.1806.
Gilbert, P. (1989) Human Nature and Suffering. London: Lawrence Erlbaum Associates.
Gilbert, P. (1995) Biopsychosocial approaches and evolutionary theory as aids to integration in Clinical Psychology
and Psychotherapy. Clinical Psychology and Psychotherapy 2: 135–56.
Gilbert, P. (1998) The evolved basis and adaptive functions of cognitive distortions. British Journal of Medical
Gilbert, P. (2007) Evolved minds and compassion in the therapeutic relationship. In P. Gilbert and R. Leahy (eds),
The Therapeutic Relationship in the Cognitive Behavioural Psychotherapies. London: Routledge, pp. 106–42.
Gilbert, P. (2009) The Compassionate Mind. London: Constable & Robinson.
Gilbert, P. (2010) Compassion Focused Therapy: The CBT Distinctive Features Series. Hove: Routledge.
Gilbert, P. and Irons, C. (2005) Focused therapies and compassionate mind training for shame and self-attacking.
In P. Gilbert (ed.), Compassion: Conceptualisations, Research and Use in Psychotherapy. London: Routledge,
pp. 263–325.
Gilbert, P. and Procter, S. (2006) Compassionate mind training for people with high shame and self-criticism: A
pilot study of a group therapy approach. Clinical Psychology and Psychotherapy 13: 353–79.
Gilbert, P., McEwan, K., Matos, M., Rivis, A. (2011) Fears of compassion: development of three self-report meas-
ures. Psychology and Psychotherapy: Theory, Research and Practice 84: 239–55.

Greenberg, L.S., Rice, L.N., Elliott, R. (1993) Facilitating Emotional Change: The Moment-by-Moment Process. New
York: Guilford Press.
Hayes, S.C. (2004) Acceptance and Commitment Therapy, Relational Frame Theory, and the third wave of behav-
iour therapy. Behaviour Therapy 35: 639–65.
Hoffmann S.G., Grossman, P., Hinton D.E. (2011) Loving-kindness and compassion meditation: Potential for psy-
chological intervention. Clinical Psychology Review, 13: 1126–32.
Ingram, R.E and Price, J.M. (2010). Vulnerability to Psychopathology: Risk across the Lifespan. New York: Guilford.
Kim, S., Thibodeau, R., Jorgensen, R.S. (2011) Shame, guilt, and depressive symptoms: A Meta-analytic review.
Psychological Bulletin 137: 68–96.
Laithwaite, H., Gumley, A., O’Hanlon, M., Collins, P., Doyle, P., Abraham, L., Porter, S. (2009) Recovery after psy-
chosis (RAP): A compassion focused programme for individuals residing in high-security settings. Behavioural
and Cognitive Psychotherapy 37: 511–26.
LeDoux, J. (1998) The Emotional Brain. London: Weidenfeld & Nicolson.
Lee, D.A. and James, S. (2012) The Compassionate Mind Approach to Recovering from Trauma. London: Constable-
Robinson.
Lucre, K. and Corten, N. (2012) An exploration of group compassion-focused therapy for personality disorder.
Psychology and Psychotherapy: Theory, Research and Practice. DOI: 10.1111/j.2044-8341.2012.02068.x.
Mayhew, S. and Gilbert, P. (2008) Compassionate mind training with people who hear malevolent voices: A case
series report. Clinical Psychology and Psychotherapy 15: 113–38.
Neff, K.D. (2003) Development and validation of a scale to measure self-compassion. Self and Identity 2: 223–50.
Panksepp, J. (1998) Affective Neuroscience. New York: Oxford University Press.
Rogers, C. (1957) The necessary and sufficient conditions of therapeutic change. Journal of Consulting Psychology
21: 95–103.
Rogers, C.R. (1973) My philosophy of interpersonal relationships and how it grew. Journal of Humanistic
Stott, R. (2007) When the head and heart do no agree: A theoretical and clinical analysis of rational-emotional
dissociation (RED) in cognitive therapy. Journal of Cognitive Psychotherapy: An International Quarterly 21: 37–50.

13
Behavioural Activation
Pierce J. O’Carroll
Behavioural activation (BA) is an empirically supported therapy for depression

(Dimidjian et al., 2011). Its origins derive from the formulation of operant learning
principles, e.g. behaviours followed by positive reinforcement are strengthened, behav-
iours followed by punishment are weakened (Skinner, 1966). Skinner was first to
speculate that depression might result from a significant reduction in behaviour previ-
ously positively reinforced by the social environment. This basic idea laid the founda-
tion for the development of behavioural models for depression (Ferster, 1973;
Lewinsohn and Graf, 1973).
Ferster (1973) formalised a theoretical behavioural model of depression highlighting both
the role of reduced behaviours associated with positive reinforcement but also identifying
the role of increased avoidance and escape behaviours. Lewinsohn and Graf (1973) pio-
neered the development of behavioural therapy for depression, which targeted increasing
clients’ behavioural activities in their positively reinforcing physical and social environ-
ments and where necessary, facilitating increased behavioural activation by including social
skills training. Due to the central focus on increased behavioural activity, the term behav-
ioural activation has become synonymous with behavioural models of depression. Although
early therapy trials were encouraging, continued development of independent behavioural
models of depression declined. This was due largely to the increasing focus given to cognitive
models of depression.

In contrast to behavioural models, which focused on behavioural activation, cognitive

models proposed a central role for irrational and distorted negative thoughts and negative
beliefs as key for understanding depression (Beck, 1979; Ellis, 1994). Cognition was the pri-
mary causal mechanism and therefore the primary target for therapeutic change. Cognitive
therapies included behavioural activation as a component of therapy, but its role was to
facilitate cognitive change, that is, consolidate changes in negative beliefs and negative
thoughts (Beck, 1979).
Interest in behavioural models as an independent therapy resurfaced in the 1990s, stimu-
lated by the publication of a component analysis study of cognitive therapy (CT) for depres-
sion (Jacobson et al., 1996). This study compared a BA-alone condition with two versions of
CT, which also included a BA component. The unexpected finding was that the BA-alone
condition achieved equivalent outcomes to both CT conditions, also that this equivalence in
effectiveness was maintained at 2-year follow-up. Adopting the principle of parsimony, BA
advocates argued that adding CT components to therapy programmes were unnecessary when
the BA component alone achieved as good outcomes. Theoretically and therapeutically, it
refocused attention on the role of behaviour in understanding and treating depression.
This renewed an interest in the development of behavioural therapy programmes for
depression. Over the past 20 years, numerous randomised controlled trials (RCTs) have been
conducted comparing BA therapies to other psychological approaches in the treatment of
depression. Several meta-analytic studies have consistently reported strong treatment effect
sizes for BA therapy compared to no-treatment controls in the treatment of depression, also,
that BA performs as well as other psychological therapies (Cuijpers et al., 2007, 2008; Ekers
et al., 2008; Mazzucchelli et al., 2010).
There are two current manualised versions of BA therapies (Lejuez et al., 2001; Martell
et al., 2010) each has retained the original focus on increasing behavioural activation as the
main component of therapy, but each has integrated new techniques, consistent with the
behavioural model. For example, increasing focus on reducing avoidance and escape behav-
iours, using functional analysis to derive ideographic formulations, using contextual analysis
to define behavioural activation within a pragmatic context, and utilising a values framework
in identifying clients valued life goals and identifying clients valued ways of behaving. BA
models also integrate aspects of cognition, i.e. conceptualising rumination and worry as
thinking behaviour and analysing this behaviour within a BA analysis framework.

The BA model views human behaviour as determined both by its past learning history and
by reinforcers in the present natural physical and social environments. This view may suggest
an image of human behaviour that is without choice or purpose but fixed by its past and
dependent on current external physical and social environmental reinforcers. That behaviours

BEHAVIOURAL ACTIVATION 331
are not a consequence of internal mental states related to intention aimed at achieving future
goals, but are explained by what has worked in the past and whether the behaviour is rein-
forced again at the present time. Although the BA perspective holds this view, it also high-
lights an instrumental role for behaviour change, in that current behaviour-reinforcement
relationships can be modified to establish new learning, which in turn will become new
learning histories. Also, BA holds that it is possible to create changes in the natural physical
and social environments that can lead to increased sources of positive reinforcement and
reduced sources of punishment (Kanter et al., 2009).
Box 13.1 Glossary
Operant behaviour: Behaviour that acts upon and produces an effect on the environment. Normally
involving voluntary action.
Respondent behaviour: Behaviour that is a response to the environment. Normally involving involuntary
action, e.g. arousal in response to threat.
Positive reinforcement: A reward following an operant behaviour. Maintains or increases behaviour.
Punishment reinforcement: Punishment follows an operant behaviour. Decreases behaviour.
Negative reinforcement: Removal of an aversive state following an operant behaviour. Maintains or
increases behaviour. Associated with avoidance and escape behaviour.
Extinction: Operant behaviour not followed by reinforcement.
Physical and social environment: Everything.
Discriminative stimuli: Specific aspect of physical and social environment (antecedent trigger).
To understand the image of the person from a BA perspective it is necessary to refer to specific
terminology from behavioural learning theory (see Box 13.1 for glossary). The meaning of peo-
ple’s behaviour is approached through understanding the function of the behaviour within the
natural context in which it occurs, both historically and currently, i.e. what reinforcing conse-
quence followed its occurrence in the past and now. BA practitioners apply a functional analysis
to understand the meaning of behaviour. This analysis requires: (1) identifying the specific
behaviour of interest; (2) identifying the natural context in which it occurs (i.e. physical and
social environment); and (3) identifying the functional relations between the behaviour and its
antecedents and consequences in the particular context. In this analysis, discriminative stimuli
(antecedent context) that precede the behaviour are identified; also referred to as triggers.
Correspondingly, the consequences of the behaviour are identified in terms of the changes that
follow in the physical and social environment (consequent context – reinforcement).
Consequences are framed within different reinforcement categories, i.e. positive,
negative, and punishment, and will either maintain, increase or decrease the behaviour it

follows. In behavioural terms, these various relationships between Antecedents,

Behaviours and reinforcing Consequences (ABC analysis) are referred to as contingen-
cies. The ABC analysis is a key assessment tool for BA therapists. To illustrate, a person
enters a social gathering (antecedent context), sees a stranger (discriminative stimuli)
and approaches and engages in conversation (behaviour), the experience is pleasant and
relaxed (consequential context, positive reinforcement). This behaviour and its conse-
quence have occurred many times in the past, and it occurs this time primarily because
its past occurrence in the presence of similar discriminative stimuli was followed by
positive reinforcement. In a clinical illustration, a client enters a social gathering (ante-
cedent context), sees a stranger (discriminative stimuli), experiences respondent behav-
iour in the form of negative arousal (triggered by discriminative stimuli stranger), and
avoids talking to the stranger (behaviour). The avoidance behaviour partially reduces
negative arousal (consequential context, negative reinforcement). Again, this behaviour
and its reinforcing consequences have occurred many times in the past and it occurs this
time because its past occurrence was followed by negative reinforcement. In both cases
the behaviours are increased and maintained, the former involves approach the latter
avoidance and escape. In the natural physical and social environments, this process of
learning is assumed to be operative and continuous, i.e. there are countless behaviour
reinforcement contingencies occurring all the time, shaping behaviour. The BA model
provides a framework for analysing the acquisition and modification of behaviours.
BA also incorporates a contextual understanding of human behaviour (Jacobson, 1997).
Although learning principles are assumed to be universal, they are not applied in a simple
nomothetic way, i.e. simply increasing behaviour to increase pleasant experiences to reduce
depression. Adopting a formulaic application of this kind does not reference the ideographic
nature of what clients are trying to achieve in their unique, natural physical and social envi-
ronments. ‘Pleasant experiences’ need to be defined functionally by showing that behaviour
increases follow positive reinforcing consequences and not simply assumed on the basis that
pleasant events will necessarily be positively reinforcing, i.e. walking in the park may be a
pleasant activity but may not be contextually relevant for clients. This can be clarified
through a contextual functional analysis, which provides unique and ideographic formulation
for the function of clients’ behaviours and the ways in which clients’ natural physical and
social environments may need to change to increase positive reinforcement and reduce pun-
ishment. So, although general learning principles apply, BA is most effectively achieved by
reference to specific clients’ behaviour, contexts, and specific behaviour reinforcement con-
tingencies. Contextualism also emphasises the notion of pragmatism in formulating change
processes. A pragmatic criterion determines whether changes in behaviour reinforcement
contingencies or changes in natural physical and social environments bring about a desired
change for clients, i.e. reduction in depression. In this regard, contextualism is not concerned
about whether something is right or wrong but simply whether it works or does not work. If
it does not, then re-analysis and reformulation is required.
One final feature of contemporary BA models of human behaviour involves the referenc-
ing of behaviours within a values framework. This is a recent integration and is consistent

with both functional analysis and contextualism. It has been used as a strategic therapeutic
technique in other psychological therapies, for example Acceptance and Commitment
Therapy (ACT: Hayes et al., 2011). Values are assessed and used in two distinct ways. One
use involves identifying the valued life goals for clients, e.g. academic success, run a
marathon, start a family, etc. Valued goals have a future point of attainment and are
assumed to function as distant sources of positive reinforcement for clients. Although,
distant this assessment can also identify short- and medium-term stages in relation to
attaining these goals, where reinforcement is more immediate or imminent. A second use
of values involves identifying valued ways of behaving, i.e. these are qualitative character-
istics of behaviour itself, e.g. behaving honestly, bravely, considerately, fairly, etc.
However, they are not viewed as rigid commandments or rules but as valued qualities that
characterise behaviour. To frame behavioural activities to be performed in these valued
ways creates a form of positive self-reinforcement for clients about behaviour itself. Both
valued goals and valued ways of behaving will be unique for clients. The behavioural
activities of humans will generally be in the service of or will function towards attaining
valued goals in valued ways of behaving.

Psychological disturbance often occurs following dramatic and/or traumatic negative life
events, involving loss and or threat, which result in changes to clients’ immediate physical
and social environments, for example, redundancy, serious accident, relationship breakdown,
exam failure, etc. (Brown and Harris, 1978). The psychological disturbance of depression
makes sense from a BA perspective, i.e. depression is an understandable response to negative
life events because sources of positive reinforcement are significantly reduced and the ‘cop-
ing’ associated with these experiences often include increased avoidance and escape behav-
iours which further restrict clients’ engagement with their natural, positively reinforcing
physical and social environments, i.e. clients withdraw (Kanter et al., 2009).
BA theory assumes that healthy behaviours become extinguished because of reduced
positive reinforcement or because of general levels of passive inactivity; also, that discrimi-
native stimuli that trigger respondent behaviour of arousal and anxiety are increased; col-
lectively these behavioural responses are accompanied by general aversive affective states,
i.e. arousal, dysphoria. Other elements of psychological disturbance seen in depression are
also accounted for within the BA model, e.g. rumination and worry. Although normally con-
ceptualised from a cognitive perspective, in the BA model ruminative behaviour is concep-
tualised as a form of covert operant behaviour, i.e. it has antecedent and consequent factors
associated with its occurrence. Rumination is assumed to be negatively reinforced by tempo-
rarily avoiding connection with external aversive environments; also it suspends active
approach behaviours to re-engage with social environments. Although these affective and
cognitive aspects of psychological disturbance are significant in understanding depression,

the primary mechanism assumed to underlie the psychological disturbance is framed in terms
of behaviour and reinforcement contingencies.

In contrast to unhealthy psychological disturbance, from a BA perspective, psychological health
is understood to arise from behaviours associated with changes in the physical and social envi-
ronments that are positively reinforcing. Furthermore, the experience of moving towards attain-
ment of valued goals and engaging in valued ways of behaving, e.g. behaving independently,
conscientiously, fairly, etc. when engaging in behavioural task, also represent sources of posi-
tive reinforcement and would be associated with psychological health (Mazzucchelli et al.,
2010). Psychological health is predicated on the basis that sources of positive reinforcement
are: (1) accessible and available; (2) varied, multiple and diverse; and (3) stable or are regularly
present in the environment. On a day-to-day basis, the provision of accessible, available, varied
and stable sources of positive reinforcement might be conceptualised as occurring at relatively
low level, i.e. as part of clients’ day-to-day routine. Nevertheless, although routines might be
considered peripheral, in the grand scheme of things, they provide a regular structure of avail-
able, varied and stable sources of positive reinforcement for clients. It provides a form of
behaviour reinforcement ‘scaffolding’ that supports general psychological health and well-
being. Clients often aim to re-establish this level of behavioural activation as a first step towards
regaining their psychological health and the re-establishment of simple behavioural tasks can
bring about significant improvements in clients mood.

Figure 13.1 outlines the BA formulation for understanding the acquisition of depression. This
is a modified version of a model outlined in Manos et al. (2010). Psychological disturbance in
the form of depression is often precipitated by significant negative life events involving threat
or loss, which entail major changes in physical and social environments that are accompanied
by changes in levels of behavioural activity (Brown and Harris, 1978). In Figure 13.1 all psy-
chological processes are surrounded by the physical and social environment. Clients are always
embedded within a physical and social context, behaviour is always being performed in relation
to that context. The nature of this physical and social environment is changed due to threat or
loss negative life events. A key consequence is that there is a reduction in access to sources of
positive reinforcement. Therefore, the general formulation outlined in Figure 13.1 can be under-
stood as follows: first changes occur in relation to ‘Behaviour’ with decreased activation of
behaviour in general, increased avoidance, escape and ruminative behaviour, and increased
depressed behaviour. These behaviours are maintained by ‘Reinforcement’, i.e. reduced levels
of positive reinforcement (R+) because of low activity, increased negative reinforcement of
(R-) of escape, avoidance and ruminative behaviour and increased positive reinforcement (R+)
of depressed behaviour. These behaviour-reinforcement contingences are accompanied by
negative affect states, i.e. depressed mood.

General formulation
Physical and social environment
Behaviour
Reinforcement Mood
↓Activation Depression
↓R+ for healthy behaviour
↑Depressed mood ↑Avoidance and escape ↑Depressed
↑R- for avoidance and escape
behaviour symptoms
↑R+ for depressed behaviour
↑Depressed behaviour
↑Ruminative behaviour
Figure 13.1 General BA formulation for depression

Figure 13.1 also shows the mechanism for the perpetuation of depression. The dotted line
coming from ‘Behaviour’ feeds back to ‘Reinforcement’. This cycle between behaviour and
reinforcement continually feeds into ‘Mood’, i.e. experiences of negative affect or depressed
mood. Over time, this leads to increased depressive symptoms ‘Depression’ and the develop-
ment of clinical depression.

In BA, intrapersonal mechanisms are not viewed as a primary process for perpetuating
depressed mood. Nevertheless, clients commonly search for reasons for their depression
and this reason-seeking tends to focus on intrapersonal explanations, e.g. that they are
weak, that they have a biological defect, that they have low self-esteem, that they have
negative beliefs, that they lack motivation, that they lack confidence etc. From a BA per-
spective, these are viewed as explanatory fictions and that the main understanding for
clients’ depression is that their behaviour is a function of their learning history and the
behaviour reinforcement contingencies within their current physical and social environ-
ments. In BA theory, these aspects of experience are not viewed as irrelevant, unreal or
unimportant. They are acknowledged, but it is held that their assumed primary role in
causing and facilitating change in depressed mood is mistaken.

The behaviour reinforcement contingences within clients’ physical and social environ-
ments represent the main mechanisms that maintain their depression. Clients’ reduced
engagement with people who are sources of positive reinforcement, or avoidance of
people and escape from social settings (behaviours negatively reinforced) all contribute

to the maintenance of depression. Additionally, clients’ depressed behaviour can some-

times be positively reinforced by family members or friends, e.g. encouraging clients to
sleep or agreeing with clients that going out is too much or engaging clients in rumina-
tive reflection on negative past events. Over time, the behaviour of depressed clients may
affect the social interpersonal environment whereby their behaviour is experienced as
punishing or aversive by relatives and friends, leading to avoidance and escape behav-
iour by relatives and friends.

Physical environments can also acquire discriminative stimulus functions, e.g. physical
reminders of past negative experiences, being alone in a quiet room, time passing on clocks,
daylight and nighttime, seeing tasks left undone, dirty dishes, neglected laundry, neglected
self-care etc. These discriminative stimuli may trigger avoidance or escape behaviour or
engagement depressive behaviour (i.e. passivity) or rumination. Some punishing reinforce-
ment contexts of physical and social environments may be out of the direct control of clients,
people criticising or rejecting clients, exclusion or discriminatory experiences, stigmatising
behaviour on the part of others. Housing and living conditions and local social disorder may
act as sources of discriminative stimuli triggering negative arousal which in turn may lead to
avoidance and escape behaviours that are negatively reinforced. The BA model is more
explicit about the effect of these negative environmental contextual factors in maintaining
depressive behaviour than other psychological approaches, which tend to focus on internal
disorder models of depression. Some physical and social environments may have many
‘pathological’ features related to maintaining depressed behaviour. Moreover, some physical
and social environments can be modified to enhance therapeutic benefits for reducing
depressed behaviour and mood, e.g. valued work, valued social engagements, valued access
to physical activities. Both of these aspects of environment could be identified as part of a
comprehensive contextual functional analysis.
2.5 Change
The BA model holds that behaviour is changing all the time; that current depressed behaviour
represents a change from previous healthy behaviour and that future behaviour change will
also occur. Clients sometimes come to understand aspects of their current depressed behav-
iour as like new ‘bad’ habits. The idea of behavioural habit is familiar to clients and can be
used to illustrate the process of behaviour change with reference to a simpler example.
Clients are asked to consider a simple behavioural habit like ‘brushing teeth’. This is a well-
learned behaviour. It is performed because it has been positively reinforced in the past and is
positively reinforced each time in the present. It works!
Clients are asked to consider what it would be like if they decided to engage in a behaviour
modifying experiment which involved them swapping hands. They are asked to imagine what
might happen. Initially, it would seem clumsy, aversive and punishing, i.e. stabbing parts of

the mouth and gums not normally treated in that way. It would feel uncomfortable. With these
kinds of punishment contingencies, it might be expected that this attempt to acquire a new
habit is quickly extinguished and the previous positively reinforced behaviour resumed.
Nevertheless, clients are asked to imagine what if they succeeded in maintaining the change
over eight weeks, then what would it be like. Clients generally accept that the new behaviour
might be more established and less aversive although it might feel odd. Clients are asked
what might get in the way of this progress. They might say ‘there is not point or value in
changing the behaviour’. A good point!
This clearly highlights the need for a value context when planning behaviour change activ-
ity. For the sake of this example, clients are asked to assume that some value for the change
has been established. What other things might get in the way? They say they might forget!
Again, a good point. This highlights the need to make explicit schedules about what, when
and where it is supposed to happen, also to keep a record that it has happened, i.e. put it in a
diary, put a reminder sign on bathroom mirror, put toothbrush in glass on the side of the
changed hand (another reminder cue). Over time, these acquire a discriminative stimuli func-
tion to signal the behaviour required. Clients are asked if these measures would increase the
likelihood of the behaviour happening? Clients generally agree.
Going back to the initial concern, that there is no point to the task, i.e. no personal value
or benefit, clients are asked what if a family member put a £1.00 in a jar every time the task
was completed. If clients maintained the behavioural experiment for eight weeks, they could
end up with a tidy sum to buy something of value. The point of this imagination exercises is
to highlight that change is possible, but, there are understandable obstacles that can be
anticipated and addressed, and that the best chance of success is when the behavioural goal
is clear, i.e. the what, when and where, also that there are valued reasons for engaging in
behavioural change exercise in the first place.
3 PRACTICE

The central goal of BA therapy is to activate clients’ behaviour in strategic ways that will
increase their experience of positive reinforcement in their natural physical and social envi-
ronments. The principle underlying this goal is: ‘the key to changing how people feel is
helping them to change what they do’ (Martell et al., 2010: 22).
One of the most important yet challenging ideas for clients in BA therapy is that behav-
ioural change and behavioural goals trump motivational, mood and thinking goals. This
seems at odd with clients, as low motivation, low mood and negative thinking tend to be
the primary ways clients experience their depression. Although clients are aware of their
behavioural inactivity, they see this as a consequence of their low motivation, low mood
and negative thinking. Therefore, from the outset there is a presumption that behaviour is
secondary and symptomatic.

When behaviour activity tasks are initially discussed with clients, they respond with ‘If I
could do that I would not need to come here’ or ‘I cannot do that, I have tried.’ Clients justify
why they cannot engage in behavioural activities, e.g. that they do not have the ‘motivation’
to engage in the activities; or whilst their mood is low they do not ‘feel like’ doing the
activities, or because their thinking is pessimistic they ‘think there is not point’. This position
implies expectations that when the clients’ experience an increase in their motivation, an
improvement in mood and think more optimistically then they will be able to engage with the
behavioural activities. This is an example of the inside-out model of behaviour change, which
is that the inside mental constructs of motivation, mood and thinking need to change before
they can engage with outside behavioural activities that may lead to positive reinforcement
in their natural physical and social environment (Martell et al., 2010).
In contrast, BA therapy proposes an outside-in perspective as central to the process of
behavioural change and the reduction of depressive symptoms. It argues that if clients’
engage in behavioural activities within their natural physical and social environments where
there are sources of positive reinforcement (outside), this will lead to an increase in motiva-
tion, improvement in mood and a reduction in pessimistic thinking (inside). This is a central
defining principle of BA therapy, i.e. that behavioural activation is primary. One of the first
tasks for BA therapist is to socialise clients to the outside-in principle. In terms of an effective
therapy alliance, an acknowledgement and acceptance of this principle by clients is a prereq-
uisite for engagement with BA therapy (Kanter et al., 2009; Martell et al., 2010).
Goals for therapy are also considered in the context of clients’ values. Therapists aim to
formulate behavioural activity goals with reference to the valued goals and the valued ways
of behaving that clients have identified. The relationship of values to goals for therapy are
explored in two ways, first, the valued goals in broad life domains are identified, e.g. relation-
ships, work or study, socialising/play and health etc. and second the valued ways of behaving
are identified e.g. to behave courageously, honestly, intelligently etc. This framework
strengthens the context for behavioural activity tasks, in that they function as positive rein-
forcers for behaviours.

Depression is a heterogeneous disorder, with varying levels of severity and complexity
occurring in all populations. BA therapy has begun to be used across wide range of popula-
tions and settings. BA lends itself as a first-line therapy option for depression as the initial
level of intervention, increasing behavioural activities, can be formulated rapidly and sim-
ply, and may be sufficient to bring about clinically significant reductions in clients with mild
to moderate levels of depression (Veale, 2008). It is argued that BA has significant advan-
tages over other forms of psychological therapies, e.g. that it is suitable for non-responders
of CT with poor verbal ability or therapies that require high levels of psychological minded-
ness, i.e. thinking about thinking and understanding processes of belief change (Ekers et al.,
2011, 2012).

The extent of current research has not identified client groups or settings where BA inter-
ventions would be unsuitable. BA takes a primary ideographic approach in its assessment and
in personalising behavioural goals for therapy therefore, it lends itself well to addressing
diverse needs in diverse contexts. However, there will be clients who, not necessarily related
to their presentation and context, may find the approach unsuitable. As BA therapy is applied
to more diverse populations and settings it is possible that certain limitations may become
apparent. The main limitations at the present time are listed below.
1. Clients who are unable to accept a BA formulation for their depression (i.e. focused on internal
reason-seeking).
2. Clients who exhibit problems with attaining core therapy alliance conditions, i.e. feel unable to trust and
feel safe in the therapy setting, are unable to agree goals that are appropriate for BA therapy, e.g. clients
say they want to increase their self-esteem and confidence first and do not see behavioural activation
goals as relevant, and clients who do not complete agreed assessment or therapy tasks between sessions.
3. Clients who are unable to commit to regular appointments.
1. The onset and maintenance of clients’ presentation for depression closely fits the model outlined in
Figure 13.1.
2. Clients should be able to engage with therapists in initial sessions and establish generic core conditions
for an effective therapy alliance: (a) trusting relationship with therapist; (b) agreement of clear therapy
goals following completion of assessment and case formulation; and (c) the active engagement with
therapy assessment and intervention tasks.
3. The client is able to provide the necessary information for completion of diaries and self-report
questionnaires.
4. The client is able to reflect an understanding of the case formulation and how it applies to understanding
their depression.
5. The client accepts as a basis for working the outside-in model of behavioural goal setting.
6. The client engages in behavioural activation tasks between sessions.

The nature of BA requires an action-focus on the part of the therapist, encouraging clients to
increase behavioural activities in their natural physical and social environments. Because of
low levels of positive reinforcement and high levels of negative reinforcement for escape and
avoidance behaviours, therapists often have to maintain their action-focus in the face of cli-
ents’ inactivity, frustration and slow progress in achieving goals. The role of the therapist is
not unlike that of the coach, who also happens to be a competent behaviour analyst and a
competent therapist.


Personal characteristics for an effective BA therapist will include those non-specific charac-
teristics associated with positive client evaluations of therapist: i.e. validating clients’ experi-
ence, being non-judgemental, expressing warmth, genuineness and support. Characteristics
specific to BA therapist are their ability to use behavioural principles in shaping clients
behaviour in session, e.g. use of discriminative reinforcement to strengthen within session
skilled and effective interpersonal behaviours. Working with depressed clients can be chal-
lenging and frustrating when progress is slow. Therapist need to have patience and retain an
action-focused orientation on the agreed therapy goals and tasks.

As BA therapy is an action-focused structured therapy there are certain skills or competencies
that that therapist should be able to demonstrate including:
1. agenda setting and adherence to the agenda is fundamental for structuring sessions;
2. eliciting feedback from clients to ensure understanding and collaboration when planning therapy
behavioural activities;
3. effective time management, to ensure specific items are addressed during sessions;
4. eliciting appropriate information for conducting an ABC functional analysis;
5. conducting values assessment with clients;
6. socialising clients with the BA formulation of their depression and the rationale underlying BA therapy
techniques aimed at reducing depression;
7. formulating clear behavioural activity goals in collaboration with clients and set appropriate, achievable
therapy tasks to be completed between sessions;
8. reviewing and evaluating therapy work, e.g. problem solving the non-completion of behavioural activity
tasks and case reformulation when there is no reduction in depressed mood, despite completing of
behavioural tasks;
9. assessing and managing risk;
10. formulating therapy maintenance and relapse prevention plans.

The therapeutic relationship in BA therapy is similar to that observed in most action-focused
therapies. The nature of the relationship is directive, practical, helpful and supportive. One
recent development in behavioural approach to psychotherapy, not fully discussed here, is
Functional Analytic Psychotherapy (FAP: Manos et al., 2009). FAP uses observations by
therapists of the interpersonal behaviour of clients within session to develop case formula-
tions of how these behaviours may be occurring in clients’ social environments. In a less
formal way, general BA therapists may make similar observations as part of their functional
analyses of interpersonal behaviour. It is likely that these assessment frameworks will con-
tinue to develop as BA is applied to wider populations.


The style of therapy can be framed within a coaching model. A common process technique
used to guide coaching is the GROW model. This model fits closely to the BA structure. The
‘G’ stands for goal or end point, i.e. this might refer to specific levels of specific behavioural
activities. The ‘R’ stands for reality, where clients are now, i.e. current levels of these behav-
iours. The ‘O’ stands for options (possibilities), i.e. this engages clients in exploring various
approaches to achieving behavioural goals (O can also stand for obstacles – which need to be
problem solved). The ‘W’ stands for what. In BA terms this is outside-in formulation, i.e. the
what, is the specific behavioural activity to be performed, where and when. Coaching gener-
ally aims to empower people to achieve goals. The role is that of guide not instructor. The
idea of guide is that the BA therapist provides techniques and support to help clients achieve
goals for themselves.

3.5.1 Assessment
A BA assessment:
1. Psychometric assessments: Beck Depression Inventory Revised (BDI-II) a 21-item self-report scale that
assesses current levels of depression (Beck et al., 1996). The Behavioural Activation for Depression Scale
(BADS: Kanter et al., 2007) is a 25-item scale developed to assess behaviours relevant to BA. There is also
a short form (BADS-SF) which has 9-items (Manos et al., 2011) that contains two subscales: (1) activation
(6 items), and (2) avoidance/rumination (3 items). Each item is scored based on how the statement applies
over the past week, from ‘0 = not at all’ to ‘6 = completely’. Total subscale scores range between 0 and 36
for activation (higher scores being good) and 0 and 18 for avoidance/rumination (these are reverse scored
so higher scores are good, i.e. low avoidance). Examples of items in the activation subscale include ‘I am
content with the amount and types of things I did.’ ‘I did things that were enjoyable.’ ‘I was an active
person and accomplished the goals that I set out do to.’ Items in the avoidance/rumination subscale include
‘Most of what I did was to escape from or avoid something unpleasant.’ ‘I spent a long time thinking over
and over about my problems.’ ‘I engaged in activities that would distract me from feeling bad.’
2. Risk assessment: Therapists are able to assess and respond to indicators of risk of suicide and self-harm.
3. Activity assessment: Clients monitor their activity levels during initial phases of therapy. This serves as a
base-line and focuses clients’ attention towards their levels of active behaviour. Activity is recorded using
diaries, recording what, where when and who, also noting information related to mood and mastery in
engaging in the behavioural activity.
4. Values assessment: Values are assessed in two ways. One assesses valued life goals in broad areas of
clients’ lives, e.g. relationships, work or study, and socialising/play, psychological and physical health, etc.
The second assess values in terms of identified valued ways of behaving, e.g. to behave considerately,
truthfully, efficiently, etc. This information is integrated into the planning of behavioural activities. These
identified sources of value provide a positive reinforcing context within which to plan and frame behav-
ioural activities. Valued ways of behaving are not conceptualised as rigid and absolute commandments,
i.e. ‘I must….’, but as qualitative characteristics of behaviour, which, to use a colour metaphor, contribute
degrees of hues and shade to the behaviour being performed.

5. ABC functional analysis: Clients provide specific examples of recent changes in their depressed behaviour
or shifts in mood that are examined using the ABC functional analysis framework. First, the antecedent
(A) context is identified, i.e. physical and social environment and key discriminative stimuli (triggers) in
which this shift occurred. A descriptive account of the behaviour (B) that occurred is clarified, what they
did. Then the nature of the reinforcing consequences (C) for the behaviour are identified, e.g. if a reduction
in negative arousal – negative reinforcement occurred, or whether depressive behaviour was positively
reinforced, or whether non-depressive healthy behaviour was not followed by positive reinforcement or
punished.
6. Case formulation assessment: Information is gathered in line with general formulation outlined in the top
of Figure 13.2. Information is derived through a process of reviewing activity diaries and the completion
of multiple functional analyses across a range of settings in which variations in depressed mood and
behaviours have occurred. This case formulation is used to explain the onset for depression, i.e. the pre-
cipitating context, also to explain the course and the maintenance depression.

A general formulation shown at the top Figure 13.2 was previously discussed in Section 2.3. The
lower part of Figure 13.2 shows the BA therapy formulation. The purpose of showing the two
formulations side by side here is to highlight the rationale of what BA therapy is targeting for
change and why. Although, these formulations have a general structure the content and context
of clients’ case formulations and therapy formulations will be unique.
Case formulation are developed in more detail with clients linking the historical context in
which contingencies between behaviours and physical and social environmental reinforcers
changed (e.g. negative life event or circumstances) leading to the onset for depression. Also,
the case formulation will outline current maintenance processes, e.g. low levels of behav-
ioural activation, negative reinforcement of avoidance, escape and rumination behaviours,
positive reinforcement of depressed behaviours. The BA therapy formulation is also devel-
oped in more detail with reference to the behavioural activities and modification of avoidance
and escape behaviours that are targeted for change. The reference to ‘pragmatic’ and ‘values’
in the BA therapy box indicates that behavioural activities will be strategically aimed and
working to reduce depression (pragmatic) whilst being consistent with the valued goals and
valued ways of behaving identified by clients.

For the BA model, there is one broad strategic aim for therapy: to increase behavioural acti-
vation and increase positive reinforcement for clients. This broad strategic aim is supported
by four generic strategies that guide the plan of therapy from start to completion. These
generic strategies are not unique to BA in terms of their aims but differ from other therapy
models in the specific techniques used to achieve these aims. The specific content related to
these strategies is detailed above in Sections 3.5.1, 3.5.2 and below in Section 3.6.2. The four
generic strategies include:

General formulation
13_Dryden & Reeves_Ch-13.indd 343

Behaviour
Reinforcement Mood Depression
↓Activation
↓R+ for healthy behaviour ↑Avoidance and escape
↑Depressed mood ↑Depressive
↑R- for avoidance and escape behaviour symptoms
↑R+ for depressed behaviour ↑Depressed behaviour
BA therapy formulation
Behaviour Reinforcement
BA therapy Mood
↓Activation Depression
BA techniques ↑R+ for healthy behaviour
↑Avoidance and escape ↓Depressed mood ↑Depressive
↓R- for avoidance and escape
‘Pragmatic’ behaviour symptoms
↓R+ for depressed behaviour
‘Values’ ↑Depressed behaviour
Figure 13.2 General BA formulation and BA therapy formulation
08-Oct-13 10:33:05 AM
1. An engagement and assessment strategy: The aims of this strategy are to validate and normalise clients’
experience of depression. The BA model views the negative affect, thinking and behavioural changes seen
in depression as an understandable response to reductions in behaviours associated with positive rein-
forcement. Therapist aim to gather information about the clients’ historical and current levels of behav-
iour, e.g. engaging clients to monitor and keep diaries about levels of behavioural activity. This strategy
also aims to obtain quantitative assessment (psychometrics) of levels of depression and levels of depres-
sive behaviour activity, which are necessary for evaluation (see above Section 3.5.1).
2. Case formulation and socialisation strategy: The aims of this strategy is to gather the necessary infor-
mation for developing an individual case formulation. Clients’ information is integrated within the
theoretical framework of the BA model. The aims of this strategy are to develop and share case for-
mulations with clients, to socialise clients to understanding depression and to focus clients’ attention
on the targets for behaviour change implicated by the case formulation. A central aim for this strategy
is the establishment of clear behavioural activity goals for therapy. The nature of these goals can
only be established after a comprehensive case formulation has been completed. Case reformulation
will be required if no progress is observed in reducing depressive symptoms (i.e. pragmatic criterion).
(See above Section 3.5.2.)
3. Intervention strategy: The aims of this strategy are to implement the therapy techniques implicated in the
case formulation. As indicated above the broad strategy is to increase behavioural activity and increase
positive reinforcement. Guiding principles associated with implementing this strategy are ‘pragmatism’
and ‘value reference’, i.e. setting behavioural activity goals within a pragmatic context – that are achiev-
able and that lead to reductions in depression – also planning behavioural activities that are related to
the values and goals for clients (see below, Section 3.6.2).
4. Evaluation and post therapy strategy: This strategy aims to evaluate the therapy intervention during and
at the end of therapy. The post therapy strategy involves outlining a general plan of maintenance and
relapse prevention.

Kanter et al. (2010) has reviewed the core components or techniques identified from pub-
lished BA therapy studies and BA therapy manuals. The following represent key techniques
commonly used in current BA therapies: (1) activity monitoring; (2) assessment of life goals
and values; (3) activity scheduling; (4) skills training (social, problem solving, etc.); (5) pro-
cedures targeting avoidance and escape behaviours; (6) procedures targeting covert verbal
behaviour (e.g. rumination); and (7) contingency management (rewards from others or
self-reinforcement).
1. Activity monitoring: This is the first practical task of therapy. It is not viewed primarily as a therapy change
technique per se but as an assessment task. However, it has been shown to decrease problem behaviours
in some studies (Kanter et al., 2010). It provides a baseline of activity levels and associated mood, it also
begins the socialisation process for clients indicating meaningful relationships between behavioural activ-
ity and mood. Discussion of information from weekly activity charts can be explored in terms of levels of
what has reduced, what is being avoided; moods associated with specific activities, general activity level
and the relation of activities to valued life goals.
2. Assessment of values: This technique involves exploring two kinds of values. One relates to valued life
goals (which give direction to life) and one relates to valued ways of behaving. Assessing values in this

way creates a client centred context within which to plan behavioural activities. The technique used in BA
therapy is adapted from other psychotherapy models, e.g. Acceptance and Commitment Therapy (ACT)
(Hayes et al., 2011). The values assessment in relation to valued life goals identifies what is important for
clients in broad life domains, e.g. relationships, work/study, socialising/play and physical and psychologi-
cal health. Valued life goals tend to be long-term, therefore therapist working with clients, aim to identify
relevant short- and medium-term goals. Sometimes valued life goals are referred to as valued directions
(Veale, 2008). Valued life goals are distinguished and assessed differently from valued ways of behaving.
Valued life goals have ends that can be attained, i.e. ticked off. Whereas valued ways of behaving are
performed in the present, they characterise our on-going behaviour, i.e. the ways we go about things.
Valued ways of behaving are conceptualised as qualitative characteristics of behaviours as they are per-
formed, e.g. to behave courageously, honestly, intelligently, truthfully, etc. Clients can aim to behave in
these valued ways in order to attain valued goals, e.g. to do 3 hours of study revision (short-term goal)
and engaging in this behavioural task, conscientiously, attentively and engagingly. Utilising the frame-
work of valued life goals and valued ways of behaving provide a positive reinforcing framework for plan-
ning behavioural activities.
3. Activity scheduling: Is the core and primary technique in BA therapy. It is included in all studies and all
treatment manuals. It is not simply scheduling pleasant activities. The use of contextual functional analy-
sis and values assessment will result in a personalised behavioural activity plan framed around what is
positively reinforcing for clients. The structure of activity scheduling is relatively simple, involving a day
planner with certain behavioural activities to do, defined in terms of what, when, where and who. The
behavioural tasks are framed by an outside-in rather than the inside-out model of behaviour change, i.e.
the goal is to complete the behavioural activity not to wait to feel motivated to do it, or to be in the right
mood to do it, or to be optimistic about doing it. The goal is to perform the behaviour as an end in itself.
Many behavioural activities may require a progressive approach, moving through a hierarchy of stages of
behavioural activity goals.
4. Targeting avoidance: Recent BA models have emphasised the importance of addressing avoidance and
escape behaviours maintained through negative reinforcement. Increases in these types of behaviour
lead to a progressive narrowing of clients’ behavioural repertoire, i.e. increased social withdrawal and
isolation. Martell et al. (2010) makes this component of the BA model explicit in therapy and teaches
clients to recognise this pattern of behaviour using the acronym TRAP: T stands for trigger (antecedent
discriminative stimuli), R stands for response and AP stands for avoidance pattern. The therapeutic
response is based on the acronym TRAC where T and R are the same but AC stands for ‘alternative
coping’ i.e. usually an approach or stay-put (non-escape) behavioural response. Reducing avoidance
and escape behaviours requires supportive behavioural techniques to increase their success. Using
information from the assessment of values can enhance the positive reinforcement for engaging in AC
(alternative coping) behaviours.
5. Skills training: These behavioural techniques are applied when the case formulation identifies skills defi-
cits in relation to activity scheduling for specific behaviours in specific environments, e.g. social skills
training, in order to approach and engage in conversation with strangers. Therapist may use role-play with
feedback to prepare clients for behavioural activation tasks in social environments. Other skills training
could include problem-solving skills, which is helpful when exploring different options to engage in
planned behavioural activities.
6. Rumination and worry disengagement: This technique has been discussed extensively in a metacognitive
model of depression (Wells, 2009). However, the proposed theoretical mechanism in a metacognitive model
is different to that in BA models. However, metacognitive strategies for disengaging from rumination can

be usefully applied in BA therapy. In the BA model, rumination is viewed as a maladaptive ‘coping’ strategy,
in that it is similar to escape and avoidance behaviour and is maintained by negative reinforcement. A
functional analysis would identify antecedents (alone in room) and consequences of ruminative behaviour.
Reduction in rumination can be achieved by techniques using rumination postponement and suspension
described in metacognitive therapy literature.
7. Contingency management: This technique involves setting up positive reinforcement for the comple-
tion of behaviour tasks. Sometimes these are explicitly set up as forms of self-reinforcement, i.e.
accessing a reward after completion of tasks. It can also be used when working with family and
friends of clients. An agreed contract could be drawn up between clients and their family and friends
where non-depressed behaviour is positively reinforce and reinforcing behaviours are withdrawn from
depressed behaviour.

BA seeks to help clients modify their behavioural activity and change their physical and
social environments to increase levels of positive reinforcement. Evidence for the process of
change should closely follow the sharing of the key strategies for therapy with clients and the
implementation of key therapy techniques. Change is monitored and evaluated by therapists
as key therapeutic processes are implemented.
1. The outcome from sharing the BA rationale with clients should show a change in the clients’ language
when talking about their therapy goals, i.e. that they are framed in terms of outside-in goals, that they
are working to achieve particular behavioural tasks or activities rather than trying to change motivation,
mood and thinking.
2. The outcome from formalising valued goals and valued ways of behaving should be evidenced by changes
in clients’ reference to valued ways in which to engage with behavioural tasks, i.e. that a task is com-
pleted for a valued purpose and in a valued way.
3. The outcome from introducing recording and planning behavioural activities should be associated with
clients’ increased awareness about the nature of their behaviour, i.e. their level of behaviour that leads to
positive reinforcement, their awareness of avoidance behaviour etc.
4. Clients will show an increase in engaging with varied physical and social environments that are positively
reinforcing.
5. Clients should indicate the development of tolerance and acceptance of negative affective states particu-
larly when challenging avoidance behaviour, also that their criterion for achieving the goal is behavioural
rather than affective (i.e. must feel less anxious to do this).
6. Clients will show awareness of when they are ruminating and indicate that they are able to suspend
engagement with rumination and focus instead on a behavioural goal.
7. Change during and towards the end of therapy should be indicated in changes to the BDI-II and the
BADS.
Problems in progress with therapy will require re-formulation, if there is no reduction in

depressed mood then behaviours and physical and social environments are functioning to
maintain low mood and require a re-analysis (pragmatic criterion).

4 CASE EXAMPLE
4.1 The client

In the six months preceding her referral, Lara, a 24-year-old second-year undergraduate, had
been struggling to maintain both her studies and her social contacts at university. She
reported a history of increasing anxiety, social withdrawal and low mood. She saw her gen-
eral practitioner (GP) who advised her to seek psychological support as a first approach.
Lara had a previous history of low mood when she was 17, which lasted for 12 months. At
that earlier time, she experienced an episode of bullying and rejection at her school. Now, the
onset for her concerns stem from an experience of ridicule and humiliation by a fellow female
student at the university. She found this experience traumatising, more so, because the mis-
treatment was perpetrated by someone who she had regarded as a friend. She believed that
her anxiety, isolation and low mood were due to a failure in dealing with this issue at the time,
also that she was deficient or weak and that these explained her continued inability to over-
come these difficulties (an example of internal reason-seeking).
4.2 The therapy

Lara was apologetic and felt shame and upset in having to come to sessions. The therapist
noted for reference this ‘apologetic behaviour’, as it could be occurring outside sessions
(it would be an example of depressive behaviour, i.e. negatively reinforced as it reduced
the threat of criticism and rejection but also positively reinforced by reassurance behav-
iour from others). The therapist maintained an action-focus style during the development
of the therapeutic relationship. As Lara was a student, the therapist framed the sessions as
both a teaching and learning opportunity (psycho-educational) as well as a therapeutic
(supportive). This normalised discussions of her depression and made coming to sessions
acceptable. The therapist also introduced the idea that the he would sometimes take on the
role of coach. The purpose of this was to highlight the action-focus of therapy work and
that the therapist would adopt the role of supporter and guide in helping Lara to achieve
behavioural goals that were important for her.

(a) Assessment
1. Lara scored 32 on the BDI-II (severe range) and endorsed the item ‘I had suicidal thoughts but would not
carry them out’. She also completed the Behavioural Activation for Depression Scale Short-Form
(BADS-SF). Lara scored 14 on the activation subscale (range 0–36: higher scores better) and 6 on the
avoidance/rumination subscale (range 0–18: items are reverse scored so higher scores mean lower avoid-
ance). Measures were repeated every two sessions.

2. Lara completed two weeks of activity diaries. The activity diaries were discussed in relation to a base-line
relative to that prior to the onset for depression. The main observations from the diaries included: (1) low
socialisation whilst at university; (2) low socialisation outside of university; (3) reduced lecture attendance;
(4) low participation in lectures; (5) reduced self-care and domestic activities; (6) increased time spent in
room alone when at home; (7) low time spent on academic revision; and (8) low engagement in sports
activities. Her daily routine was disordered, i.e. sleeping late, missing meals, doing day-to-day tasks.
3. Lara completed a values assessment. She identified three valued life goals: (1) to be successful in her studies;
(2) to develop a close friendship group; and (3) to take care of herself. These valued life goals represented
distal sources of positive reinforcement for Lara. The values assessment then focused on what behaviours
carried out today and tomorrow would work towards attaining these goals, thus more immediate short- and
medium-term goals were identified. Lara also completed a valued ways of behaving assessment. Lara iden-
tified, from a list of 60 values, the three most important that would best characterise her behaviour when
engaged working towards her life goals. For success in her studies she her studies she identified: (1) dedi-
cated; (2) curious; and (3) persistent. For close friendships, she identified: (1) complementing; (2) honest; and
(3) fair. For self-care, she identified (1) accepting; (2) caring; and (3) encouraging. These valued ways of
behaving were not conceptualised as rigid and absolute commandments, e.g. ‘I must behave in these ways!’
but, to use a colour metaphor, they were viewed as the blend of values that would be present in different
intensities of shade and hue as she engaged in specific behavioural activities.
4. Specific settings were explored using ABC functional analysis. Multiple discriminative stimuli acted as
triggers for avoidance and escape behaviour. Many aspects of her social environment acted as discrimina-
tive stimuli where avoidance and escape behaviours were performed, strengthened by negative reinforce-
ment. These discriminative stimuli were linked to the student who mistreated her. Triggers occurred in
classes, the library, recreational areas. Ruminative and worry behaviour were analysed using ABC func-
tional analysis and the main antecedent setting was being alone in her room. Ruminating reduced
approach behaviour, i.e. going out into social settings. The TRAP and TRAC analytic tools were introduced
to Lara when discussing these situations.
(b) Formulation A general case formulation and treatment formulation was developed with
Lara (see Figure 13.2). The historical context of this pattern of behaviour was acknowledged
with Lara, both its current development and her previous historical experience of a similar
situation. Her current depression was understandable in the context of the significant loss of
contact with sources of positive reinforcement. The principle of outside-in was discussed,
highlighting the primary role of behaviour as the primary target for change. The case formu-
lation and BA therapy formulation was shared with Lara emphasising two strategies for
therapeutic work. The first strategy aimed to increase behavioural activities in her natural
physical and social environments associated with positive reinforcement. The second strat-
egy aimed to target avoidance and escape behaviour associated with discriminative stimuli in
the university and other social environments, also to target and address ruminative behaviour.
These strategies were framed within her valued life goals and her valued ways of behaving,
i.e. all behaviour change was in the service of moving towards valued life goals.

Based on the formulation the first strategic focus was to increase behavioural activation.
Based on information provided by her activity diaries and her values assessment, specific

scheduled behavioural activities (what, where, when and number) were planned in the fol-
lowing areas. The principle underlying completion of these tasks was that she did not have
to feel motivated to do them, or feel in the mood to do them or to be optimistic about the
outcome to do them the task was to do them. The general domains are listed below. These
would be addressed in greater detail when planning actual behavioural activities.
(a) Success in study goal

Behaviour: Increase offering to answer questions and offering comments in class.
Behaviour: Increasing time spent revising and studying in library.
Behaviour: Attending all required lectures.
(b) Close friendship goal

Behaviour: Increasing socialising with housemates in house.
Behaviour: Increasing socialising with friends outside of house.
(c) Self-care goal

Behaviour: Tidying room and doing laundry.
Behaviour: Increasing times spent preparing food with friends.
Behaviour: Increasing sports activity.
The schedule of behavioural activities associated with each of these targeted areas of change
were agreed and planned in sessions. Behavioural activities were discussed with reference to
the question ‘What is the point?’ This is a contextual and valued focused question and refer-
ence was made to the values identified in the assessment. Also the question ‘What are the
obstacles?’ was addressed. This is a pragmatic question, i.e. what increases the likelihood of
achieving the behavioural activities? These were responded to by specifying: (1) clear objec-
tives, what, when and where; (2) creating prompts and reminders; and (3) approaching
behavioural activities with an outside-in behavioural change strategy.
The second strategic focus from the formulation involved modifying avoidance, escape
and ruminative behaviour. Some of the general behavioural activation tasks resulted in
decreased ruminative behaviour because Lara was spending less time in her room alone.
Nevertheless, Lara was introduced to a rumination postponement suspension technique to
disrupt engagement in rumination (Wells, 2009).
Direct behavioural management of avoidance and escape behaviours related to socialising
in and outside of the university were also planned. Much of Lara’s avoidance was associated
with one main discriminative stimuli of the person who perpetrated the mistreatment. This was
formulated within the TRAP analysis framework. At one stage in therapy, there was a discus-
sion about the option to engage in social skills training to develop assertive behaviour towards

this person. An alternative option was to see the functional role that this person had now
acquired (i.e. discriminative stimulus) in relation to Lara’s behaviour. Lara saw the goal of
being able to attain extinction of escape and avoidance behaviour in response to this person
(TRAC), i.e. alternative coping. Therefore, Lara’s aim was to engage in friendship behavioural
activities with other students whilst the discriminative stimulus (other student) was present,
i.e. aiming to behave in complementing, honest and fair ways towards chosen friends. For
Lara, this was not seen as being some form of rejection or exclusion of the person but simply
shaping her behaviour responses towards engaging with valued behavioural activities rather
than engaging in escape and avoidance behaviours that maintained her low mood.
Lara’s risk was assessed at each session. By session 3 Lara endorsed ‘I do not have any
thoughts of killing myself’, which she maintained for the remainder of the therapy.

Lara was seen for 15 sessions, over 22 weeks. Table 13.1 shows a summary of psychometric
measures. BDI-II score reduced from initial 32 to 10. Scores on BADS-SF BA (behavioural
activation subscale) indicate an initial rapid increase from 13 to 23 over first 5 sessions fol-
lowed by steady increase to 29. Scores on the BADS-SF AV (avoidance/rumination subscale)
indicated improvement from 6 to final score of 11 after the 15th session.
Table 13.1 Lara’s scores every 2nd session. Beck Depression Inventory Revised
(BDI-II: range 0–63); Behavioural Activation Depression Scale–Short Form:
BADS-SF BA (behavioural activation: range 0–36) and BADS-SF AV (avoidance/
rumination: range 0–18).
35
30
25
Scale Score
20
15
10
0
1 3 5 7 9 11 13 15
Session number
BDI-II BADS-SF BA BADS-SF AV

Strategic management of avoidance, escape and ruminative behaviour: Lara had become
familiar with the TRAP–TRAC model in addressing settings where discriminative stimuli
triggered respondent anxiety and avoidance and escape behaviour. She also adopted the
outside-in model of behaviour change, and used her awareness of the valued goals and valued
ways of behaving to choose alternative coping responses. In the case of rumination, she was
aware of the trigger context of being alone in her room and for a while made plans to combine
increasing behavioural activity outside of her room, i.e. going to the library or socialising
with friends. She also reported success in disengaging from rumination by postponing or
suspending it.
Lara believed she had adopted a different set of strategies for dealing with her difficulties.
She found herself sometimes reason-seeking about internal causes for her depression.
Nevertheless, she acknowledged that the most helpful things that have helped her involved
her just doing rather than being motivated, feeling like it or thinking optimistically about it.
She acknowledged that her motivation, mood and optimism have improved but that these
seem to have come about as a consequence of her actions.
5.1 Developments
5.1.1 Brief therapy
BA, as developed by Martell et al. (2010), suggested 10–20 sessions in their treatment pro-
tocol. Lejuez et al. (2001) developed Brief Behavioural Activation Treatment for Depressions
(BATD), which specified a treatment protocol of 10–12 sessions. BATD has now been used
with a number of different populations and contexts with promising results (Manos et al.,
2010). More recently, BA has also been identified as an appropriate low-intensity interven-
tion (LI) for mild to moderate depression. LI interventions are defined as low-cost, requiring
minimal specialist therapy training and allowing for flexibility in delivery, i.e. combining
guided self-help and brief face-to-face sessions (Veale, 2008).

The World Health Organisation (WHO) projects that depression will be the most burden-
some mental health problem in the world by 2030. The focus on physical and social environ-
ments as primary causes and solutions to depression means that BA is theoretically focused
to accommodate diversity. Not only has BA begun to be used with clients with depression
who are comorbid with other physical and mental health conditions, it has also been used
across the full age range, with different religious and ethnic groups and across multiple
levels of health care delivery (Dimidjian et al., 2011; Ekers et al., 2012). Social, ethnic and
cultural contexts differ but the nature of behaviour reinforcement contingencies transcends
these differences. Loss of positive reinforcement in any context is expected to create risk for
onset of depression. The emphasis on ideographic and personalised case formulations and

therapy plans creates a good foundation for skilled BA therapist to accommodate clients in
many diverse contexts.

At a research level, the limitations for BA will eventually be identified from outcome
research. One major approach exploring limitations involves using meta-analyses to examine
differential effect sizes across BA studies that have used distinct populations, modes of deliv-
ery and health care settings, e.g. gender, age groupings, e.g. adults, adolescents, etc., ethnic
groups, 10 or 20 sessions or LI interventions, in-patient or outpatient health care settings, etc.
Effect size differences, showing poorer outcomes, related to demographic factors, modes of
delivery and settings would indicate possible limitation issues. Despite 30 years of outcome
studies and several published meta-analytic studies examining the effectiveness of BA ther-
apy compared to no-therapy control groups, there is insufficient numbers of studies within
distinct populations, modes of delivery and settings to derive confident findings related to
these potential limiting factors.
At a clinical level, this issue has already been itemised in relation to unsuitability criteria (see
above, Section 3.2.1). The central key limitation in this instance may arise when clients are
unable to accept the formulation of BA therapy for understanding their depression and as a con-
sequence the rationale for the target of therapy, i.e. focusing on behaviour change. This will
require therapists to develop alternative ways to present the rationale for the BA model.

Criticisms not surprisingly come from theoreticians that propose other key psychological pro-
cesses as the key mechanisms both for understanding depression and for stipulating the process
targeted for change, e.g. cognitive models or neurochemical models of depression. These repre-
sent inside-out model of depression. However, Longmore and Worrell (2007) have shown that
the putative cognitive processes assumed to be central for understanding change have not been
found to be associated with therapeutic outcomes, i.e. emotional disorders improve whilst core
beliefs remain unchanged. This is not presented as a defence for BA theory. It is simply that BA
therapy will require a similar critical analysis to that applied to cognitive process theories, e.g. to
show that depression improves but behavioural activation remains unchanged or that levels of
positive reinforcement increase but depression remains unchanged. This kind of systematic
critical analysis has not been performed at the present time.
5.4. Controversies
A theoretical concern within behavioural formulations of depression is the critical way in
which behaviour reinforcement contingencies are arranged. An essential principle

underlying the process of learning theory is contingency, i.e. contiguousness or time

proximity between the behaviour and reinforcement. Some therapists argue that the
scheduling behavioural activities and assuming the occurrence of appropriately timed
positive reinforcement is more a hope than reality and as a consequence the hypothesis
that behavioural activation is the mechanism underlying change is considerably weak-
ened because of this lack of control. Additionally, because of the importance of contin-
gency, any delay in positive reinforcement may end up reinforcing a non-targeted
behaviour. Kanter et al. (2008) have offered a part solution to this issues by integrating
a Functional Analytic Psychotherapy (FAP) model with a BA model. FAP adopts the
same basic principles as BA but focuses more on within-session behaviour reinforce-
ment contingencies. This approach to FAP informed BA places greater emphasis on
analysing interpersonal behaviours occurring in session. However, not all aspects of
depressive behaviour can be understood to arise from problems in interpersonal rein-
forcement contingencies. Nevertheless, this remains one way in which the management
of behaviour reinforcement contingencies can be partially addressed. The central con-
cern about the active mechanisms in BA therapy requires validation.
6 RESEARCH
This brief review addresses two broad questions: (1) does BA work; and, if yes, (2) how does
it work? The first question is addressed by examination of findings from controlled clinical
trials and the second is addressed by examination of issues related to clarifying the mecha-
nisms of change underlying BA therapy.
Does it work? The pooling together of results from many studies, meta-analysis, pro-
vides a powerful evaluation for the effectiveness of therapies. Meta-analytic studies based
on controlled clinical trials comparing a BA therapy condition with either a no-therapy
control condition and or another active therapy conditions can provide an overall estimates
for effectiveness of BA therapy. Effectiveness is computed in terms of an effect size, which
is conventionally categorised as follows: d = 0.2 are small; d = 0.5 are medium; and d =
0.8 are large.1
Three meta-analysis studies are summarised here (Cuijpers et al., 2007, 2008;
Mazzucchelli et al., 2009). Cuijpers et al. (2007) conducted a meta-analysis of RCTs for
the treatment of depression in adults that compared some variants of BA therapies with
either a no-therapy control condition or other active therapy condition. Sixteen studies met
their inclusion criteria. Heterogeneity was low indicating consistency in direction of effect
sizes across studies. The average effect size for BA therapies compared to no-therapy was
1
d refers to the effect size statistic which is calculated in this instance by subtracting the mean of the
control or active treatment comparison group from BA group and dividing this by the pooled standard
deviation.

d = 0.87. A practical interpretation of this finding is that the average participant in the BA
therapies group would be placed on the 81st percentile of the no-therapy control group
distribution, i.e. 81% of the no-therapy control group would fall below the average person
in the BA therapy group.
When BA therapies were compared with other active therapy conditions the effect size
was negligible (d = 0.12) indicating no practical clinical difference between BA therapy and
other active therapy conditions. Cuijpers et al. (2008) conducted a second meta-analysis
specifically looking at RCT for the treatment of depression which compared a number of
different active therapy conditions, including BA, CBT, nondirective supportive therapy,
psychodynamic therapy, problem solving, interpersonal psychotherapy and social skills
training. Fifty-three studies met their inclusion criteria. The range of average effect sizes
between the various active treatment comparisons was small (d = -0.2 to 0.40) indicating no
superiority of any treatment over another. The mean effect size for BA compared to CBT
was d = 0.15, i.e. negligible.
A third meta-analysis was carried out by Mazzucchelli et al. (2009). They found 34
RCT studies comparing BA with a no-therapy control group or BA and CT. They
required more restrictive criteria for the BA therapy condition compared to previous
meta-analytic studies. The main finding, similar to previous meta-analyses, was that BA
was more effective than no-therapy control conditions (d = 0.78) and that BA therapy
was comparable in effectiveness with CT (d = -0.01). In summary, these three meta-
analytic studies indicate that BA therapy shows a consistent large treatment effect size
when compared with a no-therapy control condition. Less clear, is the ambiguity seen
in that all active psychological treatments appear to be relatively equal in effectiveness.
Nevertheless, in the context of these findings and adopting the principle of parsimony,
BA therapy would be the therapy option of choice. Theoretically, it requires fewer
assumptions to explain it mechanism of operation. It is simpler to deliver. It is easier to
train therapist. It has higher levels of suitability across a broad range of populations.
Although these are convincing pragmatic arguments, the studies themselves do not demon-
strate that the therapeutic benefits observed are in fact due to the mechanisms central to the
BA model of depression, i.e. increasing behavioural activity associated with increases in
positive reinforcement decreases depression.
How does it work? The crucial question for BA therapy researchers is whether the
active component of therapy, i.e. increased behaviour and increased positive reinforce-
ment, is the mechanism by which positive outcomes occur, i.e. reduction in depression.
Space restricts a detailed response to this question here but a brief discussion on some
key methodological issues are presented that may facilitate future research on this spe-
cific question.
Fundamental to addressing the questions above is the requirement of reliable and valid
measures of the key processes underpinning the BA model, e.g. measures of behavioural acti-
vation, measures of positive reinforcement, measures of depression, and measures of avoid-
ance and escape behaviour. Manos et al. (2010) provides a detailed review of measurement
issues in relation to BA research. They highlight problems for BA researchers attempting to

demonstrate temporal causal relationships hypothesised to underlie reductions in depression,

that increasing behavioural activity leads to increasing exposure to positive reinforcement that
in turn leads to improvement in mood. It is difficult to disentangle these three processes within
correlational designs and pre and post outcome studies.
Early attempts to measure positive reinforcement (pleasant events) and behavioural activa-
tion and mood were confounded, i.e. all were measured at same time, by the same instrument
(Lewinsohn and Graf, 1973). This inflated associations and reduced confidence in explaining
relationship between key theoretical processes. Since then, more strategic attempts have been
made to develop measures that separate out these processes, e.g. the BADS and BADS-SF
(Kanter et al., 2007; Manos et al., 2011). The BADS specifically measures behaviour relevant
to the BA model of depression, i.e. behavioural activation and avoidance/rumination behav-
iour. It does not assess levels of reinforcement or mood.
Other measures have been developed to assess reinforcement, e.g. Environmental Reward
Observation Scale (EROS: see Manos et al., 2010). This scale aims measure levels of the
experience of reinforcement independent of behavioural activation and engagement in avoid-
ance and escape behaviour. However, the use of pre and post self-report assessments of these
kinds will not lead to major insights into the causal role of these processes. It is necessary for
studies to use longitudinal assessment, cross-lagged panel designs and time series analysis to
gain a more precise picture of the causal relationships of these processes. In the current con-
text there are opportunities to develop and use handheld IT technologies to allow the collec-
tion of momentary data about behavioural activity levels, levels of positive reinforcement
and mood. A sophisticated schedule of data collection could be randomly programmed to
collect data from participants undergoing BA therapy.
This method of data collection would ensure representative sampling of the key processes
being investigated by BA researchers over the time that therapy was taking place. For the
moment research demonstrating a clear causal role for behavioural activity and exposure to
positive reinforcement as the central causal mechanism for depression has only been partially
supported, however the development of these new technologies will allow a more definitive
evaluation of the BA theory.
7 FURTHER READING
Jacobson, N.S. (1997) Can contextualism help? Behavior Therapy 28(3), 435–48.
Kanter, J.W., Busch, A.M., Rusch, L.C. (2009) Behavioral Activation: Distinctive Features. London; New York:
Routledge.
Kanter, J.W., Manos, R.C., Bowe, W.M., Baruch, D.E., Busch, A.M., Rusch, L.C. (2010) What is behavioral activa-
tion? A review of the empirical literature. Clin Psychol Rev, 30(6): 608–20.
Lejuez, C.W., Hopko, D.R., Hopko, S.D. (2001) A brief behavioral activation treatment for depression: treatment
manual. Behavior Modification 25(2): 255–86.
Martell, C.R., Dimidjian, S., Herman-Dunn, R. (2010) Behavioral Activation for Depression: A Clinician’s Guide.
New York: Guilford Press.

8 REFERENCES
Beck, A.T. (1979) Cognitive Therapy of Depression. New York: Guilford Press.
Beck, A.T., Steer, R.A., Brown, G.K. (1996) BDI-II, Beck Depression Inventory: Manual. Boston: Psychological Corp.
Brown, G.W. and Harris, T.O. (1978) Social Origins of Depression: A Study of Psychiatric Disorder in Women. New
York: Free Press.
Cuijpers, P., van Straten, A., Warmerdam, L. (2007) Behavioral activation treatments of depression: A meta-anal-
ysis. Clin Psychol Rev 27(3): 318–26.
Cuijpers, P., van Straten, A., Andersson, G., van Oppen, P. (2008) Psychotherapy for depression in adults: a meta-
analysis of comparative outcome studies. Journal of Consulting and Clinical Psychology 76(6): 909–22.
Dimidjian, S., Barrera, M., Jr., Martell, C., Munoz, R.F., Lewinsohn, P.M. (2011) The origins and current status
of behavioral activation treatments for depression. Annu Rev Clin Psychol 7: 1–38.
Ekers, D., Richards, D., Gilbody, S. (2008) A meta-analysis of randomized trials of behavioural treatment of depres-
sion. Psychol Med 38(5): 611–23.
Ekers, D., Godfrey, C., Gilbody, S., Parrott, S., Richards, D.A., Hammond, D., Hayes, A. (2011) Cost utility of
behavioural activation delivered by the non-specialist. Br J Psychiatry 199(6): 510–11.
Ekers, D., Dawson, M.S., Bailey, E. (2012) Dissemination of behavioural activation for depression to mental health
nurses: training evaluation and benchmarked clinical outcomes. J Psychiatr Ment Health Nurs 20(2): 186–92.
Ellis, A. (1994) Reason and Emotion in Psychotherapy. Secaucus, NJ: Carol Pub. Group.
Ferster, C.B. (1973) A functional analysis of depression. American Psychologist 28(10): 857–70.
Hayes, S.C., Levin, M.E., Plumb-Vilardaga, J., Villatte, J.L., Pistorello, J. (2011) Acceptance and commitment
therapy and contextual behavioral science: examining the progress of a distinctive model of behavioral and
cognitive therapy. Behavior Therapy 44(2): 180–98.
Jacobson, N.S. (1997) Can contextualism help? Behavior Therapy 28(3), 435–48.
Jacobson, N.S., Dobson, K.S., Truax, P.A., Addis, M.E., Koerner, K., Gollan, J.K., Prince, S.E. (1996) A component
analysis of cognitive-behavioral treatment for depression. Journal of Consulting and Clinical Psychology 64(2):
295–304.
Kanter, J.W., Mulick, P.S., Busch, A.M., Berlin, K.S., Martell, C.R. (2007) The Behavioral Activation for Depression
Scale (BADS): psychometric properties and factor structure. Journal of Psychopathology and Behavioral
Assessment 29(3): 191–202.
Kanter, J.W., Manos, R.C., Busch, A.M., Rusch, L.C. (2008) Making behavioral activation more behavioral.
Behavior Modification 32(6): 780–803.
Kanter, J.W., Busch, A.M., Rusch, L.C. (2009) Behavioral Activation: Distinctive Features. London; New York:
Routledge.
Kanter, J.W., Manos, R.C., Bowe, W.M., Baruch, D.E., Busch, A.M., Rusch, L.C. (2010) What is behavioral activa-
tion? A review of the empirical literature. Clin Psychol Rev, 30(6): 608–20.
Lejuez, C.W., Hopko, D.R., Hopko, S.D. (2001) A brief behavioral activation treatment for depression: treatment
manual. Behavior Modification 25(2): 255–86.
Lewinsohn, P.M. and Graf, M. (1973) Pleasant activities and depression. Journal of Consulting and Clinical
Psychology 41(2): 261–8.
Longmore, R.J. and Worrell, M. (2007) Do we need to challenge thoughts in cognitive behavior therapy? Clin
Psychol Rev, 27(2), 173–87.
Manos, R.C., Kanter, J.W., Rusch, L.C., Turner, L.B., Roberts, N.A., Busch, A.M. (2009) Integrating functional ana-
lytic psychotherapy and behavioral activation for the treatment of relationship distress. Clinical Case Studies
8(2): 122–38.

Manos, R.C., Kanter, J.W., Busch, A.M. (2010) A critical review of assessment strategies to measure the behavio-
ral activation model of depression. Clin Psychol Rev 30(5): 547–61.
Manos, R.C., Kanter, J.W., Luo, W. (2011) The Behavioral Activation for Depression Scale-Short Form: develop-
ment and validation. Behavior Therapy 42(4): 726–39.
Martell, C.R., Dimidjian, S., Herman-Dunn, R. (2010) Behavioral Activation for Depression: A Clinician’s Guide.
New York: Guilford Press.
Mazzucchelli, T., Kane, R., Rees, C. (2009) Behavioral activation treatments for depression in adults: A meta-
analysis and review. Clinical Psychology: Science and Practice 16(4): 383–411.
Mazzucchelli, T., Kane, R.T., Rees, C.S. (2010) Behavioral activation interventions for well-being: A meta-analysis.
Journal of Positive Psychology 5(2): 105–21.
Skinner, B.F. (1966) Science and Human Behaviour. New York; London: The Free Press; Collier-Macmillan.
Veale, D. (2008) Behavioural activation for depression. Advances in Psychiatric Treatment 14(1): 29–36.
Wells, A. (2009) Metacognitive Therapy for Anxiety and Depression. New York: Guilford Press.

PART IV
Other Specific Approaches

14
Cognitive Analytic Therapy
Mark Dunn
Cognitive analytic therapy (CAT) was developed by Dr Anthony Ryle, Consultant

Psychotherapist and colleagues over a period of 35 years commencing around 1975. It was
his intention to develop an integrative therapy that would make use of the theoretical
insights of cognitive-behavioural therapy and the object relations theorists of the British
School, hence the therapy’s name. The urge towards integration came partly from: frustra-
tion with the divided nature of psychotherapy practice in the UK; partly intellectual frustration
with the philosophical positions adopted by some mainstream theorists; and partly the urge
to give access to psychotherapeutic help to those most often excluded by reason of poor
health service provision or through a perception of their insufficient intellectual develop-
ment. In a nutshell he is against the ‘balkanisation’ of therapy and its resulting tower of
psycho-babel and for pragmatics and public usability.
Ryle started his career as a GP and became interested in counselling patients with com-
mon psychiatric and neurotic problems. He developed research into neurosis based on
repertory grid technique attempting to describe psychoanalytic formulations in cognitive
behavioural language. He found that ‘descriptions of patients’ problems based on reper-
tory grid testing produced more precise, acceptable and useful descriptions of the patients’
difficulties than did those based on hypotheses based on psychoanalytic theory’ (Ryle,
1990: 2). These researches led to an interest in the possibilities for integrating theories by
way of a common language, using cognitive language to translate psychoanalytic theory

362 PART IV: OTHER SPECIFIC APPROACHES
and naming three common types of neurotic problem understood in this way, as Traps,
Dilemmas and Snags (Ryle, 1979).
From this he developed the integrative theory of CAT in order to provide an accessible
model of mental functioning and a time limited and focused practice for both the staff
and patients of the National Health Service (NHS). It is essentially a constructivist model
of how the mind works and how it interacts with other minds. It is based in the language
of cognitive psychology, which is seen as the most accessible language for describing
mental processes and seeks to build bridges to all theories from this notional starting
point, acknowledging that the truth of the how the mind works is unlikely to ever be fully
known and even less likely to be encompassed by any one theory. He proposes that the
more theoretical and practical tools there can be integrated in the psychotherapist’s tool
box the better.
CAT’s historical roots lie in both the European tradition of psychoanalytic thinking and the
North American tradition of cognitive psychology. In CAT these ideas are seen as being like
flour and yeast in the making of bread and not, as is sometimes suggested, the oil and vinegar
in salad dressing, which may be shaken together but in reality do not mix. CAT holds that,
while the unleavened bread of CBT has nutritional value and that the yeast of psychoanalysis
has flavour (perhaps an acquired taste like Marmite), kneaded together in CAT they are more
palatable and satisfying. However, not everything can be translated: CAT tends to see the
dynamic unconscious as an unnecessary construction and the information processing models
of cognitive theory to be inhuman. The water in the bread would be the semiotic understand-
ing of the social construction of the mind in the inter-subjective field and how this is
expressed in voice, language and the body – gesture.
2. THEORETICAL ASSUMPTIONS

In CAT a person is seen as inseparable from their social environment and culture and the
person’s personality is understood to be a social construction emerging out of their envi-
ronment and culture. From the moment of birth (or even from the moment of conception)
a baby is a set of biological and psychological processes in continuous motion sensitive to
and adapting to the environment. This process continues in various complex ways until
death. In early childhood the important social environment is the parents and close family,
later on peers, teachers and others are added. In adult life peer groups, work groups and
close partnerships dominate but media also have a large shaping effect. The adaptability of
a person throughout life depends on the qualities of their early adaptive experiences.
Understanding the early development of the baby is essential to the understanding of the
person. The baby’s psychological processes are pre-set to detect and react to pattern and rela-
tionship in the physical and social environment. These are given meaning by the psychological
and verbal responses of the parents; meanings that the baby cannot not acquire. Baby’s actions,

COGNITIVE ANALYTIC THERAPY 363
including random actions, are responded to as if carrying meaning and intention and in this
way the baby’s mind is shaped to the meanings and intentions of the family and culture. The
baby’s activity meshes with the parent’s activity and is treated meaningfully. This joint activity
is described in CAT as procedures: simple at first but building up over time into complex
interactions. An example of a simple procedure would be: baby scanning the world perceives
the pattern of m/other’s face and smiles in recognition, mother perceives baby’s smile and
responds with a smile whereby both feel connected (the meaning of the interaction). This
‘smile-recognition’ procedure reaches completion through m/other’s mirroring response
(though it may continue in an escalating repetition of happy arousal). This procedure is but a
small bit-part of what develops into the more complex range of procedures of a mother–child
relationship (and, of course, we never outgrow that particularly useful procedure).
CAT’s view of early development acknowledges several psychoanalytic writers: Bowlby’s
patterns of attachment are interpreted as interpersonal procedures (Bowlby, 1988), Fairbairn’s
interpersonal object relations are reinterpreted as reciprocal roles (Fairbairn, 1952), while
Winnicott’s transitional objects mediating interpersonal experience are reinterpreted as signs
mediating interpersonal process (Winnicott, 1971; Leiman, 1992).
As the range of interpersonal interactions grows between m/other and baby, the acquisi-
tion of jointly mediated signs results in the acquisition of language and then the ability to
think as language ‘goes underground’ as intrapersonal procedures. As these develop com-
plexity, self-reflective thought becomes possible and self-consciousness emerges. In
response to self-consciousness the good parent aims to jointly mediate the procedures of
self-reflection by helping the child reflect on her thoughts, feelings and the consequences of
her actions in relation to herself and to others. This helps develop a moral sense of what in
the social environment must be adapted to and what may be resisted and changed.
M/other as mediator of the world and its meanings reduces in importance as the child
becomes increasingly shaped by dialogue with family, peers, teachers and also culture through
books, television and travel. The quality of the early relationship with parents, however, is
seen as the major factor in the ability to go on adapting to the wider world and as the source
of psychological disturbance. Any restrictions on early relating are unavoidably maintained in
adult life by re-enaction in relation to others and in the self-to-self relationship.
A person who has had a good enough childhood is therefore able to participate in social culture
both at work and in relationships and to dialogue with others. She can adapt to hostile environ-
ments to survive and can also refuse to adapt and take necessary action to change the environment.
She has a sense of her own flexibility and adaptiveness. She can live with the consequences of
what cannot be changed in a creative rather than a defeated way.

Psychological health and disturbance is conceptualised through the Procedural Sequence
Object Relations Model (PSORM). This models how the person expresses her intentions as

actions in relation to the other in repetitive, sequential ways and how responses are elicited
from the other. The mind is understood to be a continuous process of the following activities:
perceiving the thoughts and feelings of the self or the intentions of the other; appraising these
in relation to memory and belief systems; pursuing intentions through planning; enacting
plans; and appraising feedback from the results of actions.
These repetitive sequences of thinking, feeling and acting (called procedures) are aim- or
goal-oriented. Procedures can be enacted: (1) towards other people in an interpersonal way
(e.g. asking someone to pass the salt); (2) towards the self in an intrapersonal way (e.g.
reminding oneself not to use so much salt); (3) towards inanimate object-others such as food
and drink or machines (e.g. putting salt on one’s chips and eating them); (4) towards the other
as group (e.g. putting salt on one’s chips because everyone is having salt); or (5) towards the
other as culture (e.g. throwing salt over one’s shoulder to ward off the evil eye).
Procedures enacted towards other people, whether individuals or as groups, usually seek
corresponding sequences in reply from the other. So, a procedure whereby you smile at some-
one and ask them to pass the salt will be completed when they smile in return and pass the
salt. However, sequences can proceed in many directions, e.g. they may reply with a request
that you pass the vegetables, they may scowl and refuse to pass the salt or they may ignore
your request and praise your shirt etc. The theory implies that intentions usually carry a clear
indication of the reciprocation required and that if we can get the reciprocations we need
throughout the range of our activities and relationships we feel OK. We are perhaps not OK
when we are, for example, too anxious to smile and ask for the salt or too aggressive in asking,
or when the other doesn’t respond as we would wish.
The theory of reciprocal relating is derived from Object Relations Theory. CAT theory,
however, prefers to describe self and other as processes (procedures) in action rather than
objects in relation. The positions from which intentions are enacted towards the other are
described as roles. These positions are learned from earliest childhood onwards as the result
of mother taking up these positions in relation to baby and requiring or shaping particular
responses from the baby. If mother enacts a flexible and playful process with the baby then
the baby will grow up with the ability to enact a flexible and playful process with the other,
a process which allows the self to move easily through different role positions (linked in CAT
theory to the development of the key meta-role of self-reflection). If mother enacts a rigid
and strict process, the baby will grow up with a rigid and strict process encompassing few
roles enacted inflexibly. The latter case results in the kinds of problems that require psycho-
therapeutic intervention.
The notion of the role in this model is understood to be the position from which procedural
sequences are enacted. However, a role also carries an agenda, i.e. its intention (in the same
way that an actor will ask ‘what’s my motivation?’). This can be seen as: (a) the pursuit of
what is wanted or desired; (b) the avoidance of what is unwanted or feared (often the desires
of others); and (c) the acquiescing (or adapting) to what is required by belonging to culture
and group (the responsibilities of duty). The intentions of the self are always potentially in
tension with and often in conflict with: (a) the intentions of the other; (b) the demands of

culture; and (c) the fears, desires and duties of other self-roles (intrapersonal conflict). These
tensions and conflicts may be avoided by becoming skilled at negotiation and management
of both the self and of the other, including, when necessary, withdrawal from the other.
Roles are also inextricably linked to the notion of activity (cf. Vygotsky’s Activity Theory,
Ryle, 1990). Activity is simply what you are doing when you are going about your life. All
activity is seen to be procedural and driven by agendas (or intentions). Procedures describe
the steps of the activity; the role and it’s intentions describes the meaning of the activity, e.g.
what is reinforced, maintained or reduced by the activity. Self and other may agree or have
different views of the meaning of any activity leading to conflict. Role-agendas can be overt
but also covert, e.g. the activity of cooking a meal for another: (a) may maintain the self in a
caring and nurturing role while also maintaining the other in a cared for and dependent role;
or (b) may reduce the anxiety of the self by pleasing the other; or (c) may reinforce the
dominance of the self over the submissive other who is forced to eat the unpalatable; or (d) may
be a sadistic act of the self towards the humiliated and poisoned other, etc.

Psychological health can then be defined as flexible repertoires of roles and procedures that
result in mutual benefit and a sense of well-being. Psychological disturbance can be defined
as roles and procedures that are not mutual, which may benefit one but oppress or harm the
other including those that restrict or harm the self. Disorders of personality are understood to
reflect a failure to integrate roles and procedures resulting in disruptions in relating, intense
reactive affect as well as harmful coping procedures towards self and other to deal with
intense affect. Psychological health can be further defined as the ability to constantly revise
roles and procedures appropriately.
Psychological health is also defined in relation to cultural norms. In Western liberal culture
a person is generally expected to achieve psychological flexibility and autonomy reflected in
an ability to relate to self and other with high levels of communication and awareness. In
other cultures a tight repertoire of roles and procedures may be expected, reflected in inflex-
ible and dependent relating with strict role assignment. Many problems are generated by the
mixing and confusion of such different cultural demands.

Psychological disturbance is related to a fixed or inflexible early social environment. The
child cannot help but adapt. For example, parents who adopt fixed role positionings and
rigid responses will develop a child that expects those intentions from others and shapes
towards them so as to elicit those responses. In turn, the child learns she can enact those role
positions towards others reciprocally. The child adapts, but at the cost of frustration of its
natural intentions, with a resulting affect (e.g. anger or fear) described in CAT as core pain.
The playful child who is required to control herself by strict parents and is punished for

being out of control will adapt and learn to control herself but at the cost of frustrated and
ultimately lost playfulness, awkwardness and frustration around playful others and a severe
internal self-control. In adult life this may appear as a variety of disturbances such as ano-
rexia, social isolation, restricted sexual performance as well as being over-controlling and
punitive towards her own children and also eliciting strict control from her partner. In CAT
these reciprocal roles could be described as ‘controlling and criticised to controlled, crushed
and angry’.
Deeper disturbances result from early experiences of invasion, neglect and abandonment.
The intensity of such experiences can lead to a failure to integrate roles and procedures lead-
ing to quasi-autonomous self-states, roles separated by dissociation leading to a fragmented
experience of being in the world. These kinds of experience are seen as the origins of person-
ality disorder.

CAT describes disturbance as being maintained firstly by restrictions of the procedural and
role repertoire and secondly by restriction of higher order procedures of self-reflection. CAT
makes no distinction between intra and inter personal mechanisms. Roles and procedures can
govern both self-to-self, self-to other and self-to-environment all at the same time. For exam-
ple, if we are abused when a child we learn the potential to abuse ourselves, others and the
environment.

CAT focuses on typical patterns of restrictions in the self-to-self relating. These are mainly
restrictions of aware self-management and take different forms: (1) restricted self-reflection –
parents did not offer any reflection on experience; (2) disjointed self-reflection – inconsistent or
contradictory parenting disabling integration of experience; (3) errors of attribution – the child’s
false deductions about causality and responsibility; (4) unmanageable experiences – often trau-
matic, which overwhelm the ability to think, feel, act or remember; (5) silencing – abusive
experiences linked to dire consequences if mentioned; and (6) defensive anxiety reduction –
avoiding criticism or threats by forgetting desire (Ryle, 1994).

CAT recognises three typical interpersonal patterns of procedural restriction: traps, dilem-
mas and snags (Ryle, 1979). These procedures have an intra as well as an interpersonal
component. Traps describe vicious circles of thinking, feeling and acting the result of
which confirm the negative assumption driving them; dilemmas describe falsely dichot-
omised choices of thinking, feeling and acting neither of which work; and snags describe
the sabotaging of appropriate intentions due to negative beliefs about self and other often
outside of awareness.


In CAT’s understanding of dialogical terms, the mind exists in a constant bathing environ-
ment of voice-dialogues demanding our attention and interaction, both subtle and subliminal,
as well as overt and obvious. For example, the voice-dialogue of advertising or a novel can
be as powerful as that of another person. CAT’s descriptors of roles and procedures apply
equally to everything that we can pay attention to in the environment including our own
mental processes. Similarly we will gravitate towards the voice-dialogues of our childhood
derived repertoires thereby perpetuating psychological disturbance.
2.5 Change
In CAT change comes from: (1) accurate description by a relatively neutral but interested
other (the therapist); (2) the practice of recognition of roles and procedures in action through
increased self-reflection; leading to (3) revision consisting of resisting or stopping old roles
and procedures and practising new ones. While the therapist may use a variety of techniques
in support of these tasks, it is essential that the therapist resist colluding with the client’s
enaction of their unhelpful roles and procedures towards the therapist. Described in psycho-
analytic therapy as transference and projective identification these enactments are subject to
the same process of accurate description, recognition and revision.
3 PRACTICE

The goal of the CAT approach is change through the description, recognition and revision of
the client’s problematic behaviour patterns. The first subsidiary aim is to teach the client self-
reflection so as to increase self-awareness and self-management skills. A client who has the
ability to recognise her own patterns of thinking, feeling, acting and interacting, has greater
capacity to predict the outcome of interactions more successfully and thereby has a greater
degree of control and choice. The second subsidiary aim is to help the client learn to use
specific tools of self-reflection and self-management.

Individual CAT is seen as a safe first intervention for most clients seeking therapy. The therapy is
designed to be brief, collaborative and active with a negotiated and agreed target problem focus.
Therapists conduct an initial assessment to ascertain: (1) the nature of the problem; (2) personal,
psychiatric and therapy histories; and (3) motivation and alignment to the ethos of the therapy.
Initial therapy contracts are for 8 or 16 sessions followed by a 2–3 month break and then a follow-
up evaluation session at which problem resolution or further treatment can be discussed.


CAT being pragmatic does not generally attempt to treat clients with no motivation or align-
ment to the ethos. This generally excludes active substance abusers and those with uncon-
trolled psychotic episodes. CAT, by the same token, does not generally attempt to treat those
whose problems would be more effectively treated by other well-recognised specific forms
of therapy, e.g. phobias, obsessive-compulsive disorder (OCD), sexual problems, couple
problems or more everyday worries with generic counselling. Clients who, for whatever
reason, are unable to engage with a brief, active, focused approach are usually advised to seek
a more slowly opening therapy.

CAT will attempt to work with any clients not excluded by the previous criteria including
many groups not usually treated, such as the learning disabled. CAT therapists take the view
that following a brief therapy in which a client has taken two steps forward it is not unusual
that they will take one step back, therefore a brief therapy that only takes one step forward is
logically a waste of time. If the first episode of therapy only achieves description, a second
episode will be required to pursue recognition and revision. Similarly, a first episode that
only achieves description and recognition is likely to be followed by a second pursuing revi-
sion. Some clients can achieve all three steps in one therapy. Personality disordered patients
are often offered longer contracts of 24 sessions recognising the intense and disruptive nature
of the work which can prevent or delay the development of a collaborative working alliance
and often disrupt it during the therapy.

It is perhaps not too difficult to be an effective CAT therapist as the structure of the therapy
and the core model makes the task of therapy clear and comprehensible. CAT was designed
for use in the NHS by available mental-health staff often working with some of the most dif-
ficult clients. In that regards using the tools of the model effectively is more important than
the therapist’s personal qualities.
Effective personal qualities include the ability to develop a relationship with a wide range
of clients through an empathic ability to tune in to a client’s emotional state; a developed
sense of self-awareness, thoughtful self-reflection and a lively mind; and a calmness and
sense of humour under stress – what might be called ‘maturity’.

Effective skill factors include: the basic counselling competencies; an ability to recog-
nise and describe repeating patterns in the stories told by clients; an ability to summa-
rise client history and describe repeating patterns in prose and diagrams; an ability to

negotiate in a collaborative way with the client re target problems, goals, homework
etc.; an ability to recognise and resist invitations to collude with the client’s roles and
procedures and to name and challenge them e.g. abuse of the therapist, or sympathising
with or rescuing the victim.

CAT proposes a collaborative approach grounded in a contractually defined working alliance.
As contracts are usually of brief duration it is important that the therapist and client are both
active in pursuit of change. To be effective the activity has to be collaborative, ‘doing with’
rather than ‘doing to’ or ‘being with’. The therapist has to be skilled in recruiting the client to
the tasks of the therapy and explains these expectations at the outset. The therapist carefully
attunes to the client and will adjust the collaboration accordingly following Vygotsky’s theory
of the zone of proximal development (Vygotsky, 1978), i.e. suggesting tasks that the client can
manage and be stretched by but not be defeated by (tasks which can be broken down into steps
of an appropriate size), modulating the degree of challenging or sympathising etc.
Collaboration is understood as working in partnership. Therapist and client pursue an overt
agenda based upon mutually agreed descriptions of the client’s problems. Before therapy can go
forward denial of problems, submission or resistance to the therapy have to be understood. The
skill differential in the partnership is skewed. The therapist is understood to have highly developed
skills of description, recognition and revision as well as a highly developed relational ability (to
establish, maintain, repair and close the therapeutic relationship). The client is also understood to
have abilities which they bring to the encounter and the skilled therapist works at developing
the client’s abilities (perhaps in the manner of a driving instructor) as the aim of therapy is that the
client should no longer need therapy because they can solve their own problems. Though the
therapist has a range of developed skills this does not make her an expert and she should be relaxed
enough to use the mistakes she will inevitably make as grist to the mill of the therapy.

The therapist will vary their style of relating strategically depending on the client’s problem
procedures. On a dimension of active-passive, for example with a controlling workaholic, the
therapist may take up a more passive approach in order to examine the feelings that this
arouses in the client and vice-versa with a patient who feels paralysed or unmotivated.
Inevitably resistance is encountered and the therapist will work to understand, describe and
unblock it or work around it.
The therapist will set a contract with formal boundaries around appointment times, session
length, out of session contact etc. These are seen as diagnostic and transgression of bounda-
ries will be discussed with the client and understood in terms of their roles and procedures.
In the same way agreements to undertake tasks and experiments in the therapy are treated as

boundaries. Boundaries may be transgressed by agreement in pursuit of change e.g. longer

sessions, home visits, accompanying out of session experiments, but such acts are discussed
in supervision first and must be clearly in pursuit of change. By the same token there is usu-
ally no therapist self-disclosure unless in the service of recognition and revision, for example
discussing countertransference feelings.
The emotional tone of the therapy will usually be business like and serious as the therapist is
working to understand and describe the client’s core painful beliefs and feelings underlying their
problems. This requires an authentic attitude based on honesty and respect for feelings, motiva-
tions and intentions, which allows the therapist to challenge destructive thoughts and actions. In
a good therapeutic alliance humour will naturally arise, often through irony about repetitive prob-
lems and procedures (the ‘I’ve done it again!’ response), but a therapy in which therapist and
client are enjoying themselves is usually a collusive therapy that is avoiding tackling difficulties.

3.5.1 Assessment
In CAT the therapist undertakes an initial hour-long interview to establish (a) motivation
and suitability for therapy, (b) the problem areas requiring attention and (c) to agree the rules
of the treatment contract. The assessor is seeking clients who are willing to collaborate and
take an active part in reflecting on history and inter- and intrapersonal processes, i.e. not
dominated by obsessive symptoms and ideas or excruciating or overwhelming feelings. The
assessor aims to create a quick sketch of important life events, early family relationships and
current behavioural symptoms in order to pick up clues as to problematic roles and proce-
dures, how they are affecting current life and how they might play out in the therapy.

The first phase of the treatment (sessions 1–4) is in effect an extension and deepening of the
initial assessment, gathering and organising all kinds of relevant information from homework
and session work towards a written and shared case formulation or ‘CAT Reformulation’.
Sources of information include autobiographies, lifeline diagrams, questionnaires, behavioural
and dream diaries, art work such as collage or cartoon sketches and verbal or written contribu-
tions from close friends. The therapist will probably spend two or three hours of non-session time
synthesising this information, writing a coherent narrative Reformulation and constructing a
Diagrammatic Reformulation. Obviously good supervision is needed in this process.

The major therapeutic strategies of CAT are: (1) description, (2) recognition and (3) revi-
sion. These relate to the four phases of a standard treatment: (1) information gathering,

(2) reformulation, (3) working with aims and exits and (4) ending therapy. Each strategy
entails specific therapeutic techniques and these are discussed in more detail in the sec-
tion below.

Description: The aim is to arrive at a collaboratively produced account of: (a) the client’s
problems: (b) the roles and procedures that maintain them; and (c) the historical events from
which the roles and procedures arose. The account has to be agreed with the client or there
is no basis from which to proceed. The account is not The Truth, but a working hypothesis
based upon available information that may change as things proceed and new insights are
gained. It can be seen as a reworking of a life story from a fresh perspective.
(a) Techniques of description
1. Information gathering: A wide variety of methods are used. Standard therapeutic interviewing gives
descriptions of presenting problems, varieties of histories and some role and procedural insights through
the client’s theories about their problems. To augment and speed up the gathering of information the
client is asked to complete tasks between the sessions including autobiography, family trees, diary keep-
ing, recording dreams, filling out questionnaires. The therapist collates and synthesises the information
outside of the sessions and in the session attempts to make connections and put together the jig-saw
pieces.
2. CAT psychotherapy file: This document is given as homework. It lists common procedures and roles under
their type headings of Traps, Dilemmas and Snags. The client indicates ones that seem to fit. It also lists
unstable states of mind and extreme ways of feeling, common to those who would be diagnosed as suf-
fering from personality disorder. The file is ‘off the peg tailoring’ allowing the therapist to find quick and
reasonable fit descriptions that can then be adjusted by hand rather than go through the lengthy business
of ‘bespoke tailoring’.
3. Reformulation: prose accounts: The name reflects the idea that the therapist is reworking the client’s own
formulation of their problems. It is the therapist’s written prose account of what she has heard and gath-
ered, a drawing together of ideas, hypotheses and insights into a coherent narrative. Importantly the
presenting problems will be re-presented as target problems (TPs) and the underlying procedures (TPPs)
maintaining them will be named. The reformulation is read out to the client. If it has depth, balance and
empathy and adequately names both the client’s core pain, and the way they cause pain to others, then
it can produce a powerful cathartic effect on the client who, often for the first time, has the feeling of
being deeply understood. The therapeutic alliance is usually strengthened. The client is invited to make
changes and reflect on the account so that it can be agreed, being the foundation on which change is
built. The reformulation is usually written in the second person (‘...when you were a child...’) but the
therapist may, for strategic reasons, write in either the first or third person, to bring the client closer to or
to distance them from the material respectively (‘...I was abandoned by my father...’; ‘...he was a sensitive
boy whom everybody ignored...’).
4. Reformulation: diagrammatic accounts: This is a collaborative in-session technique where client and thera-
pist work with blank paper or a whiteboard to draw out sequences of behaviour. The therapist collates and
synthesises these sketches into a more complete map called a sequential diagrammatic reformulation

(SDR) that is shared, agreed and then used to guide the therapy. The SDR-map and the prose reformulation
should describe the same material but in a different form. It is seen as essential to change as it is a literally
portable tool for self-reflection, enabling the client to (1) understand where they are and (2) predict what
will happen next, thereby creating the possibility of (3) choice of action. Like an A–Z the SDR-map shows
the one-way streets and dead-ends of the client’s usual relating and as the therapy develops new routes
and exits are added to the map. The SDR-map is useful in the session helping the understanding of the
client’s weekly material, allowing therapist and client to think together, speculate and pre-empt, but also
allowing role transference and disruptive procedures to be immediately understood and defused before
disrupting the therapeutic alliance. The SDR-map is equally valuable in supervision to understand transfer-
ence and countertransference feelings.
Recognition: A typical reformulation will result in an agreed list of two or three salient problems
linked to the roles and procedures maintaining them, which are targeted for change. The origins
of these in the client’s early life will have been understood as far as possible. The strategy now
(from around session 5) is to aid the client to recognise how they enact these roles and proce-
dures in their day-to-day living thereby maintaining the problems. Recognition must come
before revision, it being axiomatic that you can’t change what you can’t recognise. Recognition
is worked on in the weekly sessions but is also the central homework task for the client.
For example, a depressed client complains of being overwhelmed at work. The client and
therapist agree a target problem description: ‘I don’t know how to manage my workload.’
They are able to describe a placation trap where the client feels she must please her boss
when he gives her overwhelming amounts of work for fear if she protests she will be
sacked. The therapist identifies the client’s early family situation as the origin of the placa-
tion trap, where her mother’s love was conditional on her looking after the house and her
sibs and her protests were met with criticism and rejection. The procedure is identified as
operating both at home and at work. The client’s task is to recognise when she placates and
accepts burdens. Initially this may take discussion at each next therapy session to recognise
the repeating pattern. With the aid of a diary focused on this pattern the time elapsed
between an act of placation and the ‘A-ha! I’ve done it again’ of recognition decreases until
recognition occurs at and then just before the act. The client is then ready to attempt revi-
sion of the procedure. The more places where recognition occurs the quicker the procedure
can be moved to revision, e.g. at work, at home with the children, with the partner, with
friends, with the therapist etc.
(b) Techniques of recognition
1. Problem focused diary keeping and rating sheets: The client is invited to keep a daily diary focused on the
agreed TPs, TPPs and roles. The diary reminds the client of the focus and is a place to record instances of
recognition as well as any new insights about triggers, repetitions, feelings, associations etc. The diary is
discussed in session. Recognition and revision of TPs, TPPs and roles can be briefly rated each session on
graph paper as a means of discussing progress and maintaining the focus and motivation.
2. Using the SDR: The client is invited to carry and regularly refer to the SDR as an aid to developing reliable
recognition (‘I did it again, I’m here again.’). The SDR is brought to the session for discussion, development

and annotation. As recognition improves new insights are possible and these are added to the map.
Occasionally the whole map may need redrawing when an un-integrated part of the self is revealed.
The SDR is the main tool for working with personality-disordered clients. When the meta-
procedures for mobilising roles in relation to contexts and for connecting the repertoire of
roles together are underdeveloped (often due to early trauma) then dissociation results and
the client’s roles are described as a number of disconnected self-states. The client is expe-
rienced as shifting rapidly from one state to another with sudden changes of affect, tone
of voice and posture and discontinuities of cognition and memory. It is often as if different
voices with different agendas are speaking. The task of therapy here with the help of the
SDR is the development of the meta-part of the self that can recognise the self-states and
voices.
3. In-session enactments, Transference and Counter-transference: In sessions the therapist maintains her
focus on the Reformulation and attempts to avoid being distracted or blown off course. The therapist
helps the client recognise enactions towards the therapist, (e.g. in the example above helping the client
recognise how she is placating the therapist by suggesting lots of things she herself can do to change)
and names them on the SDR.
Inevitably the client will enact their map towards the therapist. CAT recognises two types:
(1) identifying transference; and (2) reciprocating transference (Ryle, 1998). In the former
the client seeks to deny differences and to take on the therapist’s role and characteristics;
in the later the client seeks from the therapist a reciprocation of one of her problematic
roles. The therapist’s task is to challenge the iden tification, resist reciprocating and to
invite recognition of the transference. In terms of the thoughts and feelings evoked by the
client (countertransference) CAT again recognises identifying and reciprocating types. In
the former the client induces in the therapist feelings associated with one or other of the
client’s roles, particularly where the affective component of the role may not be openly
expressed (e.g. bland tales of horror); in the latter the client induces in the therapist feelings
associated with the reciprocal role to the client’s role and is a key way for the therapist to
identify the client’s role. As before the therapist’s task is to recognise to which role the
feelings belong, to not dance to the client’s tune and to invite the client’s recognition of
what is occurring. Transference is not gathered in the psychoanalytic sense but the CAT
therapist will usually check out her feelings in supervision before attempting recognition
in session with the client.
Revision: Revision of roles and procedures should logically result in the disappearance or
amelioration of problems. Revision is pursued through defining and putting into practice
more adaptive aims and exits. Once recognition is reliable then possible aims and exits can
be discussed and plans made for out of session experiments, the results of which, both suc-
cesses and failures, are discussed at the next session. Aims are general and are negotiated
with the client as to how things could be changed for the better. Exits are the particular plans
and tactics that operationalise the aim. Continuing the example above, the Aim might be

defined as ‘Saying no to the excessive demands of others’. Exits are then proposed for each
life situation, e.g. politely refusing extra typing at work, asking partner to wash-up at home,
limiting best-friend’s demands to babysit, negotiating homework with therapist. The least
threatening situation is tackled first so as to provide likely success and an increase of confi-
dence before moving on to more difficult situations.
Revision is inevitably difficult as it means disturbing the complex mesh of the client’s
procedures/roles with those of others in her life. Much time is spent in therapy looking at the
possible consequences of revision and planning aims and exits accordingly. Typically
improving one situation will only make another situation worse, for example the client’s job
may be precarious and saying no may result in redundancy or the partner may get aggressive
or threaten to leave when asked to help around the house. The therapist and client will then
discuss whether even greater changes are called for or whether a way to tolerate the situation
can be found.
As revision of procedures and roles depends on what is defined as problematic. There is
no approved or set way of thinking, feeling, acting or being in CAT. What is problematic for
one person may not be at all for another. For example, someone who is anxiously placatory
may experiment with being more assertive; an aggressive person may experiment with
being more conciliatory. The reformulation process looks closely at where such behaviours
come from and the underlying beliefs about others – that they are bullies or wimps – needs
to be challenged. Entertaining new ideas about how others will actually respond to us is the
first part of revision; real in vivo experiments producing new information is the second.
Experimental failures give as much helpful information as successes.
Context is also important since what is maladaptive in one context may be adaptive in
another. For example, anxious placation is likely to lead to being taken advantage of and
feeling used; when a mugger with a knife asks for your wallet it is likely to increase your
chances of not being hurt.
Revision of roles and procedures is usually implicit in the description. For example, a cli-
ent who always takes up a ‘caring for others but feeling needy and neglected’ role will be
invited to experiment with toning down the quality and quantity of her caring and to try
expressing her own needs by asking for specific acts of care from others. Clearly the revision
process requires the solid foundation of the description of the early life situation where the
role arose and acknowledgment and expression of the core painful feelings of anger and loss
the client is carrying in relation to their childhood neglect as well as the fears of what may
happen if she expresses her needs. If this work has been done then the client should be able
to undertake appropriate revision experiments working towards a satisfactory new role of
mutual care and the ability to make appropriate demands without guilt or fear.
Revising self-destructive procedures: Clients who harm themselves or who are
addicted usually have the goal of stopping what they are doing. Once appropriate psy-
chiatric or rehabilitative care is established therapy can be tried. Stopping such behav-
iours is only possible when the client has some idea of why they are doing it in the first
place, hence the power of accurate description, particularly of the core painful issue
lying at the heart of things – usually childhood abuses and traumas. Accurate description

of how the early abuses are re-enacted in current life allows recognition and the possibil-
ity of alternative actions; for example better communication to prevent the angry rows
that lead to binge drinking, or phoning a friend to talk out desolate feelings rather than
overdosing.
Revision usually requires access to and expression of core painful feelings about early life
events during the sessions before self-harming behaviour can change. In the same way accurate
description and recognition of intra-personal conflict and the ‘voices’ by which it is often
expressed is required before the client can feel more in charge and thereby able to resist internal
impulses; for example in the typical conflict between a harsh, critical and crushing internal
parentally-derived voice and a crushed and worthless child-derived voice where the self identi-
fies with the child role, the harsh voice causes agitation and distress which is only relieved by an
act of self-harm (a kind of appeasement) leading to the relief of a blank or cut-off state for a while
before the cycle escalates again. Revision requires an externalisation of the harsh voice and a
dialogue supported by the therapist that aims at rebalancing the internal role repertoire.
Revising split-roles: Clients assessed as having a borderline or narcissistic personality
structure are understood to oscillate between idealising roles (e.g. perfectly caring, com-
pletely understanding, totally accepting, fusing with, admiring) and denigrating roles (e.g.
abusing, ignoring, rejecting, abandoning, rubbishing). Relationships inevitably collapse
under the burden of such extreme idealising into denigration and conflict often leading to
harmful behaviour. Recognition of the oscillating cycle allows a revision of controlling the
urge to idealise or denigrate and practising staying with good enough, ordinary relationship
while processing anger at past denigrations of self, grief for the loss of early ideals, and
shame and regret for denigrations inflicted on others.
Technical flexibility: CAT is an integrative model both in terms of theory and technique.
The principle here is to have as many tools in the therapist’s toolbox as possible and to not
restrict the client’s or therapist’s potential and creativity. CAT therapists may use dreamwork,
active and passive imagination exercises, gestalt techniques, role-play and empty chair work,
art therapy exercises, body work, active emotional expression (e.g. anger work), ritual enact-
ments, in vivo CBT exercises, word association, story/myth telling and poetry. For example,
a client who is emotionally and cognitively blocked may be invited to lie down quietly and
attempt to free associate. Whatever is attempted must be in service of description, recognition
and revision and be properly understood in the therapy.
Ending therapy and following up client’s progress: Because CAT is usually practised in brief
contracts of 16–24 sessions, the closing phase of the therapy is important and ending is discussed
from the very first session. A follow-up session 2–3 months after the last session is part of the
contract. The period from the end to the follow-up is where the client has to ‘fly solo’ and try to
put into practice what they have learned in the therapy reporting back their success or failure at
the follow-up. Another aspect of collaborative working is that the client is discouraged from
regressing into a passive, dependent attachment on the therapist – in effect the client has to ‘get
down from mother’s lap and explore the world’, mitigating the pain of ending.
Inevitably the ending recapitulates to some degree the client’s early losses and the therapist
will be concerned to have discussed these and worked with the feelings involved. If this work

is not done it is likely that the client will avoid the pain of ending by not turning up or by
sabotaging or rejecting what has been gained from the work.
The four last sessions of the therapy are given to this agenda and to writing goodbye letters. The
therapist writes a prose summary of what has been worked on, what has been recognised and
revised and what needs further work including comment on the course of the therapeutic relation-
ship and likely sabotage of gains. The client is invited to write their own view of the therapy
providing an opportunity to share their feelings of gratitude, frustration or disappointment.
The follow-up session provides reflection and perspective on the therapy and closes the
episode of treatment. It is the time and place for discussion of further treatment options,
whether more CAT or a different form of treatment.

The change process in CAT is clearly defined, task focused and based on the assumption that
change occurs through increased awareness. The first task then is to construct as accurately as
possible a description of the client’s problematic procedures and roles. Inextricably linked to
this is the construction of a plausible hypothesis of why the client is doing what they are doing,
i.e. what it means and where it originates in early adaptations to environment. Part of this
process is the redistributing of responsibility for trauma and suffering to where it most reason-
ably belongs, identifying and challenging distorted beliefs and thinking as well as identifying
appropriate affects and their expression.
Having arrived at a jointly agreed description of how things stand, the therapy then turns
to the pursuit of recognition in action. The task is now to develop awareness in life and in the
session, practising self-reflection with the therapist and to reflect on changes. The achieve-
ment of consistent recognition in action moves the task on to revision, the development of
changes through the practice of aware experimentation in life and in the session with the
therapist. The result of successful experiments is new learning that can be generalised to
other situations and hopefully the disappearance of the target problems. Metaphorically
speaking, the logs of present experience become jammed on the rocks of early experience,
blocking the flow of the river of adaptability; the therapy unjams the logs, freeing up the flow.
However, it is also true that in times of stress (lots of logs coming down the river at the same
time) the client may revert back to their old map (the rocks in the river haven’t moved and
the logs jam up again); more therapy may then be needed at that point.
4 CASE EXAMPLE
4.1 The client

Franko, a 28-year-old man of mixed ethnicity parentage referred himself for therapy con-
cerned about the state of his relationship, wanting but fearing breaking up with his boyfriend,

alternatively anxious and depressed at the prospect. He also wanted help with stopping peri-
odic bouts of heavy drinking, cannabis use, bingeing on food and casual sex. He had been
offered anti-depressants by his GP but did not want to take them. He described the relation-
ship as a dead-end and the boyfriend as an absent workaholic. He was better than his previous
boyfriend who had a bad temper when drunk and was violent to him whenever he disagreed
or tried to stand up for himself. He was concerned that he was habitually choosing unsuitable
men and admitted that he found being on his own intolerable leading to an upsurge of symp-
toms including dissociative elements such as long periods of immobility and staring into
space. He worked in the music industry, had a supportive group of friends, liked to surf and
to play guitar.
He was the only child of an African doctor father and an Irish nurse mother. He was born
and raised in Africa until his father died of a stroke when he was ten. Following that he was
sent to Ireland to live with mother’s relatives. In his mid-teens he came to London to live with
his mother and her new husband and children. This did not work and when he finished school
he moved out and started to play in bands. He described his childhood as very happy with his
father until the accident. Mother was described as hard-working but anxious, struggling to
cope and drinking. His stepfather’s children were out-of-control and bullied and abused him
until he left to live with his boyfriend.
4.2 The therapy

A contract for 16 sessions was made and the therapist started to gather information and under-
stand the client’s story. The client was quite voluble initially and it was difficult for the
therapist to speak. The therapist continued an open stance to the patient’s communications
for the first few sessions whilst gently insisting on some homework tasks and their review
whilst working towards identifying some target problems and the underlying patterns and
roles. He was forthcoming with homework, filling out the psychotherapy file, a lifeline and
a symptom diary. The therapist could clearly identify anxiety driven placation in the sessions
and a sense that the client might run away. The therapist discussed with the client the possibil-
ity that he perhaps feared the therapist would turn out to overworked and unavailable like his
mother or critical, rejecting and abusive like his stepfather and stepsibs. After this discussion
he settled into a more collaborative and productive rhythm in the sessions with the therapist
often located in the good-father role. Supervision discussed the implications of that role for
the ending of a brief therapy and care was taken to discuss that role with the client and to stay
mindful of it, allowing it to be experienced as a conscious benefit rather than stumbling into
a re-traumatisation at ending.

Exploring the client’s history and homework brought father’s death into focus as a core problem
that had disrupted his development and created much of his symptoms. Mother was abroad at

the time of the accident and he was in school. When he got home from school father was not
there which was unusual. Eventually a friend phoned to say his father was at the hospital. He
went to the hospital where father was in a coma. He waited at his bedside at the hospital for
three days until his mother came and then father died. He remembered a lot of the three days
blankly staring at a wall. Being a smart kid he realised that he would now have to grow up fast,
look after himself and his father and cope on his own; this was then compounded by his mother
sending him away (probably because he looked very like his father). From these events the
therapist could identify a pattern of anxious attachment – veering between submissive and
powerless clinging dependency and fragile self-control and self-sufficiency. Compounding that
was the fear that any attached relationship would inevitably lead to sudden tragedy or rejection
and abandonment. Stepfather’s rejection and abuse of him set a pattern of low self-worth, anx-
ious placation and putting up with bad treatment in order to stay attached.

Following standard CAT practice the therapist produced a written reformulation to share with
the client. This set out in narrative prose a pulling-together of what the client had shared and
was well received, leading to much grieving and a sense of relief. The written account
focused on conveying an empathic response to the client, that his story had been heard; not
just the bare facts but also the feelings, the meanings, the implications and the nuances that
were producing the problematic patterns of thinking, feeling and behaviour that were result-
ing in the troubling symptoms. At the same time a menu of problematic roles and procedures
in first-person voice was produced as the focus of the therapy going forwards and also a
sequential diagrammatic reformulation, the same but in ‘map’ form.
(a) Reciprocal role procedures 1 and 2 In a relationship it is as if I have to be: either sub-
missive, controlled and potentially abused (RRP 1) or I run away but end up feeling lost,
lonely and abandoned (RRP 2) and have to find any new partner.
(b) Target problem procedure 1 and 2 When in a relationship I anxiously have to perform
to be acceptable which means being caring, helpful and pleasing at all times (TPP1). If I’m
not that or if I stand up for myself against bad treatment (TPP 2) I will be rejected and aban-
doned confirming my low worth.
(c) Target problem procedure 3 I try to cope with constant feelings of anxiety by drink-
ing, smoking cannabis and binge eating. I find brief relief but the anxiety always returns.
(d) Target problem procedure 4 When things go wrong I can feel suddenly overwhelmed
with feelings of desolation and hopelessness. My ‘fuses click out’ and I dissociate –
depressed, immobilised staring. Sometimes cutting helps me reset and reconnect.
(e) Target problem procedure 5 Mostly it is easier to avoid relationships and try to be
emotionally self-sufficient but I end up feeling lost, lonely and anxious.

TPP 1
Controlling In new
Abusing Rejecting
relationship
Humiliating Abandoning
try to be
Caring
Helpful
Pleasing but
anxious
RRP 1
Submissive RRP 2 Rejected
Controlled Abandoned Lost
Abused Lonely Anxious
Worthless
Scared
TPP 2
Resisting
Stand up
for myself
TPP 4 Potential TPP 3 Brief
Assertive
sudden relief through
abandonment Using, Drinking
Dissociate TPP 5 Self- Bingeing on
Fuses click out sufficient Food and sex
Avoiding
relationship
Figure 14.1 SDR: Franko
The therapy sessions focused on further understanding how these patterns originated,
going through particular examples in the past, in his current life and in the therapy relation-
ship. As the instances became clearer his mindfulness of their action on a day-to-day basis
improved quickly. For example, his best friend cancelled a social date at the last moment
deciding to go out with other friends. This ‘tripped his fuses’ but the dissociation lasted only
ten minutes rather than several hours or days as had been the case previously. He reported
that even though he felt blank and dissociated he was aware of a small ‘pilot light’ in his mind
that was still on and thinking that this was what we had discussed in therapy. Similarly due
to a personal emergency I had to cancel a session at the last minute but he turned up having
not received my message. This time he felt a moment of things slipping towards dissociation
before asserting control of himself, telling himself that there would be a good reason for my
absence and to get on with his evening. He acknowledged his fear that I might have died and
that that would be upsetting and sad but he did not dissociate or drink/smoke/binge. Perhaps
fortunately he then got my message.
The sessions towards the end of therapy were spent thinking through and preparing for the
ending. This was a conscious and mindful ending that allowed for the sharing and processing
of the therapy in goodbye letters. He did not avoid the ending and felt OK.


The client made several positive changes during therapy. First, he ended his relationship and
decided to have a period out of any close personal relationship so as to work on managing
his anxious feelings in other ways. From this he opened up much more with his close friends
about his childhood, his patterns and his needs; they responded positively and more mind-
fully towards him. Second, he put some time and effort in to meeting and evaluating his
extended family network as he felt he had rather abandoned them. He discovered positive
relationships with his African relatives and started to develop a warm and supportive relation-
ship with them. Third, he decided, with no pressure from the therapist, to try a course of
anti-depressants to modulate his anxiety and help him resist his drink/cannabis/food habits.
He found them helpful. Fourth, he eventually embarked on a relationship with a man who
lived in Italy and who was only around intermittently. He felt that this would be a good test-
ing ground for his anxious attachment problems.
At follow-up he had maintained his progress though was not by then in any relationship.
5.1 Developments
5.1.1 Brief therapy
In 1982, Ryle commenced to develop CAT as a brief, focused, integrative, individual
psychotherapy treatment for NHS patients. He published many papers and two main
books developing the core integrative theory of the Procedural Sequence Object
Relations Model (PSORM). During this period Ryle was also experimenting with practi-
cal innovations that would facilitate brief treatment by focusing on target problems
including the use of questionnaires, prose reformulation letters to the patient summaris-
ing understandings, the use of flow chart style diagrams as well as techniques from CBT
such as diary keeping and rating sheets. In keeping with the integrative ethos Ryle would
exclude nothing that might support and motivate both the client and the therapist and
empower them to make changes.
In the 1990s Ryle continued to develop the theory and practice of CAT in his writings,
extending it to include an understanding of the origins and behaviours of those diagnosed
with personality disorders, particularly borderlines and narcissists. He conducted incon-
clusive theoretical debate with Kleinian and other psychoanalytic writers (Ryle, 1992,
1995). In collaboration with Finnish psychologist Mikael Leiman he extended CAT
theory to integrate the theoretical ideas of two Russian Psychologists, the Activity
Theory of Vygotsky and the semiotic theory of Bakhtin (Leiman, 1992, 1994). In the
2000s CAT psychotherapists have developed applications of the model to a wide variety
of client groups and clinical and non-clinical settings (e.g. Pollock, 2001; Hepple and
Sutton, 2004).


CAT has now been used with a diverse range of clients and problems with some success. The
basic model has only needed modification when working with personality-disordered clients
where the integration of fragmented self-states is of paramount importance. These modifica-
tions include longer treatment contracts – typically 24 sessions, a focus on tracking self-states
via monitoring of changes in voice, body, dialogue and actions rather than roles and proce-
dures, with a corresponding reliance on diagrammatic formulations to steer the therapy. For
other groups, for example the learning disabled, simpler forms of understanding are worked
with and more time given.
CAT, like many therapies, can struggle to work successfully with clients from particu-
lar ethnic, cultural or religious backgrounds where the autonomy and self-responsibility
of the person is denied and self-reflection and education is discouraged. CAT would
describe these cultures as having strongly socially-enforced narrow repertoires of roles
and procedures (for example a typical split of submissive, dependent and controlled roles
for women with dominant, non-dependent and controlling roles for men). CAT can be
more helpful to clients bridging two cultures by describing their choices in role and pro-
cedure terms thereby allowing for a clearer understanding of the likely consequences of
different choices.

CAT itself is, by definition, a limited approach. It is usually time-limited, which means
needing to focus on selected target problems thereby leaving other problems aside.
Without the time limit CAT can take problems in turn in an open-ended way until they are
resolved. CAT requires clients to develop awareness and reflective capacity. This can take
a varying amount of time depending on the client. Those who have great difficulty in
reflecting are probably best served by behaviour therapy. CAT does not well serve those
who are interested in a slow and perhaps more passive exploration of and reflection on
their inner world. CAT does not yet theorise the transpersonal, the dynamic or collective
unconscious or the body.
There are many recognised ways in which the therapy can be frustrated. Here are four:
1. Failures of description: The therapist can get the description wrong due to partial information some-
times due to denial (e.g. of being an abuser), dissociation (e.g. of being abused) or where the ‘false
self’/adapted structure is seen to be all there is, or by not developing it jointly with the patient. Often
descriptions can be disagreeable or unagreeable due to shadow feelings such as envy or shame
being named.
2. Failure to handle parentally derived roles: Most clients have intrapersonal conflict between parentally
derived roles and child adapted roles, e.g. ‘harshly critical and demanding’ to ‘crushed but striving’. The
client usually seeks help due to the miseries of the child-adapted role but at the same time the power
of the parentally derived role feels threatened by the therapist’s help. Empathising with the child

adapted role without naming and challenging the parentally derived role maintains the conflict and
defeats change. Recognition and revision of both roles is needed.
3. Failure to name secondary gains: Narcissists often defeat therapists because the secondary gain of the
therapist’s attention is more satisfying than the primary gain of becoming an ordinary, good enough
person (defined from the therapist’s point of view). Similarly clients stuck in the abused victim role often
prefer the secondary gain of the therapist’s empathy rather than the primary gain of the self-esteem
derived from standing up to abuse.
4. Failure to understand resistance to demands: Clients who have been bullied or oppressed in childhood
display a range of typical responses to any kind of demand particularly from perceived authority figures
(including therapists): (1) gloomy, depressed submission, (2) passive resistance (must–won’t), (3) sabo-
taging resistance, (4) active and often destructive rebellion (must not – will). This needs to be described
and recognised via a discussion of reasonable versus unreasonable demands before any therapeutic
alliance can be achieved.

There has been little overt criticism of CAT so far, perhaps because integration of psy-
chotherapy theory and practice is the current zeitgeist. Early criticisms of CAT came
mainly from the psychoanalytic/psychodynamic tradition, pointing out that the analytic
understandings integrated into the CAT model were misunderstandings. In particular, it
was felt that inter- and intrapersonal processes could not and should not be reduced to
roles and procedures on a diagram. CAT was essentially seen by psychoanalytic thera-
pists as a dry cognitive process unlike the deeper, more nuanced and more nourishing
process of psychoanalytic therapy. One criticism took a swipe at written reformulations
pointing out that real ‘milk’ (of human kindness in analysis) was better than the word
‘milk’ written on paper. CAT has also been subject to the same informal criticism of
being too brief that all types of brief therapy are open to. CAT is in effect only brief
because of the financial limitations of the NHS, medical insurance and the average per-
son’s wallet. CAT is mostly practised episodically allowing for resource limitations to be
negotiated.
The dialogue on theoretical differences about the nature of the mind and self will no doubt
continue and CAT will remain open to exploring and incorporating new developments in
theory and practice. Client feedback clearly indicates that CAT is certainly deep and nourish-
ing enough while respecting the client’s autonomy.
5.4 Controversies
There are no controversies preoccupying CAT therapists at the current time. This probably
reflects its collaborative ethos but may also reflect its theoretical origins in the thinking of
only one person (i.e. Ryle) and also its relatively short history so far.

6 RESEARCH
The evidence base for the effectiveness of CAT can be described under three headings:
1. Controlled outcome studies.

2. Uncontrolled, naturalistic outcome studies with measured outcomes.
3. Detailed studies of phenomenology and change: process research.
Controlled outcome studies: The gold standard of research is the RCT (randomised control
trial). CAT has published a few demonstrating effectiveness including Brockman et al. (1987)
on the effectiveness of trainees giving brief CAT therapy, Fosbury et al. (1997) on CAT with
diabetes treatment compliance, Treasure and Ward et al. (1997) on CAT for anorexia. Chanen
et al. (2008) describes an RCT of CAT in early intervention with borderline personality dis-
order. Further studies are needed but have inevitably been hampered by the continuing scar-
city of research funding.
Uncontrolled, naturalistic outcome studies with measured outcomes: There are a few stud-
ies of non-randomised, typical outpatient groups showing significant effects. These include
Dunn et al. (1997) on neurotic outpatient clinic clients (n=135), Garyfallos et al. (1998),
Pollock (2001) on adult survivors of childhood abuse and Ryle and Golynkina (2000) on
borderline personality disorder (n=27).
Detailed studies of phenomenology and change: In terms of process variables there are
increasing numbers of studies exploring the effectiveness of different variables in CAT. The
effectiveness of Reformulation was studied by Bennett and Parry (1998); Pollock et al.
(2001) investigated the effectiveness of the Personality Structure Questionnaire in identifying
self-states in personality disorders; Sheard et al. (2000) investigated the effectiveness of a
three-session model of CAT for repeating self-harmers; Walsh et al. (2000) looked at particu-
lar reciprocal roles in relation to asthma mismanagement.
Single case studies describing CAT include: Ryle et al. (1992) and Dunn (1994). Much
more work needs to be done and published to establish the particular benefits of CAT but this
is likely to be a slow accumulative process given the current research environment. At the
present time CAT seems to be as effective as any other brief therapy.
7 FURTHER READING
Hepple, J. and Sutton, L. (2004) CAT and Later Life: A New Perspective on Old Age. Hove / New York: Brunner-
Routledge.
McCormick, E.W. (1990) Change for the Better: A Life Changing Self-help Psychotherapy Programme. London: Unwin.
Ryle, A. (1995) Cognitive Analytic Therapy: Developments in Theory and Practice. Chichester: John Wiley & Sons Ltd.
Ryle, A. and Kerr, I. (2002) Introducing CAT: Principles and Practice. Chichester: John Wiley & Sons Ltd.
Ryle, A., Leighton, T., Pollock, P.H. (1997) Cognitive Analytic Therapy and Borderline Personality Disorder: The
Model and the Method. Chichester: John Wiley & Sons Ltd.

8 REFERENCES
Bennett, D. and Parry, G. (1998) The accuracy of the reformulation in cognitive analytic therapy: a validation study.
Psychotherapy Research 8: 84–103.
Bowlby, J. (1988) A Secure Base: Clinical Applications of Attachment Theory. London: Routledge.
Brockman, B., Poynton, A., Ryle, A., Watson, J.P. (1987) Effectiveness of time-limited therapy carried out by trainees;
a comparison of two methods. British Journal of Psychiatry 151: 602–9
Chanen, A.M., Jackson, H.J., McCutcheon, L.K., Jovev, M., Dudgeon, P., Yuen, H.P., Germano, D., Nistico, H.,
McDougall, E., Weinstein, C., Clarkson, V., McGorry, P.D. (2008) Early intervention for adolescents with border-
line personality disorder using cognitive analytic therapy: randomised controlled trial. British Journal of
Psychiatry 193: 477–84.
Dunn, M. (1994) Variations in cognitive analytic therapy technique in the treatment of a severely disturbed patient.
International Journal of Short-Term Psychotherapy 9(2): 119–33.
Dunn, M., Golynkina, K., Ryle, A., Watson, J.P. (1997) A repeat audit of the cognitive analytic clinic at Guys
Hospital. Psychiatric Bulletin 21: 1–4.
Fairbairn, W.R.D. (1952) Psychoanalytic Studies of the Personality. London: Tavistock.
Fosbury, J. et al. (1997) A trial of cognitive analytic therapy in poorly controlled Type 1 patients. Diabetes Care
20(6): 959–64.
Garyfallos, G., Adamopoulou, A., Mastrogianni, A., Voikli, M., Saitis, M., Alektoridis, P., Zlatanos, D., Pantazi, A.
(1998) Evaluation of cognitive analytic therapy (CAT) outcome in Greek psychiatric outpatients. The European
Journal of Psychiatry 12: 167–79.
Hepple, J. and Sutton, L. (eds) (2004) Cognitive Analytic Therapy and Later Life. Brunner-Routledge.
Leiman, M. (1992) The concept of sign in the work of Vygotsky, Winnicott and Bakhtin: Further integrations of
object relations theory and activity theory. British Journal of Medical Psychology 65: 209–21.
Leiman, M. (1994) Projective identification as early joint action sequences: a Vygotskian addendum to the
Procedural Sequence Object Relations Model. British Journal of Medical Psychology 67: 97–106.
Pollock, P.H. (2001) Cognitive analytic therapy for borderline erotomania: forensic romances and violence in the
therapy room. Clinical Psychology and Psychotherapy 8: 214–29.
Pollock, P.H., Broadbent, M., Clarke, S., Dorrian, A., Ryle, A. (2001) The personality structure questionnaire (PSQ):
a measure of the multiple self states model of identity disturbance in cognitive analytic therapy. Clinical
Psychology and Psychotherapy 8: 59–72.
Ryle, A. (1979) The focus in brief interpretive psychotherapy; dilemmas, traps and snags as target problems. British
Journal of Psychiatry 134: 37–46.
Ryle, A. (1990) Cognitive Analytic Therapy: Active Participation in Change. Chichester and New York: Wiley.
Ryle, A. (1992) Critique of a Kleinian case presentation. British Journal of Medical Psychology 65: 309–17.
Ryle, A. (1994) Consciousness and psychotherapy. British Journal of Medical Psychology 67: 115–23.
Ryle, A. (1995) Critique of a Kleinian case study: defensive organizations or collusive interpretations? A further
critique of Kleinian theory and practice. British Journal of Psychotherapy 12(1): 60–8.
Ryle, A. (1998) Transferences and countertransferences: the cognitive analytic therapy perspective. British of
Journal Psychotherapy 14(3): 303–9.
Ryle, A. and Golynkina, K. (2000) Effectiveness of time-limited cognitive analytic therapy of borderline personality
disorder: Factors associated with outcome. British Journal of Psychotherapy 73: 197–210.
Ryle, A., Spencer, J., Yawetz, C. (1992) When less is more or at least enough: two case examples of 16-session
cognitive analytic therapy. British Journal of Psychotherapy 8: 401–12.
Sheard, T., Evans, J., Cash, D., Hicks, J., King, A., Morgan, N., Nereli, B., Porter, I., Rees, H., Sandford, J., Slinn, R.,

Sunder, K., Ryle, A. (2000) A CAT-derived one to three session intervention for repeated deliberate self-harm:
A description of the model and initial experience of trainee psychiatrist in using it. British Journal of Medical
Treasure, J. and Ward, A. (1997) Cognitive analytic therapy in the treatment of anorexia nervosa. Clinical
Psychology and Psychotherapy 4: 62–71.
Vygotsky, L.S. (1978) Mind in Society: The Development of Higher Psychological Processes. Cambridge, MA:
Harvard University Press.
Walsh, S., Hagan, T., Gamsu, D. (2000) Rescuer and rescued: applying a cognitive analytic perspective to explore
the ‘mis-management’ of asthma. British Journal of Medical Psychology 73: 151–68.
Winnicott, D.W. (1971) Playing and Reality. London: Tavistock.

15
Solution-Focused Therapy
Alasdair J. Macdonald
1 HISTORICAL CONTEXT AND DEVELOPMENT IN BRITAIN
1.1 Historical context

Solution-focused brief therapy (SFT) is a goal-oriented, competence-based approach.
Solution-focused therapists seek to help clients achieve their preferred outcomes by
facilitating conversations about solutions. SFT was founded in the 1980s by a group of
family therapists who worked at the Brief Therapy Center in Milwaukee, USA. The lead-
ers were Steve de Shazer and Insoo Kim Berg who had met at the Mental Research
Institute (MRI) in Palo Alto, California. After marriage they moved to Milwaukee, ini-
tially planning to reproduce the work of the MRI in that city. However, their own ideas
soon developed in other directions. According to de Shazer, Berg’s contribution was her
skilled and innovative work with clients, while his was to articulate the logic behind it. de
Shazer’s writing and teaching were immensely influential, especially after they began
their programme of international workshops. He died in 2005 and Insoo Kim Berg died
suddenly in 2007.
Families came to the Center in Milwaukee with multiple, chronic and complex problems.
Members often argued about the nature of the problem and who was to blame. Parents and
children became defensive in this conflict arena and were unwilling to consider their need
to change. Thus, the MRI approach of seeking out attempted solutions was less effective.
After a time the team began to stop asking families about their problems and asked instead
about what their solutions would look like. They asked each family member how they would

know the situation had improved: what would they notice that was different? Taking this as
a starting point, the team found that families spent less time arguing over their problems.
They discovered that the more they encouraged family members to notice times when things
went better, the more the family seemed to change. When families focused more on their
solutions, they talked less about their problems.
Since the seminal papers and books of the 1980s, SFT has built an international following
of professionals across disciplines. It has moved beyond the boundaries of therapy to apply
its techniques in a wide variety of fields, such as:
• business: coaching, project management, appraisal, team building;

• education: tutoring, pastoral care, mentoring and teaching;
• mediation, advice and guidance;
• psychology;
• social work, including child protection;
• health care and health maintenance.
SFT is used extensively with groups, teams, couples, families, young people and children.
Some practitioners use the approach in a purist form while others integrate it into their exist-
ing practice. In 1993 the European Brief Therapy Association, with its largely SF member-
ship, began to organise annual conferences, which attracted practitioners from all over the
world. These annual conferences have continued in a variety of different European cities and
in collaboration with SF associations on other continents.
Evan George, Chris Iveson and Harvey Ratner, three social workers and family therapists,
were the pioneers of SFT in the UK. In 1987 they discovered a mutual interest in brief ther-
apy when they were working and teaching together in London. They first explored the MRI
model of brief therapy but were soon persuaded by the work of Steve de Shazer to begin to
experiment with his SF model. Their success in using the model attracted the interest of other
professionals who, in turn, sought training in the approach. To meet this need the team estab-
lished the Brief Therapy Practice, later to be renamed as BRIEF. This group remains the
leading source of SFT training in the UK.
Many of the leading figures in the brief therapy field such as Bill O’Hanlon, Steve de
Shazer, Insoo Kim Berg, Yvonne Dolan, Michael Hoyt, Scott Miller, Linda Metcalf, Ben Furman
and Michael Durrant began to visit the UK to lead seminars and workshops. In 2000 a
Master’s degree in SFT was made available, designed and led by Bill O’Connell. Until then
training had taken place mainly through short modules delivered by practitioner-trainers or
through private organisations.
In 2002, a small group of practitioners met in Birmingham to explore the need for a
National Association. They agreed that the purpose of such an association would be to:
• enable practitioners to share good practice;

• raise the national profile of SF practice;
• provide information to the general public about the approach and facilitate access to SF practitioners;
• explore professional issues such as accreditation.

SOLUTION-FOCUSED THERAPY 389
In 2003, this founding group established the United Kingdom Association for Solution
Focused Practice (UKASFP), which quickly recruited a substantial membership. It publishes
an online newsletter and a Research Review, has established a successful annual conference,
stimulated regional groups and launched a website (www.ukasfp.co.uk/). The Association has
begun a process of accreditation for practitioners and provides a directory of members. The
energy, enthusiasm and commitment behind the Association reflect the dynamism that drives
the SF movement in the UK.
In the early days, SF literature was almost entirely American. de Shazer was a prolific
writer who contributed a stream of articles and published several books. His books were
seminal texts, from Keys to Solutions in Brief Therapy (1985), through Words Were Originally
Magic (1994), to More than Miracles (2007). Insoo Kim Berg also published a number of
influential textbooks reflecting her own deceptively relaxed style of work.
The first UK-authored book was Problems to Solutions (1990) by Evan George, Harvey
Ratner and Chris Iveson (now in its second edition). There is now an extensive bibliogra-
phy including books in English, Swedish, German, Mandarin and Japanese. There are
many published papers on research and other aspects of SF work: about 1500 new publica-
tions in 2011.
The history of SFT in the UK is one of rapid growth and increasing maturity. It has pro-
gressed from a small number of pioneers into a major player in the therapeutic field. Many
practitioners in the UK make use of it in mental health, learning disability, substance misuse,
education, coaching and management. Its use in health education and in return to work issues
is expanding. SFT offered a time-limited, goal-oriented way of working which suited the
needs of a busy society. It clearly focused on finding solutions rather than introspection or
history. It appeals to clients as more practical than traditional therapies, while being less intel-
lectually and emotionally demanding than cognitive-behavioural therapy. Within a relatively
short time it has made its mark and joined its relatives in the therapy family tree.

The SF image of the person is that of a resilient, skilled, imaginative, idiosyncratic problem-
solver. Human beings are creative and flexible solvers of the problems presented by their
social environment. The human brain is an amazing treasure house of bright ideas and a
repository of a lifetime’s solution-memories. One’s thinking can transform in seconds, then
being expressed in speech and in actions. In response to focused questioning people can
become more aware of their own abilities, and they may also recall their previous unsuccess-
ful solutions! SF therapists communicate to their clients that ‘there’s nothing wrong with you
that what’s right with you can’t fix’. Rather than attempt to fix what may be wrong, the
emphasis is on finding out what works for the client and how they could find ways of doing
more of it.

There is, in SFT, a strong commitment to the empowerment of clients, coupled with an
optimistic assumption about the inherent abilities of people. Relying on the client’s abili-
ties means that the therapist takes the pragmatic position that clients are doing their best
most of the time. Instead of regarding client resistance as something to work on, the
therapist reads it as a message to do something different in order to engage the client on
his or her own terms.
Respecting the client’s autonomy is also a warning against rescuing or problem solving on
their behalf. The therapist does not find solutions for the client from within his or her own
repertoire, but together they work to find solutions that fit the client. Instead of searching for
a quick fix, the emphasis is on finding small steps forward in the belief that small changes
can lead to big changes. Advice may be given where clear guidelines exist, but this is less
common in human affairs than might be supposed.
Some critics dismiss SFT as a version of ‘positive thinking’, or a version of ‘pull yourself
together’; this is a caricature. Pressurising people to see the positives in every life situation
minimises or denies the complexity and the shadow side of the human condition. In daily life
we see that most people are over-optimistic already. This appears in estimates of journey time
and hopes for the sale price of our house. SFT acknowledges the negativity, the loss, the pain
and the confusion in our lives. Therapists who push people to move on are not working
within the SFT framework.
The philosophy behind SFT is social constructionism. This epistemology also underpins
Kelly’s The Psychology of Personal Constructs (1955), Neuro-Linguistic Programming
(Bandler and Grinder, 1979), the Brief Problem-Solving model developed at the MRI by
Watzlawick et al. (1974), and the Narrative approach as described by White and Epston
(1990). The MRI and the SFT model owe much to the seminal thinking of Gregory Bateson
(1972) and Milton Erickson (1980).
Constructionism argues that meaning is created through social interaction and negotiation.
It proposes that we have no direct access to objective truth independent of our linguistically
constructed versions. It argues that theories are not objective versions of external reality, but
a socially constructed framework of ideas that emerge within a cultural, political and social
context. The constructionist position challenges our belief that reality exists independently of
us, the observers. The knower actively participates in constructing what is observed.
Constructionism contradicts our hopes that reality is discoverable, predictable and certain.
We agree the meanings that we will allocate to ideas as we talk about them. For example,
‘freedom’ has very different meanings to individuals of different ages, genders and economic
status. What it means for one specific client on one particular issue will emerge in discussion,
not from the dictionary.
In therapy, the client and the therapist explore a range of meanings for the client’s experi-
ences and work towards negotiating a provisional understanding. This does not mean that any
explanation for a problem will suffice, but it underlines the subjectivity and cultural relativity
of the language we use to describe our realities. Therapy becomes a dialogue in which both
partners construct what is meant by the problem and the solution. The problem does not carry
an objective, fixed meaning. Instead, clients tell and retell their story using language that

reshapes the social reality by which they live. In Watzlawick’s phrase (1984) ‘reality is
invented, not discovered’.
For the SF therapist this constructionist foundation means that:
• The client’s perceptions and experiences (provided they are legal and ethical) are privileged above those
of the professional.
• There is flexibility in negotiating a possibility narrative, which will open up new options.
• The task is to join with the client in order to co-create a new and empowering narrative.
• The client is viewed as an expert in his or her own life.
• The therapist’s expertise lies in guiding the process and keeping the dialogue within a SF frame.
• The therapist pays careful attention to the client’s context.
• The therapist builds upon the client’s competence and strengths.
• The therapist needs to be aware of her own values, blind spots and biases.
The SF approach claims to be minimalist both in theory and in practice. It has adopted
William of Ockham’s principle, that it is vain to do with more what can be achieved with less.
Being minimalist means that the therapist works pragmatically with what is already there in
the client’s life. This principle of utilisation has its roots in the work of Milton Erickson
(1980). Utilisation covers not only the positive, solution-oriented aspects of the client’s life,
but also those elements that might be viewed as neutral or even problematic.
In SFT it is not considered necessary to search for the origins or causes of people’s prob-
lems. The work is more in the present and about the future than it is about the past. If a
client has a theory about the causes of his problem, the therapist will accept it if it increases
the chances of the problem being solved, both in the short and the long term. ‘My father
caused my problem’ is helpful if it leads to ways of being different from father and solving
the problem more effectively. It is not helpful if it leads only to discussion about unchange-
able past events.
By containing the amount of problem talk about the possible causes of the problem, the
client is able to think past the problem and become more aware of his resources and options.
Instead of analysing the problem, the therapy focuses on the client’s observations of changes
and how they came about. This attention shift aims to help the client learn how to maintain
or expand the desired changes. When the client is primed to look out for and pay attention to
evidence of progressive change he is more likely to see it.
The therapist elicits the client’s pattern of problem-solving strategies by enquiring how the
client has dealt with similar problems in the past. Having discovered what works, the thera-
pist encourages the client to keep doing it.
SFT assumes that clients:
• can construct solutions with minimal, if any, analysis of their problems;

• have many resources and competences, some of which they and others are unaware of. We know that
most people do not use a fraction of their potential mental capacity;
• are more likely to be open to possibilities for change if they are connected to experiences of success,
rather than failure;

• have many ideas about their preferred futures;

• are already engaging in constructive and helpful actions (otherwise their situation would be worse!).
SF therapists accept that some clients believe they must get to the roots of their problems; for
the SF therapist this is not essential, and in some cases it becomes part of the problem. The
search for explanations or root causes can lead people to look for anyone or anything to
blame and can become a diversion from finding real and lasting solutions. Added to that,
there are often divisive opinions about problem definition and ownership of problems. Some
clients may get stuck because they constantly revisit memories of past events that disem-
power them and make them fatalistic about the future.
When clients live with problems they become experts about every detail. They give thera-
pists a guided tour so that they can learn what life is like for them. Some clients will have no
idea how to escape problems and move on to solutions. They may resign themselves to life
within the problem with all its limitations and difficulties: for some people, it is too frighten-
ing to consider change. They will need a lot of encouragement and support to go even a little
way. Some may be willing to risk a brief interlude in order to try a solution before they com-
mit themselves to moving forward.
By engaging in solution talk the therapist gives clients the opportunity to visit options on their
own terms without feeling that they cannot return to their previous state if they wish. Those who
find this a helpful experience may wish to develop a new set of strategies. Remembering what
they liked about the conversation may motivate them to take the next big step.
SF breaks the connection between the problem and the solution. Its practitioners have found that
they can help clients find solutions without reference to the content of the problem. They reject the
view that understanding the problem must necessarily precede a lasting and genuine solution. They
challenge the idea that we need to gather detailed information and the history of the problem in
order to find solutions that fit. SF therapists work on the basis that the solutions do not need to look
like the problem. The fact that the problem has been around for a long time and is complex need
not mean that it will take a long time to solve or that the solution should be equally complex. Since
the approach is not dependent upon the content of the problem, a SF therapist will use similar types
of interventions with all clients, irrespective of the nature of the problem.
However, although the SF therapist does not need to hear about the problem in detail, the
client may want or need to talk about it (Macdonald, 2011). This may apply especially if the
problem has not been discussed with someone before. Problem talk is important when it
clearly meets the needs of the client, it becomes an important part of the bridge to the future.
SF practitioners recognise and accept this. Occasionally material of extra-therapeutic impor-
tance may be disclosed such as a potential risk of abuse or self-harm. In that case, other action
outside the therapy room may be necessary to ensure the safety of individuals.

It may be clear from the above that medical terms do not sit easily with SFT. Since SFT does
not seek to explain problems it does not have a conceptual framework for psychological

disturbance. This may lead to the exclusion of SF research when treatments are being
researched, since diagnostic categories are usually the core of such enquiries.
SFT does not take a position in relation to the interaction between thinking, feeling and
behaving. It is, however, firmly opposed to intrapsychic explanations for problems and favours
a more interactional frame, which pays attention to the specific context of the client’s life.

Given what has been written already, it will come as no surprise to say that if you were to
ask a SF therapist how psychological disturbance is acquired then you would be likely to get
the response, ‘I wouldn’t think about it in that way.’ SFT does not have a theory to explain
how people become psychologically disturbed. It does not believe that understanding
pathology is necessary for the client to collaborate with the therapist in the search for solu-
tions. SF therapists are sceptical of the power position occupied by the therapist who holds
a map or a theory that suggests how people became or continue to be psychologically dis-
turbed. A healthcare professional, or an educator, may have their own ideas about the origin
of a difficulty, but that is often not needed for the therapy conversation. Since the starting
point for therapy is where the client would like to get to, there is minimal attention to his-
tory, formulations or speculations about where the client has been. If the client chooses to
share with the therapist an account of how they think their problems began, the therapist
listens and empathises. But he or she would not be proactive in seeking out this information,
unless the agency required it. Collecting a case history may be useful for research, risk
assessment and therapist-as-expert therapies, but it is of secondary importance to a client-
centred, future-oriented approach.

When people spend excessive time analysing their problems they strengthen the neural net-
works in the brain attached to their memories of the problem. Recalling the details around the
problem experience causes the brain to search for associated memories of other problems. This
reactivates memories and feelings of sadness, anxiety, fear or whatever. This re-enactment
imprints a fresh memory of the problem experience. When these pathways have developed over
a long period of time and been regularly revisited, it becomes more difficult to break the con-
nections. Similarly, when a person reflects upon previous successes, skills and resources, the
brain automatically seeks evidence of a similar kind. When positive feelings such as joy, satis-
faction and pride accompany the memory, the brain records this rewarding and empowering
experience and reinforces the pathways to solutions. This brings chemical rewards at a neuronal
level which, in turn, motivate the client to repeat the solution experience.
We store our experiences of major life events in our long-term memory and are particularly
able to access those with strong emotional resonance. Johnson describes the brain as ‘an

associative network in which thoughts are represented by groups of neurons distributed

throughout our brains that fire in sync with each other. Certain thoughts have more neurons
in common than others. Neurons that fire together, wire together’ (2004: 200). When we
revisit our memories we trigger off other associated memories. From a SF standpoint the
consequences of this are that:
1. The therapist discourages the client from revisiting those problem neural connections, which the client
has maintained by dwelling upon their problems. By neglecting the problem pathways the neural connec-
tions will become weakened.
2. Conversely, the therapist encourages the client to build new pathways to solutions. This fires off other
neurons associated with memories of solutions in their memory bank. These connections will become
stronger the more the client thinks and talks about how to make the changes they want.

SFT argues that by dwelling upon disturbance, deficits and problems, the individual is likely
to attract more of the same. Presenting yourself in a particular light leads to responses from
other people which can often strengthen our own assumptions about ourselves. These
assumptions can be positive or negative. People can become experts about their problems,
believing that they know why they have them, but have no idea how to overcome them. They
can become attached to, yet trapped by, professional-inspired labels. The problem-label may
become justification for a fatalistic resignation to the status quo. Some drug abusers, for
example, label themselves as ‘junkie’ or ‘smack head’, communicating their belief that they
are bound forever to their problem.

The most important part of our environment in terms of behaviour is the social context in
which our behaviour occurs. Actions which are undesirable in our home town may lead to
military distinction on the battlefield. Thus the social environment can be crucial to our mak-
ing changes. Further, our own reactions to environmental factors may move us in a useful
direction, or may not. So exploring our usual reactions may allow us to change to more effec-
tive ways of responding.
2.5 Change
SFT does not propose a specific sequence or pattern of change applicable to all. As the
Buddhists say, change is a universal constant. Instead, based upon clinical experience, the
premise of SFT is that people change more quickly when they focus on useful changes, rather
than what has happened already. They make further changes as they become aware of
changes already happening in their lives. When they realise that their problem is not fixed
but is in a constant state of evolution, they become more hopeful that they can influence its
course. Change becomes more attractive and attainable when people face it from a position

of self-confidence, believing that they have the capacity to rise to the challenge. SFT supports
this position by giving clients affirming, honest and life-enhancing feedback, free of blame,
criticism and judgement. Most people are far more likely to risk change when given time and
space to reflect upon their own unique set of resources, solutions and strategies. People
change when:
• they know what to change, when to change and how to change;

• they believe that there is something better than their present circumstances;
• they tap into what is best about themselves;
• they find reasons to be hopeful, optimistic and dynamic.
3 PRACTICE

The goals of therapy are those proposed by the client in negotiation with the therapist in clear,
specific and measurable terms at the start of the work. SF work is client-centred in the sense
of staying close to the client’s agenda, context and capacity. SF therapists will assist the client
in keeping the goals achievable and practical, for example, keeping the focus on a child’s
bedwetting, not aiming at universal good behaviour in all aspects.

The agency in which the therapy is taking place may have specific selection criteria but the
model itself does not impose set criteria as to who might benefit. SFT can be offered as an option
for any client, although not every client will find it helpful. SFT does not appear to be harmful
even when it is ineffective. Even very diffuse goals can be a useful starting point. SF is currently
used with a wide range of challenging clients including offenders, substance misusers, survivors
of sexual, physical and emotional abuse, people with learning difficulties and those with mental
or physical health problems. Anecdotal evidence suggests that many clients who did not engage
with problem-focused therapy find the SF process more accessible. Since change often occurs
quickly, SF work can be tried while awaiting more detailed treatment if required.
While there are many practitioners who see themselves as exclusively SF and are purist in
their practice, there are many others who take an integrated position. They use the core interven-
tions and subscribe to the beliefs and values of SFT, but where appropriate also use interventions
from other therapies. This is consistent with the SFT principle, ‘if it doesn’t work, do something
different’. It also embraces the maxim that the model fits the client and not the client the model.
Some clients undoubtedly benefit from a fusion of SFT and other approaches. For example, post
traumatic stress disorder in military veterans often benefits from a combination of Eye Movement
Desensitisation and Reprocessing (Shapiro, 2001) and SF (Henden, 2011).


Some clients present themselves as the sole or central aspect of the problem. It may be useful
to accept this position, at least at the start. Others are only accessible as individuals, for
example offenders in prison, where access to families is geographically or socially impracti-
cal. Change is often more rapid if families or partners can be involved in the treatment.
However, fears of blaming or hostility can make this difficult.

As in any psychological treatment, the Rogerian traits of empathy, warmth and genuine-
ness are essential. In many respects the alliance with the client is more crucial than tech-
nique. Respectful curiosity, a lack of blaming and the ability to accept diversity are all
valuable elements in building the therapeutic alliance. Celebrating diversity by working
with client’s unique beliefs, values and strategies, requires the therapist to have a mindset
that goes beyond mere acceptance of difference, to one that is fascinated and excited by
the range of attitudes and life styles chosen by clients. It is important to keep out of the
client’s way. In practice, this means trusting the client to know what works best in his life
and not interrupting his own problem-solving mechanisms by introducing therapist-initi-
ated solutions.
3.3.2 Skills shown by effective therapists

SF therapists require the ability to:
• Listen attentively and be able to feedback to the client those aspects of the client’s narrative which SFT
privileges e.g. evidence of the client’s resources. A key skill for the therapist is to reflect back positive aspects
of what the client has said and to add a phrase or question, which orients the client in the direction of solu-
tions and resources. Throughout the interview the therapist gives their undivided attention to the client and
matches language in order to demonstrate connectedness to the client. This active listening, which includes
non-verbal as well as verbal communications, ensures that the therapist stays close to the client.
• Time the shifts from problem-talk to solution-talk and be able to step back if the client proves unprepared
for the shift. Many practitioners new to SFT intervene too early and talk about solutions without first
acknowledging and validating the client’s concerns and feelings. Forcing the pace often results in the
client being less willing to engage.
• Be disciplined in staying on the track of solutions, not being diverted by the search for explanations.
• Pace the number and frequency of questions. Since therapists ask a lot of questions they need to pay
attention to the client’s body language to ensure that the interview does not feel like an interrogation.
The therapist’s tone of voice and facial expressions are also important factors in securing the collabora-
tion of the client.
• Be sensitive to the use of language. This is a key skill as careful choice of language can open up or close
down possibilities. For example, SF therapists use qualifying phrases such as ‘so far’ or ‘as yet’ to suggest
that some time in the future the problem will be resolved.

• In SF resistance is understood to be a reaction of the client to some misapplied idea or process. The
worker views resistance as a signal to change the style or pace or focus of the session. The therapist
checks out with the client ‘Is this helpful?’ ‘Is this what you want to talk about today?’ ‘Do we need to
do anything different?’

A SF relationship is a respectful collaboration in which the client’s expertise is given equal
weight to the therapist’s. The latter’s expertise lies in creating a therapeutic environment and
setting the direction of the conversation in a manner consistent with SF principles. The exper-
tise of the client lies in reflecting upon their experience and coming to a realisation of what
works for them. They are also responsible for the agenda: the goals for the work. The thera-
pist’s role is not to offer solutions or give advice, but to facilitate client solutions by questions
and reflections. The emphasis is on enabling clients to tap into their own resources: their res-
ervoir of skills, strengths and strategies, which will help them to overcome their problems.
Listening attentively, keeping the client on solution-track, reflecting back the client’s compe-
tence, promoting the client’s use of the imagination, summarising the client’s unique set of strate-
gies: these are the key contributions of the SF therapist. Technique does not make a therapist SF. It
is the quality of the relationship underpinned by SF values that makes someone genuinely SF.

Having observed many major figures in SFT using the approach, it appears that there is no one
authentic SF style. On the one hand there is a dynamic, high-energy style, exemplified by the
charismatic Bill O’Hanlon. On the other, there is the gentle, warm and quiet style, characterised
by Insoo Kim Berg. Steve de Shazer himself had a laconic, laid-back style that gave the impres-
sion he was not listening, when in fact he heard and picked up on almost everything! Generally
speaking, SFT encourages a relaxed conversational style. Neither self-disclosure nor personal
therapy are requirements for SF practice. One noticeable feature of SF interviewing is that there
is often humour in it, when the therapist judges it appropriate within the therapeutic alliance.
Perhaps the emphasis on the client’s strengths, skills and successes makes it easier for them to
share humorous moments. Steve de Shazer said once that his only worry about the future of SFT
was that someone would try to impose one single way of being SF.

3.5.1 Assessment
The therapist seeks to know the client’s understanding of the problem in terms of its name, fre-
quency and duration. Any pre-session changes are noted as evidence of motivation and commit-
ment. Suitable goals are negotiated, although these need not be precisely specified. Exceptions
to the problem are noted, even if these seem minimal or trivial. Responses to the miracle question

clarify goals and commitment, as well as improving the mood within the session. Scaling clari-
fies the current situation and future aspirations. It is usually helpful to know the immediate fam-
ily or social context in which the patient lives as this improves mutual understanding. A
knowledge of local facilities such as housing agencies or drug programmes is also helpful.
3.5.2 Formulation
Information drawn from the assessment over one or more sessions provides knowledge about
goals and commitment to solutions. Past ability to overcome difficulties may be a useful
resource. Available social support and some knowledge about financial and educational mat-
ters will usually have emerged in the conversation. The therapist will often be familiar with
other agencies who have been approached, and with local or national resources unknown to
the client. Thus advice-giving may form part of the feedback, if the client is thought to be
receptive to this. At least it shows the client that the therapist is trying to be helpful!

From the initial contact the therapist focuses on the theme of change. He or she uses pre-
suppositional language to convey to the client that change is inevitable; that it is already taking
place and that it will continue. For example, talk will focus on when change takes place, not if it
does. As clients experience the immediate benefits of change, this will empower them to make
further changes. When the client requests a therapy session he or she is recruited as an active
agent in the process. Beyebach and colleagues (1996) found that those clients who have already
made useful pre-session changes are likely to have a better outcome. When the client is able to
report positive pre-session change this indicates that they have already raised an awareness of
‘what works’ and has identified specific exceptions to the problem. Identifying pre-session
change gives momentum to the session, as well as a clear message to the client that observations
are key to finding solutions. It underlines the fact that the client has some power to shape their
own future. This is a powerful message for clients who may have felt stigmatised or de-skilled
in having to seek or be sent to have therapy. For many clients with a long history of criticism and
failure, this awareness of their strengths and achievements comes as a revelation. It challenges
their expectations about being exposed or made vulnerable during therapy.
(a) Problem-free talk Unless the client is distressed or launches into an urgent account of
their difficulties, the therapist takes some time at the beginning of the first session to engage
in conversation about the client’s interests or leisure pursuits. These conversations are more
than icebreakers. They often provide clues about:
• metaphors or illustrations which will resonate with the client;

• the client’s strengths, qualities and values;
• strategies which may work for the client.

Problem-free talk also underlines the fact that there is a lot more to the client than any dif-
ficulties s/he may be experiencing.
(a) Being brief Many SF therapists emphasise the brevity associated with the approach.
Psychotherapy research identifies that change usually takes three to six months, whatever the
model and whatever the problem. So brevity refers to the number and length of sessions, not
to the time period for therapy. Long-term disorders may require long or episodic intervention
but often each sequence involves a relatively small number of sessions, often only five or six.
(c) Competence seeking SF therapists draw particular attention to examples of their cli-
ent’s competence. The skilled therapist senses when to reflect back these strengths and
qualities. When doing this they invite clients to recognise them and to apply them in the cur-
rent situation. This feedback must be realistic or the client will reject the picture as being
overly positive. A tiny success can mark the path for larger changes. If in doubt these points
can be kept until the intervention at the end of the session.
(d) Building on exceptions Instead of asking questions about the occasions when clients
experienced their problems, SF therapists direct their attention toward times when the problems
were managed better. These episodes are called exceptions or parts of the miracle. There are
always exceptions to any problem experience because everyone has highs and lows, ups and
downs, good and bad times. These exceptions may be evidence to clients of their own construc-
tive strategies. Highlighting and exploring these exceptions enables clients to become aware of
how they made them happen or made use of them when they happened by chance. They can
begin to think about how they could repeat and expand these helpful strategies.
(e) Scaling Although scaling is not exclusive to SFT, the questions used were largely devel-
oped for SF work. Therapists use a scale of zero to ten to help clients:
• measure progress;
• build confidence and motivation;
• set small identifiable goals;
• develop strategies.
Ten on the scale represents the best it could be and zero the worst. Scaling is a simple, prac-
tical technique, which clients can use between sessions to measure their progress and to plan
their next steps.
(f) The miracle question ‘The problem’ is of the past; scaling is firstly an assessment of
the present. The miracle question (MQ), described by Steve de Shazer (1988) and attributed
to Insoo Kim Berg, is an intervention used by SF therapists near the beginning of therapy,
aimed at moving forward towards a brighter future. It is designed to help clients bypass prob-
lem talk. Answers to the MQ may become the main focus of the work. It can be a powerful

intervention, accessing material not easily unearthed by conventional questioning. The MQ

can sometimes clarify, reveal and on occasions dissolve problems. The question is asked in
the first session unless the client is clearly not ready to address hopeful topics. It may be
asked again if the therapist, at the client’s request, is addressing a new problem. Some clients
experiencing bereavement and other forms of crisis need a simpler dialogue with an empha-
sis on managing the immediate future rather than on miracles. Some with severe alcohol
problems or physical disability may focus on small changes rather than miracles. The ques-
tion is an invitation to the client to describe how his day-to-day life would look when his
problems disappeared.
(g) Between session activity By the end of the interview the therapist will usually have
elicited some ideas from the client as to what can be done next to make things better. In the
feedback the therapist will pull these together, usually using the following principles:
(i) If it works keep doing it.

(ii) If it doesn’t work stop doing it.
(iii) Small steps can lead to big changes.
(iv) Do something different.
In addition to these the therapist may invite the client to carry out:
• A noticing experiment. This is observational, most commonly given to clients who have struggled to
answer questions about their experience and who do not see themselves as able to take action. The
therapist asks the client to notice times when the problem is not so bad or times when someone else
does something they value or when they do something they feel good about.
• A pretending experiment. This is when the client is asked to behave for a short time as if the miracle has
happened and to notice anything that is different in that time.
(h) Feedback At the end of each session the therapist takes a short break to compose a short
message for the client. Some therapists will actually leave the client and go elsewhere to do this
for a few minutes, perhaps in discussion with a reflecting team. Others remain in the room,
saying ‘This is a complex situation; I need a few minutes to think about it.’ They quickly scan
their notes and compose the feedback. During the feedback the client is not invited to join in as
this is part of concluding the session. The feedback follows a clear and simple sequence:
Acknowledge the problem briefly

↓
Positive feedback
↓
Summarise client achievements
↓
Link to goals
↓
Negotiate next step


In order to be brief the therapist will:
• treat every session as if it could be the last, especially the first one;
• project confidence and hope that much can be achieved in limited time;
• stay close to the client’s view of the problem;
• trust and consult the client;
• believe that ‘more’ does not mean ‘better’;
• be curious only about solutions and sometimes not even about them;
• intervene as minimally as possible;
• avoid a focus on ‘the problem’;
• match the client’s language;
• deconstruct problems into goals;
• use what the client brings;
• negotiate attainable goals.
(a) Pre-session change In the contact about the first appointment the therapist may
ask the client to notice any changes that take place prior to the first appointment. When
the client comes to the first session the therapist will express curiosity about what might
have changed. If the client can report beneficial change the therapist will ask, ‘How did
you do that?’
(b) Looking for exceptions The therapist supportively explores with the client the circum-
stances in which the exception took place. He or she may use questions such as:
• How did you do that?

• What was the first thing that you did?
• How did you know that was going to be useful?
• What needs to happen for you to do that again?
Having unearthed evidence of exceptions the therapist encourages the client to keep doing
what works.
(c) The miracle question: therapeutic technique Its usual form is similar to this:
‘I’d like to ask you a strange question, which might need some imagination, OK? Suppose you go to
bed tonight as usual, and while you are asleep a miracle happens, and the problem that brought you
here today is solved. But you are asleep and do not know that the miracle has happened. When you
wake up, what will be the first signs for you that a miracle has happened and that the problem is
solved?’
In asking the MQ the therapist may hope to clarify goals, find exceptions and generate opti-
mism. The therapist follows up the first answer by further questions, closely linked to the

client’s answers. ‘So after you’ve managed to…, what else will be different after the miracle
has happened?’ Each answer contributes to the client’s preferred scenario and helps to clarify
available strategies. As therapists expand client’s miracle answers, they listen for exceptions:
times when even a small part of the miracle has happened. They also listen for evidence of
strengths, qualities and competence. They use circular questions to scan the client’s system
or network. ‘Who else will notice that the miracle has happened? What will they see that is
different? How will they respond? If they respond like that, what do you think you will do?’
The miracle question requires focused concentration by the therapist: the therapist asks
repeatedly, ‘What else will you notice?’
During the session the therapist will write down or remember the client’s answers, as
they will be central to the feedback given at the end of the session. A helpful way of draw-
ing the MQ to a close is to ask scaling questions in relation to some of the answers. Steve
de Shazer’s final work More than Miracles (2007) suggests that all scaling should come
after the MQ, which assumes that all first sessions will use the MQ. Some therapists like
to open the session with ‘What are your best hopes for this session?’ instead of using the
miracle question.
(d) Scaling Therapists invite clients to think about their position on the scale by asking such
questions as:
• Where were you a day or two ago?

• What was happening when you were higher on the scale?
• Where do you hope to be in the next few weeks?
• What needs to happen for that to come about?
Clients are invited to think where other significant people would put them on the scale, since
social reinforcement is a major factor for us all. SF therapists encourage clients to consider
small steps they can take which will move them perhaps one point up the scale. This is con-
sistent with the SF principle that small changes can lead to big changes. It is often the case
that when clients commit to making small changes they build momentum that takes them
much further than they had originally planned.
(e) Closing question
‘Before we finish, is there anything that you want to mention that we have not covered?’
This is a safety question, allowing disclosure of new issues. These may require urgent explo-
ration or may be held over for the next session.
(f) Acknowledge the problem It is important to begin by acknowledging the problem

briefly in one or two sentences. This shows that the therapist has been attending to the cli-
ent’s words and avoids the impression of underestimating or trivialising the problem.

(g) Positive feedback about client achievements The therapist gives positive feedback
about the client’s participation in the session and specific examples of what the client is doing
in between sessions to sort out the problem.
This may include comments such as:
• I was really impressed by the way you …

• I appreciated the fact that you …
• I thought that it was a great help the way that you …
• It was good to hear that on Monday when you normally would have done …, you managed to do …
instead.
• Another important thing you did this week was to ... and I know that wasn’t easy for you to do.
These comments should be genuine and grounded in specific examples. The purpose of this
summary is to reinforce and encourage the client to keep doing what works.
(h) Link to goals The therapist may link this evidence of progress with the client’s goals.
• It sounds as if what you managed to do on Tuesday when you … is just the kind of thing you’re
working on.
(i) Negotiate next step The therapist suggests a next stage: what the client is going to do
before the next meeting. (The words ‘Homework’ and ‘task’ are avoided as being too direc-
tive.) Clients like the therapist to offer suggestions and advice although they will not neces-
sarily accept the advice. They often come up with their own different ideas after the therapy
session.
Although the elements of the session are presented here in the usual order, the therapist
will use their judgement about the sequence. If a client begins the session by saying
‘Only a miracle can help me’, the therapist may well move at once to the MQ and ask
the other questions later in the session. It is valuable to give the clients the choice about
how long it should be before the next appointment. As a rule they will ask for a longer
gap than the therapist expects, revealing their own self-confidence about managing their
situation for a while. If they have chosen their own time interval it is less common for
them to request earlier appointments or to miss subsequent ones. In asking if they need
to come back at all, it is best to assume that anything which is not an outright ‘No’ should
be treated as a ‘Yes’. It is safer to offer an appointment that is not kept than to fail to
offer one which is needed.
(j) Return visits Every return visit begins with the question ‘What’s better?’ It is impor-
tant to show confidence in the chance of progress. Successes are amplified ‘How did you
do that?’ Difficulties can be explored in non-critical questions: ‘How did that happen?’ or
‘How did you cope with that?’ Then the therapist proceeds to scaling and feedback with
a new next step. It is unusual to remind clients where they placed themselves on the scale

at their last visit, unless they ask specifically. The scale is a personal internal measure and
so the numbers in themselves are not significant: what matters is the current score and the
next step. If their score is the same on the scale or lower than at the last visit then a
reminder about this can be experienced as criticism. If they are higher now than before
then it is more important to explore this achievement than to make comparisons with the
past, which cannot be changed in any case. The same sequence of questions applies after
one return visit or twenty.

The entire SF process is about eliciting and expanding positive change in the client’s life.
It is based upon the assumption that change is inevitable but that awareness of the direc-
tion of change is useful if the client is to achieve the stated goals. Making this awareness
explicit is a goal of the work: that is the rationale for targeting exceptions, resources and
goals. Right from the start of the work the therapist helps the client to imagine the ending,
‘How will you know you don’t have to come here anymore?’, ‘What will your manager/
partner/probation officer have to see before they realise what you have achieved?’
One starting point for the change process can be agreement about what the client does not
want to change. If it is possible to define this, it frees the client to explore what he they do
want to change. Faced with a complex and chronic set of problems it is possible for client
and therapist to be overwhelmed by the task ahead. This is less likely to happen in SFT
because the therapist will not get bogged down in the details of the problems and will not
believe that they require complex solutions. Most therapists recommend that the client
works on the largest problem first and then moves on to others if necessary.
However, the SF therapist recognises that not all clients are equally motivated towards
change and that it is not helpful to imagine that they are. It has been suggested that the rela-
tionship between therapist and client can be characterised as either:
• Visitor: one in which the client does not believe that they need to change anything. Trying to persuade
the client of the case for change is usually unproductive. It is often better to join with the ambivalence
and explore the current situation in a non-judgemental way. Fisch et al. (1982: 39) describe this type of
client as a ‘window shopper’ who slips into a shop in a heavy shower with no intention of buying any-
thing. Sometimes it happens that they end up buying something, but often they don’t. It could be argued
that SFT has an advantage over problem-focused therapies with this type of client, as there is no need
the client to admit to a problem. Exploration could focus on what the client would like to keep the same
or be different in life without going down the problem exploration route.
• Complainant: one in which the client agrees that there is a problem but sees the solution as lying else-
where, often in someone else changing their behaviour. The therapist listens empathically, matches
language and frame of reference and where appropriate, gives positive feedback. The therapist asks
coping questions which draw out what he is already doing to stop it getting worse and in some instances
this can lead on to how the client could make life better, even if the other person or situation did not
change.

• Customer: a relationship in which the client recognises that there is a problem over which there is some
control and is ready to do something about it.
• Recognising these styles can be helpful to the therapist in choosing which responses to make. However,
they have not been shown to have any direct connection with outcomes.
The ideas of Prochaska and DiClemente (Prochaska and DiClemente, 1982; Prochaska, 1999)
can also be useful to the therapist in selecting responses. They suggest that different interventions
are needed according to which stage of change the client has reached. So in pre-contemplation
(not in the next six months), providing information may be all that is acceptable to the client. In
contemplation (perhaps six months prior to change), information, thinking about resources and
approaches to the situation are possible topics. In preparation (weeks before change), how to
make change and what resources to use become significant. In action, the process is under way.
Prochaska suggests that this element takes about six months, which is in keeping with other
research on psychotherapy. In maintenance, relapse prevention and relapse management are
central. This stage is predicted to last between six months and five years but can last a lifetime.
Finally, termination, when the client has left the whole issue behind for ever.
4 CASE EXAMPLE
4.1 The client

Jane is an 18-year-old woman who presented at the surgery requesting help for her drinking prob-
lem. She has been drinking heavily for two years; approximately two bottles of wine and two litres
of cider every night until she becomes unconscious. She began drinking aged 11. She reported
violence in the family, death of a close relative and conflict between parents and grandparents
(‘maternal don’t like Dad and paternal don’t like Mum – they all make it very obvious!’).
Jane has been getting steadily more short tempered and verbally abusive to family mem-
bers, particularly Mum. A physical attack on Mum precipitated her referral. Despite this
heavy drinking and worrying behaviour Jane manages to attend college and has a part-time
job working in a hotel. She is worried that she may get expelled from her course if her drink-
ing does not reduce dramatically soon. She is on no medication although she has complained
of abdominal pain/discomfort for the last few months.
4.2 The therapy

Jane was open about her drinking. She had referred herself so the possibility of collaboration
existed from the start. She had little trouble in identifying usable goals. Her college course
and her part-time job showed that she was able to set goals and persist with difficult tasks.
There was already useful support from the family and her friends, suggesting that she was

able to make and maintain individual relationships. The therapist remained respectfully curi-
ous throughout, and made a point of using the client’s language in every response. This is an
invaluable tool for building relationships, in SF or in any conversation.
4.2.2 Assessment and formulation

An example of the interview dialogue: notice the matching of the client’s language in every
question.
• Problem
T What do you want to get out of being here today?

C Don’t know. I suppose I just want you to help me stop all this drinking.
T How many days in the week does the drinking occur?
C Every day.
T Do you drink the same every day?
C Yes; four to five pints of lager both at lunchtime and teatime as well as wine in the evening plus
spirits at weekends.
T Lager and wine…when did you start drinking this much?
C I’d say it’s been this heavy for about two years.
T Two years...Who else notices that you are drinking so heavily?
C My mum…I hit her last week when she told me off about drinking.
T Who else notices as well as your mum?
C Other family told me to get myself sorted out after I had hit my mum. I think the depression is the
problem to blame.
T Mostly we can only work with one problem at a time. Which is the biggest issue for you at present?
C The drinking worries me most but it comes from the depression.
T We can move on to other problems if necessary, after the drinking.
Problem: Jane drank four to five pints of lager both at lunchtime and teatime as well as
wine in the evening plus spirits at weekends, which had developed over the past two
years. She regarded this as a problem. Her mum and family members had noticed this
problem, which had led her to hit her mother when criticised. Presession changes included
reducing drinking somewhat and submitting four college assignments. She had also
started driving lessons and spent time with friends who were more moderate drinkers. Her
goals were to spend more time doing things with friends, get her work in on time and to
feel less tired and fed up.


(a) Exceptions to the problem When things were going better Jane was getting on better
at home with everyone, especially Mum, and enjoying college more, She spent more time
talking to friends when she did not have hangovers.
(b) Miracle question Her replies to the miracle question were that she would have no
hangover and would not drink in the afternoon. She thought that her mum would notice first
(smiling instead of nagging) and that others would notice thereafter.
(c) Scaling Another excerpt from the interview dialogue, near the end of the first session.
T Where is the problem today on a scale where 0 equals the worst and 10 equals the best that you
hope for?
C I’d say maybe 4 or 5.
T Nearer to 4 or nearer to 5?
C 5.
T What will need to happen or change for you to go up half a point on the scale from 5?
C Sort things out with my bad drinking friends.
T How will you sort things out with them?
C I’ll tell them that I need to concentrate more on my college work.
T As well as you concentrating, how will other people recognise when you are one point up on the scale?
C They will see me happier, more in control of everything and that I’m noticeably drinking less. I’ll be
less short tempered and rude to people (especially Mum) and just be nicer in general to be around!
T You say you are at 5 on the scale today. If we think about a different scale from 0 to 10, how
committed are you to controlling your drinking? Give it a number?
C How committed … you mean how determined am I to sort it? I guess 8 or 9 out of 10; I don’t
want to be in this trouble in a few months time.
T What will help you to be out of trouble, since you are 8 out of 10 determined to sort it?
C I have fixed things in my life before, and my mum and friends will help.
T Before we finish, is there anything that you want to mention that we have not covered?
C No, I don’t think so.
Jane placed herself at five on the scale. She thought that to move up half a point she would
need to sort things out with her bad drinking friends, by telling them that she needed to con-
centrate more on college work. She thought that others would notice her being less short-
tempered. Using a separate scale, she was able to rate her commitment to achieving her goals.

(d) Feedback The feedback at the end of the first session was: (Acknowledging the
problem) – You have been worrying a lot about your drinking. (Compliments) – I am
really impressed that you have begun to cut it down. You work really hard and you know
what you want out of life. You have lots of good ideas about how to cut down your
drinking. You have thought of some practical steps such as not going out with drinking
friends, working long hours at the weekend, taking less money when you go out and not
mixing drinks while you are out. (Suggestion) – You plan to try some of these before next
time. How soon shall we meet again, if we need to meet? Jane asked for another
appointment in two weeks’ time.
(e) Return visit When asked what was better, Jane reported bad marks for an assignment
the previous day and a strong wish to drink thereafter. Texting a friend and going for a walk
with her had been helpful. Otherwise she had had several days without alcohol. She attributed
this to will-power and to advice and support from her mother. She placed herself at six out
of ten on her recovery scale. If relapse threatened she said that she would phone the clinic
and/or talk to her mother.
Therapist feedback from this visit: (Acknowledging the problem) – You have had times when
you drank a lot or wanted to drink more. (Compliments) – You have managed this by having
will-power and by using help from your friends and your Mum. You have successfully had days
without any drink and other days without much drink. You are proud of yourself when you have
good marks for your College work. You have good ideas for what to do if you feel like drinking
too much. (Suggestion) – I think that you should keep on doing the things that are working for
you. How soon do you want to come back again? Do you need to come again?

In the event this client telephoned to say that all was well and that she did not intend to keep
the appointment. She was not referred to the service again in the subsequent two years.
Likely factors in this improvement were the client’s initial recognition that she had a
problem, and the fact that she had already made attempts to control this. She had good
family support and was herself intelligent and motivated for change. She was able to focus
on friends who would assist her efforts. Feedback about her academic performance was an
important source of self-esteem for her, as was her own belief in her will power.
5.1 Brief therapy

SF therapy often requires few sessions, commonly between one and seven. However, this
brevity is a by-product of the method and not an aim. The aim is ‘Not one more session than
is necessary.’ The number of sessions is led by the client, as in Freud’s method, and not by

some textbook rule. Sessions may be close together in time or may extend over months;
however, about 25% of clients only require one session.
5.2 Working with diversity

So far, SF work appears to be appropriate for many countries and cultures. There are com-
parison studies from China, Korea, Iran, Taiwan and Mexico. The Health Promotion sys-
tem in Hangzhou, China, is adopting SF models; textbooks are being translated into
Mandarin and Cantonese. There is a Japanese textbook of SF psychiatry. Insoo Kim Berg
was herself a Korean native and taught widely in the Far East. South Africa, India, Hong
Kong and Singapore have had training workshops. SF management conferences are held in
Japan and Europe. Doctors Without Borders, the American Red Cross and other aid agen-
cies employ SF trainers to assist their work in African and other impoverished countries.

Although SFT is helpful to many clients, there are times when it is not effective. The research
evidence is that SF is effective for about 70% of clients, which is similar to the success rate for
other forms of psychotherapy. Clients may need the option of another style of therapy if progress
is slow or non-existent. Based on anecdotal evidence I suggest that SFT is ineffective when:
• The therapist has a limited understanding of the rationale behind the approach and is simply a technician.
• The therapist combines SF with problem-focused techniques and confuses themself and the clients.
• Clients want a quick fix and are unwilling or unable to explore their solutions repertoire.
• Clients are convinced that they cannot find solutions until they have got to the bottom of the problem.
When not to use SF approaches? This question was addressed by the Dutch management
consultant Coert Visser (http://solutionfocusedchange.blogspot.com) when, in 2009, he iden-
tified three settings in which SF approaches might be less relevant:
• If there is reason to think that the complaint primarily has to do with physical or technical causes. For
example, chest pain or a flat tyre.
• If there is a proven standard approach for the type of problem, such as writing a job application.
• If there is an urgent situation or danger, the therapist may first need to take some direct action. For
example, if a client discloses information about current sexual abuse, the rules of evidence and the pos-
sible summoning of other agencies may be relevant before therapy can proceed.
Sometimes a client will identify that another treatment model or a medication has been more
helpful to them in the past than their current model of therapy. In that case it may be useful
to follow the client’s plan, at least on a trial basis. One can then look at other options if this
plan is not successful.


A comment sometimes made about SF models (as about Positive Psychology) is that they are
too American and not suited to British clients. Naturally, the sensitivities and attitudes of
clients have to be taken into account in all therapies. Some practical aspects of this are
addressed in training since a major part of SF therapy is its emphasis on the client’s perspec-
tive and language.
Other practitioners have suggested that SF therapy lacks a theoretical basis. However,
Steve de Shazer was a respected proponent of the work of Wittgenstein. Some of his books
(1994, 2007) present what amounts to a theory of the SF approach in Wittgenstein’s terms.
Interpersonal therapy (IPT) was developed as a sham treatment and has no theory, but has
proved to be a useful treatment in a number of disorders. Hypnotherapy is widely used and
has no agreed theoretical basis: it continues to be used because it is effective for some clients
and some problems.
5.5 Controversies
Many practitioners and management consultants now call themselves ‘SF’ or ‘solution-
oriented’. However, their grasp of the model and how to apply it appear to be very limited.
Books titled ‘solution-oriented’ sometimes have almost no mention of any of the original
authors or sources. Similarly, books have been written by famous stage hypnotists and by
mental health ‘experts’ which use the miracle question and other techniques word-for-word
but do not acknowledge that some other worker created these techniques. There is therefore,
controversy about how the field might be regulated, especially on the international scene.
Different countries have widely different rules about ‘therapy’ and the registration of health
practitioners.
SF therapists rarely define their clients or their work by the diagnostic categories used in
medicine. As in other aspects of psychological treatments, diagnostic categories have not
been found to predict the outcome of therapy. Specialist teams have better results than aver-
age with defined client groups, but this may be due to process skills and not to diagnosis as
such. As a result SF successes are rarely quoted in national or international treatment proto-
cols. There is debate about whether SFT should give in to short-term economic pressures and
force the use of diagnostic categories such as DSM-5 (already a deeply controversial text),
or instead stick to the reality of talking treatments, and hope that time will bring others to the
realisation of the true facts of these approaches?
6 RESEARCH
There are currently 119 relevant published studies of SFT. Two meta-analyses by Kim in 2008
and Stams in 2006 are summarised below (Franklin et al., 2011). There are 19 randomised

controlled trials showing benefit from SF approaches, with 9 showing benefit over existing
methods. Of 45 comparison studies, 36 favour SFT. Effectiveness data are also available from
some 5000 cases with a success rate exceeding 60%; requiring an average of 3 – 5 sessions of
therapy time. (www.ebta.nu; www.solutionsdoc.co.uk). These studies show consistently that
SFT has the same effectiveness rate as other therapies, while using fewer sessions than most
other therapies.
The meta-analysis by Stams et al. (2006) selected 21 studies comprising a total of 1421
clients. They examined client characteristics, the type of problem, the characteristics of
the intervention, the form of the study and factors that might affect publication bias. The
authors calculated Cohen’s d (d of 0.80 means large effect; d = 0.50 moderate effect; and
d = 0.20 small effect). The mean effect of SFT on reduction of problems was d = 0.37
which implies a small to moderate positive effect. This effect was not better compared to
the ‘treatment as usual’ control group, though the effect was better than the ‘no-treatment’
condition (d = 0.57).
The meta-analysis showed that SFT had more effect on behavioural problems (d = 0.61)
than on marital, psychiatric and ‘other’ problems (respectively, d = 0.55, 0.48, and 0.22). The
meta-analysis showed that adults profited more from SFT than children, and that clients in
residential settings profited more than clients treated in non-residential settings.
The authors explain the fact that SFT does no better than ‘treatment as usual’ by the
hypothesis that all forms of therapy are equally effective and that common factors determine
the effect of a therapy. The authors concluded that SFT satisfies ‘the client’s need for auton-
omy’ more than other treatments and is shorter.
The meta-analysis by Kim (2008) examined 22 studies (1349 clients) using three catego-
ries based on the outcome problem each study targeted. A large number of other factors were
also examined. The study found that SF brief therapy demonstrated small but positive treat-
ment effects in favour of SF approaches. Cohen’s d produced an overall weighted mean effect
size estimate of 0.11 for externalising behaviour problems, 0.26 for internalising problem
behaviours, and 0.26 for family and relationship problems. Only the magnitude of the effect
for internalising behaviour problems was statistically significant at the p<0.05 level, thereby
indicating that the treatment effect for the SF group was different than the treatment effect in
the control group. This meta-analysis places SFT as being as good as ‘treatment as usual’,
that is, equivalent to other therapies. Like Stams et al., Kim found the greatest effectiveness
for personal behaviour change.
Kim’s work shows that an average of 6.5 sessions was required across the included studies
to produce these effects. Stams et al. showed that SFT tended to be shorter than other thera-
pies. The significance of these two meta-analyses is greater because they used very different
methods to identify and include studies. Only eight studies appear in both, so these authors
have examined a wide variety of work. An influential systematic review was that of Gingerich
and Eisengart in 2000. Fifteen outcome studies meeting their criteria were found: 5 were
strong, 4 moderately strong and 6 were weak.
Knekt and Lindfors (2004) from Finland reported the most detailed and lengthy compari-
son study of psychotherapies. The first report was of a randomised comparison study; 93 SFT

clients against 98 short-term psychotherapy patients, all with anxiety or depression of more
than one year’s duration. For SFT 43% (mood), 26% (anxiety) achieved recovery by 7 months,
maintained at 12 months. The figures for psychodynamic patients were 43% and 35% respec-
tively. Thus, there was no significant difference between therapies, but SFT was faster for
depression. Short-term therapy was better for ‘personality disorder’, which was a relatively
simplistic construct in this study. Sessions averaged 10 over 7.5 months for SFT and 15 ses-
sions over 5.7 months for short-term therapy. No figures for partial recovery are given. There
was no apparent social class difference for outcome.
The foremost exponent of process research in SF is Jay McKeel. His latest review (in
Franklin et al., 2011) identifies some key points. Clients often report pre treatment improve-
ments, especially if the therapist asks presuppositional questions. The techniques used in SF
sessions have been found to achieve their intended purpose. Some SF techniques engender
optimism about achieving treatment goals. Clients appreciate the positive atmosphere and the
collaborative process. However, acknowledging problems and the therapeutic relationship in
general are not linked with successful outcomes in SFT.
A number of studies (Macdonald, 2011) suggest that SFT offers equal benefits across
socioeconomic classes. This is important in a world where many lack resources due to pov-
erty and conflict. Seven published studies have shown that client’s own scaling correlates
well with objective outcome measures.
7 FURTHER READING
Henden, J. (2008) Preventing Suicide: The Solution-focused Approach. Chichester: John Wiley & Sons Ltd.
Jackson, P.Z. and Waldman, J. (2010) Positively Speaking: The Art of Constructive Conversations with a Solutions
Focus. St Albans: The Solutions Focus.
McKergow, M. and Clarke, J. (eds) (2007) Solutions Focus Working: 80 Real Life Lessons for Successful
Organisational Change. Cheltenham, UK: Solutions Books.
Milner, J. and Bateman, J. (2011) Working with Children and Teenagers Using Solution-Focused Approaches.
London and Philadelphia: Jessica Kingsley Publishers.
O’Connell, B. (1998/2005) Solution Focused Therapy (2nd edn). London: Sage.
8 REFERENCES
Bandler, R. and Grinder, J. (1979) Frogs into Princes. Moab, UT: Real People Press.
Bateson, G. (1972) Steps to an Ecology of Mind. New York: Ballantine.
Beyebach, M., Morejon, A.R., Palenzuela, D.L., Rodriguez-Arias, J.L. (1996) Research on the process of solution-
focused brief therapy. In S.D. Miller, M.A. Hubble, B.L. Duncan (eds), Handbook of Solution-Focused Brief
Therapy. San Francisco, CA: Jossey-Bass, pp. 299–334.
de Shazer, S. (1985) Keys to Solutions in Brief Therapy. New York: W.W. Norton.
de Shazer, S. (1988) Clues: Investigating Solutions in Brief Therapy. New York: W.W. Norton.

de Shazer, S. (1994) Words Were Originally Magic. New York: W.W. Norton.
de Shazer, S., Dolan, Y., Korman, H., Trepper, T., McCollum, E., Berg, I.K. (2007) More than Miracles: The State of
the Art of Solution-focused Brief Therapy. New York: Haworth Press.
Dolan, Y. (1991) Resolving Sexual Abuse: Solution-focused Therapy and Ericksonian Hypnotherapy for Adult
Survivors. New York: W.W. Norton.
Dolan, Y. (2000) Beyond Survival: Living Well is the Best Revenge. London: BT Press. (Previous publication: Papier
Mache Press: USA 1998.)
Erickson, M.H. (1980) Collected Papers. Vols 1–4 (E. Rossi, ed.). New York: Irvington.
Fisch, R., Weakland, J.H., Segal, L. (1982) The Tactics of Change – Doing Therapy Briefly. San Francisco:
Jossey-Bass.
Franklin, C., Trepper, T., Gingerich, W.J., McCollum, E. (eds) (2011) Solution-focused Brief Therapy: A Handbook
of Evidence-Based Practice. Oxford University Press: New York.
George, E., Iveson C., Ratner, H. (1999) Problems to Solutions (2nd edn). London: BT Press.
Gingerich, W.J. and Eisengart, S. (2000) Solution focused brief therapy: a review of the outcome research. Family
Process 39: 477–98. (Updated version: www.gingerich.net).
Henden, J. (2011) Beating Combat Stress. London: Wiley-Blackwell.
Johnson, S. (2004) Mind Wide Open. New York: Penguin.
Kelly, G.A. (1955) The Psychology of Personal Constructs. New York: W.W. Norton.
Kim, J.S. (2008) Examining the effectiveness of solution-focused brief therapy: a meta-analysis. Research on Social
Work Practice 18: 107–16.
Knekt, P. and Lindfors, O. (2004) A randomized trial of the effect of four forms of psychotherapy on depressive
and anxiety disorders: design, methods and results on the effectiveness of short-term psychodynamic psycho-
therapy and solution-focused therapy during a one-year follow-up. Studies in Social Security and Health, No.
77. Helsinki, Finland: The Social Insurance Institution.
Macdonald, A.J. (2011) Solution-focused Therapy: Theory, Research and Practice (2nd edn). Sage: London.
Prochaska, J.O. (1999) How do people change, and how can we change to help many more people? In Hubble,
M.A., Duncan, B.L., Miller, S.D. (eds), The Heart and Soul of Change: What Works in Therapy. Washington, CD:
American Psychological Association. pp. 227–55.
Prochaska, J.O. and DiClemente, C.C. (1982) Transtheoretical therapy: toward a more integrative model of
change. Psychotherapy: Theory, Research and Practice 19: 276–88.
Shapiro, F. (2001) Eye Movement Desensitization and Reprocessing (EMDR): Basic Principles, Protocols, and
Procedures (2nd edn). New York: Guilford Press.
Watzlawick, P., Weakland, J., Fisch, R. (1974) Change: Principles of Problem Formation and Problem Resolution.
New York: W.W. Norton.
Watzlawick, P. (1984) The Invented Reality. New York: W.W. Norton.
White, M. and Epston, D. (1990) Narrative Means to Therapeutic Ends. New York: W.W. Norton.

16
Interpersonal Therapy
Susan Howard
Interpersonal psychotherapy (IPT) had a unique beginning. Most new psychotherapies

develop either from clinical observation, e.g. psychoanalysis, or from psychological
theory, e.g. behaviour therapy. By contrast, IPT began as a research condition in the late
1960s, when American researchers led by Gerald Klerman investigated the efficacy of
anti-depressant medication in a randomised controlled trial (RCT). A group of expert
therapists identified the factors in the successful treatment of depressed patients; this
included the importance of social and interpersonal stress in the onset and maintenance
of depression. From this they developed a ‘high contact’ therapy condition, which pri-
oritised interpersonal functioning. To the surprise of the researchers the high contact
condition was very effective. It was eventually manualised as a short-term therapy
emphasising thorough assessment and ending phases and became known as IPT (Klerman
et al., 1984).
There is a paradox at the heart of IPT. Despite forty years of excellent efficacy findings,
IPT has only recently become a mainstream psychotherapeutic intervention. One theory
about this relative lack of penetration is that IPT’s founders focused on adapting the original
protocol to expand the range of client groups treated rather than exploring theoretical issues,
including understanding the mechanisms underlying change. The advantage of this pragmatic
approach is that IPT has not experienced the theory-driven schisms, which have characterised
most other therapies. However, the lack of debate about theory may have resulted in

clinicians feeling that they have little to contribute to the development of IPT beyond its
adaptation to new client groups.
Until recently British interest in IPT has centred on pockets of activity, including
Edinburgh, Oxford, Leicester and London and, with the exception of Scotland, there were
relatively few practitioners outside of research settings. However, IPT’s impressive
research base led to its inclusion in the National Institute of Clinical Excellence (NICE)
guidelines and the Scottish Intercollegiate Guidelines Network (SIGN) for the treatment
of depression in adolescents and adults and for eating disorders. Consequently IPT was
included in the second wave of the Increasing Access to Psychological Therapies (IAPT)
initiative as a treatment for depression. IAPT funding has substantially increased the num-
ber of IPT practitioners being trained and Britain is now amongst the leaders in offering
community (rather than research-based) IPT. The inclusion of IPT as a required National
Health Service (NHS) therapy has led to increasing interest amongst therapists, referrers
and those commissioning NHS services with an accompanying expansion in the range and
number of clients offered IPT.
In addition to IAPT training courses, five centres offer IPT training to NHS and private
practitioners: Edinburgh, Surrey, Leicester, London and Lincoln. Candidates for training
must have a psychotherapeutic qualification, as IPT training assumes existing therapeutic
competence (e.g. in psychodynamic approaches, cognitive behaviour therapy or counselling)
and training seeks to build on existing skills. Recently clinical psychology doctoral pro-
grammes have included IPT practitioner training as part of their curriculum, including those
at Surrey, Edinburgh and Glasgow universities.
IPT-UK is the British organising body for IPT. Like other national organisations it is
affiliated to the International Society for Interpersonal Psychotherapy (ISIPT), which is based
in the USA and which organises bi-annual conferences.
In recent years there has been a move in some parts of the IPT community to correct bias
towards pragmatism and pay more explicit attention to theory. There was always recognition
that when IPT was first developed ideas about ‘best practice’ were embedded in theory, even
if that theory was not explicit or used for heuristic purposes. From the outset IPT acknowl-
edged theoretical debt to Adolf Meyer, who introduced the notion of the life-span at the
beginning of the twentieth century; Harry Stack Sullivan who founded the Interpersonal
School of Psychoanalysis; John Bowlby, the founder of Attachment Theory; Brown and
Harris who advocated the importance of life events in the development of depression.
However, more recently some researchers have been more explicit about theory, in particular
Scott Stuart, who has embedded IPT in attachment theory (Stuart and Robertson, 2003). In
the UK the Surrey University IPT course is at the forefront of grounding training in attach-
ment theory.

INTERPERSONAL THERAPY 417

IPT conceptualises people from three different but interrelated perspectives: as having attach-
ment needs; as social beings; and as communicators. Taken together these three perspectives
emphasise the importance of the impact of interpersonal factors on functioning rather than
what happens at an intrapsychic level.
Firstly, and most importantly, IPT conceptualises people within the framework of
attachment theory, which proposes that we have an instinctual drive to form close inter-
personal relationships with others. The quality of our later attachment relationships is
determined largely by our early experience. How our childhood caregivers behave
towards us will impact on our future capacity to develop trusting and supportive relation-
ships. As we mature we develop what John Bowlby, the founder of attachment theory,
called an ‘internal working model’ (IWM) of relationships. Our expectations of relation-
ships become shaped by our IWM that, in turn, influences our interpersonal behaviour
according to identifiable attachment styles. Bowlby argued that we function at our best
when our attachment needs are met, which include being able to trust and confide in those
with whom we have close relationships. ‘Not only young children …, but human beings
of all ages are found to be at their happiest and to be able to deploy their talents to best
advantage when they are confident that, standing behind them, there are one or more
trusted persons who will come to their aid should difficulties arise.’ (Bowlby, 1973: 359).
Stable attachment relationships are not necessarily satisfactory, but they are important for
our psychological equilibrium. IPT argues that when individuals face challenging or pain-
ful life events, those who are able to deploy interpersonal resources to support them are
far more resilient to the attendant stress than those who cannot.
Secondly IPT conceptualises people as inherently social and influenced by the social roles
they occupy. Harry Stack Sullivan, arguably the most influential theorist in the development
of the interpersonal perspective, proposed that we can never be thought of in isolation from
the interpersonal relationships in which our lives are embedded. Sullivan emphasised the
importance of family and friendship roles, roles we have at school or work and in leisure
activities. These determine how we develop, how we perceive ourselves and how we are
perceived by others. Our social networks are important for our interpersonal functioning,
which in turn impact on our intrapsychic functioning.
Lastly IPT conceptualises people as more or less effective communicators of their needs
within different relationships. Kiesler (1996, cited in Stuart and Robertson, 2003) proposed
that individuals negotiate three aspects of a relationship: affiliation (the degree to which they
have positive or negative feelings for the other); dominance (the degree to which one person
takes charge of the relationship and decisions made within it); inclusion (the degree to which
each individual in the relationship considers the relationship important). Each aspect of the
relationship is manifest in how the person communicates and Stuart and Robertson argue that
attachment theory forms the template upon which specific communications occur. According
to Kiesler, there is a conditioning effect caused by how the communication is responded to

by the other which sets in train a reinforcing cycle where the response elicits a predictable
further communication, which itself is reinforced. Over time the cumulative effect of these
communications determines the nature of a given relationship and the extent to which the
needs of the participants are satisfied.

IPT is conceptualised within the bio-psycho-social model. This means that IPT takes account
of biological, social and psychological factors when thinking about how an individual copes
with life’s vicissitudes. Biological factors include genetic inheritance, illness, disability, inju-
ries, hormonal changes or the impact of medication. Social factors include relationships with
family, friends, colleagues and the person’s wider social network; the extent to which these
are satisfactory and supportive and whether there have been gains or losses in the network.
Psychological factors include attachment style, cognitive style and defence mechanisms – the
lens through which the client engages with the world. Attachment theory is the lynchpin in
how IPT understands disturbance and health; it identifies two overarching categories of
attachment – secure and insecure.
Controversially, for many non-medical IPT practitioners, IPT conceptualises depression
is an illness which is diagnosable. The person with depression is understood to be in need
of help to cope with the illness, and IPT clients are encouraged to refrain from certain
obligations that they find difficult to meet at the beginning of their therapy. At the same
time the client is clearly given the message that being ‘sick’ is not a desirable state and
that he is required to work with the therapist to get out of it and take up the reins of his
life again.

An insecure attachment style is associated with greater vulnerability to psychological
disturbance than is a secure attachment style. This is related to three factors. The first is
what Bowlby called the Secure Base (SB) phenomenon. The SB is best described as the
means by which we cope with anxiety and distress; it is associated with a reduction in
anxiety and feeling satiated and soothed. While in childhood the SB is a person and exter-
nal, during maturation the SB becomes a representation and internalised. It is turned to
when a person is in difficulty, sometimes instead of relying on another person and some-
times as well as doing so. The SB is not necessarily supportive and positive, despite the
inference implied by the word ‘secure’. The child who has had to rely on someone who is
unavailable and inconsistent can develop a maladaptive SB and its use lead to further
distress. For those who are insecurely attached activating the SB may involve behaviour
that reduces anxiety while at the same time resulting in self-harm or self-loathing, such as
drinking excessive alcohol or self-starvation.
The second factor is how the person’s IWM processes relational issues. People with inse-
cure attachments are likely to have more transient and ambivalent relationships and are less

able to moderate affect through interpersonal relatedness. Consequently they can be over-
whelmed by affect when distressed or dismiss it so that painful experiences do not get pro-
cessed. They see themselves as unworthy of help and those who they relate to as unavailable
or unwilling to give help; they perceive themselves as being unsupported even when support
is available. Consequently, when in psychological pain, they find it difficult to seek assis-
tance from those close to them and are highly sensitive to the potential for rejection. They
cannot trust that the other can understand their difficulties or tolerate their feelings, which
can lead to despair and further distress. After a major conflict the insecurely attached person
is more likely to view the other person negatively, leading to greater anxiety and an exacerba-
tion of relationship difficulties.
The third factor is to do with the insecure person’s capacity to mentalize. The ability to
mentalize is a function of being able to imagine the other person from the inside – their
thoughts, feelings and intentions – while simultaneously being able to imagine how one is
perceived and experienced by the other. The capacity to mentalize facilitates supportive and
consistent interpersonal relationships, since the good mentalizer is much more able to build
rewarding relationships, judge emotional situations so that his own and the other’s needs are
taken into account, and ask appropriately for help. There is a strong link between insecure
attachment and poorer mentalization. Consequently, when the insecurely attached person
engages in help-seeking behaviour, he is less likely to communicate in a way that gets his
attachment needs met. This is because he does not see himself as someone deserving of help
and/or he fails to take the needs of the other properly into account or gauge the impact of his
behaviour.
Disruption of attachment relationships through death, moving, conflict etc. can lead to
crisis. Because he is less able to use others to moderate and regulate the associated affect, the
insecurely attached person is more vulnerable to the impact of the crisis and therefore to
psychological disturbance.
IPT conceptualises psychological disturbance as relating to one of four focus or ‘problem
areas’. The most common is role transition, when a person has difficulty in adapting to a
change in role. This may involve a normal life event, such as having a baby or retiring, or
may be the result of an abnormal event, such as an accident leading to permanent disability.
Even though the change may be seen as positive (e.g. a promotion) the client experiences a
sense of loss following the change in his identity and a corresponding disruption in his social
network.
The second most common problem area is interpersonal role dispute in which relationship
difficulties precipitate or maintain disturbance; sometimes this can follow from a role transi-
tion, for example disputes following the birth of a baby as the couple redefine their roles. The
most common type of dispute is with a partner, parent, friend or work colleague.
The third area is unresolved grief in which the client is has become stuck in the mourn-
ing process. IPT makes a clear distinction between adjusting to life following bereavement
(a role transition) and being stuck in the process of grieving the death of a significant other.
Only those whose depression is the result of difficulties in grieving are included in this
focal area.

IPT uses the interpersonal sensitivity focus when there is no evidence of disturbance being
triggered by a specific interpersonal situation or life event. It is the least common focus in
depression, but more common in eating disorders. Clients presenting with difficulties in this
focal area often have difficulties in trusting or relating to other people. This creates problems
in establishing and/or maintaining stable relationships and frequently leads to long-term
social or emotional isolation. Although typically the client in this focal area has a sparse
social network, sometimes he seems to have a well-populated network that on closer inspec-
tion is unstable and lacks intimacy.

Security of attachment is strongly linked to greater satisfaction with interpersonal rela-
tionships and better psychological health. Psychological health is accounted for by the
secure person’s greater ability to rely on those close to him and to regulate affect through
relatedness. Attachment relationships are characterised by flexibility and the way attach-
ment needs are communicated increases the likelihood of them being met. A greater
capacity to mentalize facilitates stable relationships that are mutually supportive.
Because they are less likely to use defensive and destructive strategies, the securely
attached are better able to manage conflict. Following a major conflict they report an
increase in positive feelings, trust and intimacy indicating that conflict can strengthen
rather than weaken close relationships.
Securely attached people are able to use their SB both to reduce anxiety and consequently
distress, and as a platform to explore the world, thus increasing pleasure. Their IWM views
themselves as worthy of help and the other as wanting to provide that help.

IPT’s position has historically been that it does not make aetiological statements. Instead,
it notes the reciprocal link between psychological distress and social functioning. IPT
proposes that, when depressed, a person’s social functioning deteriorates: they are more
likely to withdraw from social relationships; they are less able to use their relational net-
work for support; they are less able to manage conflictual relationships. It also proposes
that those who have disrupted or unsatisfactory interpersonal relationships are left vulner-
able to the emotional impact of interpersonal crises such as conflict in an important rela-
tionship, the loss of an important relationship or the impact on relationships resulting
from a change of role.
However, the emergence of attachment theory as a theoretical framework within which
IPT can be understood leaves IPT in a somewhat equivocal position, since in the attach-
ment literature there are clear directional links between early experience and the later
development of psychological disturbance. Attachment theory argues that those who are
insecurely attached are more vulnerable to later disturbance because of the lack of a con-
sistent and reliable SB and because of an IWM that has problems establishing truly

intimate and trusting reciprocal relationships. Consequently, when managing difficult

situations there is less confidence that there is someone ‘standing behind them’ as a sup-
port and comfort. Furthermore, the communication of distress is either unclear or done in
a way that the other becomes reluctant to help. The insecurely attached person then feels
alone and unprotected, which leaves him vulnerable to the impact of stressful situations
and events.

In acknowledging the reciprocal link between psychological and social functioning IPT implic-
itly identifies the mechanism that perpetuates psychological disturbance: once someone is symp-
tomatic social withdrawal reinforces a feeling of aloneness and lack of social support which
leads to further withdrawal – and so on. It particularly highlights difficulty in acknowledging and
communicating the need for support and help as important maintaining factors.

While noting the presence and importance of intrapersonal mechanisms such as negative
cognitions or difficulties in mentalization, IPT does not specify how intrapersonal factors
maintain psychological disturbance. Having said this, however, the attachment focus of IPT
does hypothesise that the lack of feelings of self-worth associated with insecure attachment
makes it particularly difficult for clients to access the help available to them in their network
when they experience psychological disturbance.
2.4.2 Interpersonal and environmental mechanisms

The IPT model does not distinguish interpersonal and environmental factors and addresses
both together. Interpersonal mechanisms are considered crucial in perpetuating disturbance
and IPT specifically draws attention to the impact of reciprocal interpersonal interactions on
the maintenance of depression and eating disorders. Non-reciprocal role expectations are
seen as pivotal in maintaining relationship difficulties as is unclear communication and/or
making interpersonal assumptions that maintains negative beliefs about being cared for.
Difficulties in managing the impact of role change in maintaining important relationships and
social networks and the inability to use support to grieve the loss of a significant other are
factors for some clients. Most people who are depressed or who have eating disorders with-
draw socially, thus cutting off from available social support and pleasure and some have
ongoing difficulty in developing and/or maintaining ongoing supportive relationships.
2.5 Change
IPT is a practical therapy that seeks to bring about symptomatic relief through changes in
interpersonal behaviour, which increase the client’s feeling of connection and support within

his social network. Although IPT recognises that unconscious factors such as the Secure Base
and Internal Working Model influence the individual’s behaviour, therapy focuses on those
elements that are more consciously accessible to the client. The client may not be aware of
how he behaves and how his patterns of behaviour impact on his interpersonal relationships,
but by highlighting these patterns the therapist can help him to understand them and work
towards change.
IPT fosters change initially through the creation of a secure base, which enables the client
to be more open to exploring the inner pain that accompanies psychological disturbance and
to thus increase his motivation to bring about change. The primary focus is on improving the
quality of the client’s external relationships and attachments rather than through increasing
dependency on the therapist.
IPT emphasises the importance of the elicitation of affect in bringing about change and
seeks to titrate affect so that the client is neither cut off nor overwhelmed by it. It is well
documented (Holmes, 2010) that cognitive appraisal in the context of optimal levels of affect
creates the hormonal environment in the brain that optimises the creation of the new neural
circuits that are the hardware of psychological change.
3 PRACTICE

IPT has two overall goals. The first is symptomatic relief; the second is to address the social
and interpersonal problems associated with the onset and maintenance of symptoms. As a result
the client manages relationships and life situations more effectively and is better placed to cope
with future difficulties. Despite its basis in attachment theory, there is no expectation that IPT
will significantly impact on overall security of attachment (though see Ravitz et al., 2008).

Clients who have characteristics making them good candidates for any short-term therapy
will also be good candidates for IPT. The literature points to the following factors for all
short-term therapies:
• The client can form an early therapeutic alliance enabling productive work over a short time-scale. This
requires sufficient capacity to trust his therapist so that he can seek and receive help.
• The client is psychologically minded, is curious about and willing to explore his thoughts and feelings
with his therapist. His defensive system must allow him to communicate his difficulties without being
incapacitated by shame.
• The client is motivated to change rather than simply wanting the absence of symptoms. This involves:
understanding the psychological nature of his difficulties; being willing to participate actively in therapy
and committing to attend sessions regularly.

• The client is not experiencing a very high level of psychological disturbance: he is not actively suicidal; he
is not experiencing a psychotic episode; he does not demonstrate significant anti-social or psychopathic
personality features.

As well as the factors outlined above, clients are deemed unsuitable for IPT if they:
• exhibit symptoms not treatable by IPT, including very high levels of anxiety; social phobia; high levels of
social dysfunction; current alcohol or drug abuse;
• cannot recognise interpersonal issues and/or connect them with their difficulty in functioning when
prompted by the therapist;
• cannot relay a narrative regarding interpersonal incidents that occur outside therapy in sufficient detail
to be able to examine them with the therapist;
• have an insecure-unresolved attachment status since the attention to affect in IPT is likely to lead to
difficulty in regulating affect both in and outside therapy.

Most IPT is conducted as individual therapy, both because this is the primary evidence base
and because the majority of practitioners are trained to deliver it. However, there is a strong
evidence base for delivering IPT in a group and there are some specific situations where IPT
is delivered in a couple’s format.
IPT group: IPT particularly lends itself to this format, since the group becomes the labora-
tory for testing out new interpersonal skills (Wilfley et al., 2000). For many people group
therapy can reduce the psychological isolation and shame associated with their psychological
difficulties. IPT groups are homogeneous, either by virtue of the presenting problem (e.g.
binge-eating disorder) or the identified focal area (e.g. a role transition group for depressed
older people who have recently moved into residential care). Consequently referral to a group
is partly determined by whether the individual has difficulties concordant with the groups on
offer. IPT groups are closed, so a client may be offered individual therapy when there is no
group available. Although the exclusion factors for Group IPT are the same as those for indi-
vidual IPT, when both are available clinicians are likely to refer for individual IPT when the
client is more socially withdrawn and less able to function in a time-limited group or where
the client states a clear and implacable opposition to group work.
Couple therapy: IPT for cognitive impairment (IPT-CI; Miller, 2009), is for couples where
the referred client has early dementia and the partner or significant other attends in order to
support the work of therapy outside sessions. The significant other also works on their own
role transition into being a carer. Consequently only those who are suffering from dementia
and their partner would be referred.
Individual IPT in preference to another model offering family or couple therapy: Individual
IPT is useful when disputes with a significant other have triggered or are maintaining their
symptoms but the referred client does not have the ego strength to manage couple or family
therapy. It is particularly useful when a non-depressed partner declines couple therapy as the

referred client can get help with the relationship without feeling that they are doing couple
therapy on their own. Individual work allows the client to analyse and practise managing
disputatious interactions in the safety of therapy before interacting with the other person. IPT
also encourages a significant other (or sometimes more than one, though not at the same
time) to come to some sessions; this is with the objective of understanding the client’s diffi-
culties and helping them as appropriate.
The presence of the significant other often opens up useful discussion about each person’s
expectations of the other and how their communication styles contribute to the perpetuation
of their relationship difficulties and the referred client’s symptoms. Sometimes a successful
intervention, where the significant other has attended some sessions or the referred client has
become more confident having managed joint sessions, can lead to a referral to address long-
standing family or couple difficulties.

It is always difficult to properly differentiate therapists’ personal characteristics from their
therapeutic skill set given that, as therapists, we are the tool, as well as the deliverer, of
therapy (Howard, 2010). This is particularly the case for a therapy like IPT that is affect
based and therefore requires the therapist to have a set of internal resources that enables her
to engage with her clients’ feeling states. So in the following sections I have made a distinc-
tion between those skills that can be directly taught and those that might be viewed as skills
but are more a manifestation of the therapist’s personal characteristics.

The first and most important attribute for a successful IPT therapist is her own secure attach-
ment; this can be something she grew up with or acquired later, e.g. through personal therapy.
The securely attached therapist is more sensitive to her clients’ needs and more emotionally
available. She manages the overt demands and explicit dependency needs of clients better
and is less likely to experience strong and unhelpful reactions to them (Slade, 1999). Slade
proposes that the securely attached therapist is able to care in a straightforward way and
compares this to the insecurely attached therapist whose care is vulnerable to distortion in the
service of meeting her own needs. The securely attached therapist is better able to provide a
reliable secure base and the empathic attunement crucial in an affect-based therapy like IPT.
She is also a better mentalizer and therefore more likely to remain open to her own experi-
ence as well as that of her client.
Other therapist attributes essential to IPT follow from security of attachment and include:
authenticity enabling real connection with the client; the ability to build and maintain a
therapeutic relationship combining caring with clear boundaries; the ability to elicit, sit with
and contain strong affect to enable the client to safely experience it; possession of a consist-
ent set of internal boundaries that allows the therapist to appropriately explore interpersonal
relationships with the client both outside the therapy room and, when necessary, in the

therapeutic relationship; the capacity to communicate difficult information in a clear way;

and the capacity to internally manage endings, so that proper attention is paid to the emo-
tional impact on the client.

IPT therapists take the ‘expert’ role. This involves being able to demonstrate and be comfort-
able in owning one’s role as an expert in mental health, including giving advice, psycho-
education and reassurance in doses appropriate to the client’s needs. It also involves directing
sessions, so that the tasks of each phase of therapy are addressed. The effective therapist
balances being directive and focused, while at the same time maintaining IPT’s avowed sup-
portive stance and attendance to the therapeutic alliance.
The effective IPT therapist is able to communicate optimism to the client, thus conveying
hope about a finding a solution to his difficulties. The skill here is to convey this to the client
in an authentic manner that takes account of his feelings, rather than to impose an optimism
that he experiences as out of touch with his experience.
To be an effective therapist requires focusing on the achievement of the agreed goals of
therapy. Since these goals are interpersonal in nature she must maintain an interpersonal
focus throughout therapy. Outcome research in IPT has shown that the maintenance of the
interpersonal focus and the capacity to build a good therapeutic alliance are the two most
important therapist factors in determining outcome.
Lastly the effective therapist needs to be able to manage the ending, in particular its affec-
tive aspect. IPT acknowledges that the ending is something that is often avoided by both
client and therapist and designates four sessions to cover issues that arise, which include
taking feedback regarding the effectiveness of therapy. The IPT therapist needs to be able to
model accepting both positive and negative feedback as well as giving feedback in a genuine
manner.

The first task of the IPT therapist is to foster a positive therapeutic relationship. The onus is
on the therapist to create an environment ‘in which there is a high degree of inclusion and
affiliation’ (Stuart and Robertson, 2003: 28). IPT pays particular attention to those processes
known as common factors of psychotherapy – warmth, empathy, affective attunement and
positive regard.
IPT fosters a positive transference, so that the client experiences his therapist as ‘on his
side’. However, the IPT therapist does not routinely interpret the transference; instead she
uses the transference relationship to elucidate understanding of the client’s relational difficul-
ties outside the consulting room. She directly interprets transference material only when a
transference issue threatens to derail therapy or she judges that a transference issue needs to
be tackled head on.

At the same time IPT therapists make overt use of the therapeutic relationship by iden-
tifying and providing feedback on recurring interpersonal patterns and/or communication
difficulties when these become manifest. They use the therapeutic relationship to under-
stand the client’s pattern of engaging with others and the interpersonal distortions that
impact on his relationships. Having linked these patterns to events outside the consulting
room IPT therapists help the client to change by trying out new ways of communicating
within sessions.
Because interpersonal sensitivities clients often have a very restricted social network, there
may be few opportunities for them to practise new relational skills, so the relationship with
the therapist is a more central feature of therapy. It acts as a model or template for other
relationships and the therapist may make sparing use of transference. In other focal areas the
therapist gives feedback about how the client relates to her and how this can impact on his
relationships outside therapy. For example, working within role disputes feedback on how the
client communicates with her can be used to illustrate why communication breaks down in
an identified conflictual relationship.

In order to create and maintain a positive therapeutic alliance the IPT therapist needs to
be experienced as warm and open. She also needs to balance a number of – sometimes
competing – ways of being with her client: being focused on the goals of therapy while
maintaining the therapeutic alliance; being open to the client’s affective experience as
well as maintaining the structure of the session; balancing careful listening with being
directive when necessary. While facilitating the expression of affect she is careful to
titrate affect levels so that cognitive appraisal is possible without undermining the client’s
experience of feeling understood.
The therapist’s style is essentially active and at times she will use direct advice and reas-
surance, especially in the early sessions or when progress is slow. Her activity is character-
ised by how she intervenes to help the client identify the interpersonal implications of the
focal problem; the way she helps the client identify and use interpersonal resources that can
support change; how she identifies obstacles to change; how she helps the client appraise the
consequences of change.
Lastly, the therapist is transparent in her relationship with the client; she shares much of
her thinking about the nature and cause of his difficulties and how she perceives the thera-
peutic relationship. She models open and straightforward communication with the explicit
objective of helping the client to communicate more effectively.
3.5 Assessment and formulation

For the purpose of clarity I will, throughout this section, discuss the assessment of the
depressed client. However, adaptations for other presentations follow the same format.

3.5.1 Assessment
A thorough assessment is central in IPT to establish the direction of the work in the middle
sessions. The assessment takes place over the first three to four sessions and comprises:
obtaining a detailed picture of the presenting problem; diagnosing the depression; obtaining
a history; mapping the client’s interpersonal network.
The diagnosis of depression is established through administration of standardised instru-
ments and a clinical interview that explores presenting symptoms in more detail. The assess-
ment of symptoms includes affective, interpersonal, cognitive and behavioural elements as
well as exploration of any co-morbidity, e.g. anxiety symptoms. It is essential to evaluate
whether the client is at risk of self-harm or harm to others.
Establishing the individual client’s symptomatic profile is important since this will be
reviewed at the beginning of each session and will be used as the basis for the relapse pre-
vention plan at the end of therapy. It is essential to pinpoint the onset of the current episode
of depression (or worsening of symptoms in someone with chronic depression) since the
interpersonal factors in play at the time give valuable information about the nature of the
interpersonal factors involved in the onset and maintenance of the depression.
Having diagnosed the depression, the client is given the ‘sick role’ (see above,
Section 2.2) and there is an exploration of the interpersonal resources available to him
to facilitate a temporary withdrawal from some of his obligations as well as an explora-
tion of who might engage with him in pleasurable activities. His response gives the
therapist an early indication of the extent to which he can use his interpersonal network
as a resource. The client who refuses to consider his network as a resource may be
unsuitable for IPT.
The Time Line generates important information about the client’s life including entries
into and exits from his social network (for example the early or recent death of a signifi-
cant other) and life events or physical problems the client has needed to negotiate.
Attention is paid to any previous episodes of psychological disturbance, particularly the
interpersonal factors in play at the time as well as the success of any treatment. The
therapist uses this opportunity to gather information that will facilitate a hypothesis about
the client’s attachment style based on factors such as the quality of his narrative in
describing his life and experiences.
The Interpersonal Inventory provides a wealth of information about the client’s close
relationships, social network and how he functions interpersonally. Therapist and client
together create a written record of inventory information, which can be added to as
therapy progresses and reviewed at the end of therapy. It is helpful to get information
across a number of domains including family, work or school, leisure activities and
friends. This creates an opportunity to assess where the strengths are in the network as
well as the difficulties. It also facilitates identifying recent exits from and entrances into
the network and the impact of these changes on the client. For example, it highlights
whether the client has suffered a significant bereavement or has lost a close relationship
as the result of conflict.

Some clients describe a wide and varied network; others identify only a few people. The
perceived adequacy of a person’s support network is a better predictor of mental health
than its actual availability; so someone who has only three people in his network but per-
ceives the support he gets as adequate is better protected than someone who populates his
Inventory with twenty or thirty people but who feels there is no-one there for him. It is
also important to assess whether a person’s network is dense or diffuse as there is evi-
dence that dense networks (where everyone knows everyone else) can be more problem-
atic than diffuse networks where they don’t. In a dense network conflict with one member
can lead to difficulties with other members because of divided loyalties. By contrast when
it is diffuse the client can be in conflict with one part of his network while being supported
by other parts of it.
IPT recognises the importance of different types of relationships in a well-functioning
network so it assesses a number of dimensions: emotional; practical; motivational; and
social. It’s important to identify discrepancies between what the client feels he currently
experiences in a given relationship and what he would ideally hope for or may have had in
the past. To this end the client is asked to highlight satisfying and unsatisfying aspects of key
relationships and is helped to identify potential areas for change in them. It is also important
to find out how often the client is in contact with those in his network and the type of contact
he has (e.g. is it always by phone, or do they meet face to face?).
Non-reciprocal role expectations in current relationships are important, since they are
often associated with conflict. This might be in one important relationship (for example,
a husband and wife with different reciprocal role expectations following retirement), or
more pervasive where the client reports a lack of reciprocity and associated dissatisfac-
tion across a range of relationships. The IPT therapist is interested in finding out about
the impact of the client’s depression on his relationships, including whether the depres-
sion has resulted in interpersonal conflict and the extent to which he has withdrawn from
his network.
Although IPT primarily focuses on current issues it is helpful to get information about
the client’s early relationships, particularly their quality and the impact of any early rup-
tures in attachment relationships. It is also important to identify general patterns in rela-
tionships (e.g. someone who was bullied at school and later at work). Again the IPT
therapist is listening carefully not only to the content of what the client says, but how he
tells his story and describes his relationships. This will give her further clues as to his
attachment status.

As noted above in Section 2.2, an IPT formulation takes into account the biological, social
and psychological factors linked to the client’s presenting difficulties. The formulation must
be transparent and lead to jointly agreeing a problem area and focus for the treatment phase
of therapy. Usually the therapist will prepare a provisional formulation to bring to the session,
which is discussed and amended in the light of the client’s reflections on it. The client should

be given the option of having a written copy. Formulations are presented in either narrative
or diagrammatic form. My preference is for the narrative formulation, since the experience
of hearing one’s own story seen through the eyes of another can itself be a healing and vali-
dating experience.
The formulation should point therapist and client to agreeing on one or, on occasion, two
of the four IPT problem areas as the focus for work in the middle sessions. The chosen focal
are must be affectively meaningful for the client as well as linking temporally to the onset
and/or maintenance of symptoms. It is essential that the client feels able to work in the chosen
problem area. For example, Julie felt unable to accept a disputes focus even though it was
apparent to her therapist that a covert dispute with her idealised mother was central to her
depression. However, Julie was able to work on the role transition involved in leaving home
and there were opportunities in doing so to begin to address some of the difficulties in her
relationship with her mother. Towards the end of the middle sessions Julie could acknowl-
edge the difficulties in her relationship with her mother and in the last few sessions it was
decided to add a second focus to allow inclusion of disputes work.

IPT focuses on four major domains: interpersonal; affective; behaviour change; and cognitive.

Interpersonal: IPT explores symptoms in terms of interpersonal relations, emphasising cur-
rent relationships. The therapist explores the bi-directional relationship between changes in
symptoms and interpersonal contacts (for example noting that symptoms worsen or improve
following an interpersonal exchange) in order to highlight the link between them. The thera-
pist uses the therapeutic relationship to provide feedback on the client’s communication and
relational style as well as to provide a Secure Base in which difficult and painful issues can
be explored.
Affective: IPT therapists aim to increase their client’s awareness, acknowledgement and
acceptance of a range of emotions, particularly painful affect. The purpose of this is to
facilitate acknowledgement and acceptance of painful affects that cannot or should not be
changed, to help the client use his affective experiences in bringing about desired interper-
sonal changes and to encourage the development of unacknowledged and/or new desirable
affects in order to facilitate growth and change.
Behaviour change: in order to maximise the potential for ongoing symptomatic improve-
ment, the IPT therapist promotes change in the client’s interpersonal behaviour outside
therapy by encouraging the use of techniques practised inside therapy.
Cognitive: IPT therapists draw attention to their clients’ distorted thinking; however, this
is at the level of understanding its impact in relation to significant others rather than system-
atically working with negative cognitions as in CBT.


Interpersonal: Communication analysis is a central IPT technique which involves identi-
fying how the client’s communication style can negatively impact on his relationships
through ambiguous or indirect communication, unjustified assumptions about the other’s
intentions, closing down communication, or a confrontational or defensive style. The cli-
ent is asked to identify a recent, difficult exchange and/or conflict with a significant other
and describe it in detail, including both verbal and non-verbal components, using a
‘video-camera’ metaphor. He is also asked about the context in which the exchange
occurred and is encouraged to express how he felt and what he would have wanted to say.
He is helped to understand the implicit and explicit intentions of both parities and reflect
on how the other person might have experienced and understood the interaction. Lastly he
is helped to identify those non-reciprocal role expectations that maintain the interpersonal
difficulty.
Use of the therapeutic relationship is another major interpersonal technique. This has been
described in some detail in Section 3.4.
Affective: the IPT therapist helps the client to begin to acknowledge and accept his emo-
tions through initially communicating her understanding of his affective state. She helps him
to stay with and explore what he is currently feeling in order to recognise and accept it,
including the normalising of negative emotions, and then helps him to carefully track his
emotional state during the session. She also helps him to differentiate feelings in action and
to use his affective experiences to guide interpersonal understanding and changes. She
facilitates her client’s use of therapy sessions to express and understand strong emotions; she
helps him to discriminate between when the expression of strong emotion is appropriate
outside of the session and when it may undermine relationships.
Behaviour change: IPT identifies three main behavioural techniques: directive techniques;
decision analysis; and role-play.
Directive techniques include psycho-education, advising (for example sleep hygiene for
sleep difficulties) and giving information. These techniques are generally used sparingly to
foster confidence in the therapist’s expertise and knowledge as well as to enhance the client’s
sense of mastery regarding his condition. The extent of their use varies according to the needs
of the individual client.
Decision analysis is the IPT term for problem-solving. The client is helped to consider a
range of options (and their consequences) in solving a problem. Before beginning it is impor-
tant that therapist and client have thoroughly explored the problem and its affective and
interpersonal associations. The next step is to establish the goals of the decision analysis –
what does the client consider an acceptable outcome to his problem? Then the client is helped
to generate options; if he has difficulty in doing so the therapist needs to help. Finally the
client is asked to choose which option best meets the goal he has set and therapist and client
then discuss how to implement his decision.
Role-play frequently, though not always, follows communication analysis or decision
analysis. Role-play has two purposes: firstly it provides in vivo evidence of how the client
interacts with others; secondly it gives the client the opportunity to try out and rehearse new

ways of communicating with his external network in the safety of the therapy room. It is
important that the role-play is properly set up and discussed so that the subject matter and
goals are clear, (e.g. ‘I want to be able to communicate to my wife, without losing my temper,
how hurt I feel when she sides with my daughter against me’). It is helpful for the client to
take the role of both himself and the other person. Reverse role-play gives the opportunity
for the client to see the difficulty from the other’s perspective and for the therapist to model
alternative approaches to his communication.
Cognitive: there are two techniques in addressing cognitive distortions. The first is to offer
the client reassurance that that this kind of thinking is part of his depression and that it will
become less problematic as he addresses his interpersonal difficulties and his depression lifts.
The second is to explore with him how his cognitive distortions impact on his relationships.
For example helping the client to see that acting on the belief that he is unwanted leads to
him withdrawing from his relationships thus leaving him isolated with his fears about being
unwanted going unchallenged.

In general significant symptomatic relief occurs in all focal areas during the second half of
therapy. After that, there is a consistent improvement that continues after therapy ends. This
pattern may well be linked to the time it takes for the client to begin to ask appropriately for
his needs to be met and to otherwise start changing interpersonal interactions. However, once
change begins the client enters a virtuous cycle where increased social contact and more
rewarding relationships lead to greater trust and an increased ability to use relationships for
support and pleasurable activity.
Other changes are more closely linked to the problem area chosen as the focus for therapy:
In role transitions change involves mourning and thus letting go of the old role and then
engaging more positively with the new one, establishing a more balanced view of both. As
therapy progresses the client practises the interpersonal skills he needs to manage the new
role, initially within the sessions and then within his social network.
In role disputes the client begins by identifying and exploring the nature and stage of the con-
flict (impasse, where there is an absence of discussion; renegotiation which often involves open
argument, or dissolution where the relationship is irrevocably damaged). The client is helped to
identify the non-reciprocal role expectations and communication patterns that perpetuate the dis-
pute and to develop skills to improve his own communication and interpersonal style.
In unresolved grief change involves reconstructing the client’s relationship to the dead
person including helping him to mourn his loss and to take a more balanced view of the
relationship. He is helped to revisit and re-evaluate the circumstances of the death and the
social support available at the time as well as evaluating the impact of his loss on his current
life. Lastly the client is helped to build new relationships and interests.
In the interpersonal sensitivities focus the client is helped to change by coming to
understand how past relationships have broken down or become unrewarding and his

contribution to this. He is then helped to build the interpersonal skills necessary to

engage in more rewarding relationships. Because of the pervasive nature of the difficul-
ties in this focal area there needs to be a realistic appraisal of what is possible over a
short time-scale.
4 CASE EXAMPLE
4.1 The client

Marie was a 62-year-old divorced woman who grew up in the United States. She looked
considerably younger than her years and paid careful attention to her appearance. Her general
practitioner (GP) referred her to my private practice for depression, which followed redun-
dancy six months earlier; her attempts to find work had been unsuccessful in an increasingly
competitive market. She complained of feeling friendless and lonely and, following her
redundancy, socially isolated. ‘I am on the scrap-heap,’ she said. ‘No-one wants me any
more.’ Redundancy had been a surprise; she had been made redundant when others kept their
jobs. She explained that going to work staved off ongoing feelings of aloneness and point-
lessness. I felt she was candidate for IPT because of the acknowledged interpersonal focus of
her depression.
4.2 The therapy

Although Marie reported a disabling fear of scrutiny and negative evaluation from others,
she denied difficulty in trusting me. She felt reassured when I took the expert role and this
laid the foundation for an early positive alliance. However, I found myself increasingly
irritated by her. Through peer supervision I realised that I was burdened by feeling that I
was failing her, despite there being no objective evidence I was doing so. Recognising this
helped me to understand some of her interpersonal difficulties since her feeling of not
getting what she wanted from others was evident in her description of her interpersonal
relationships.
Her positive alliance to me and my insight into how others may experience her made it
possible to use the therapeutic relationship to discuss difficult issues regarding her expecta-
tions of her relationships and communication style once therapy progressed into the middle
sessions.

Diagnosing the depression: Marie scored 22 (out of a maximum 27) on the Patient
Health Questionnaire (PHQ-9), indicating severe depression. The clinical interview
highlighted that her most significant symptom was thoughts about death; however, a risk

assessment revealed that Marie’s relationships with her children and grandchildren were
highly protective. Other significant symptoms included lack of energy, anhedonia, social
withdrawal and difficulties in decision-making. When we discussed the sick role Marie
was initially reluctant to seek help within her network. She took a significant step by
telling her daughter that she was suffering from, and being treated for depression and
needed her help.
The time line: Marie had experienced a number of previous episodes of depression: follow-
ing her arrival in the UK at the age of 20, after her divorce ten years ago and following the
birth of her first grandchild five years ago. Medication had helped, but she had experienced
unpleasant side effects and was not taking it during this episode.
Interpersonal inventory: Given that she had identified herself as socially isolated, I was
surprised to discover that Marie had an extensive social network. She had good relationships
with her ex-husband and three children. She often stayed overnight to babysit her elder son’s
children and was usually invited to spend the next day with the family. The inventory also
revealed a significant number of long-standing friendships both in the USA and in the UK
and several local acquaintances she met with regularly.
There had been some significant losses from her network, including a close friend who was
in the final stages of dementia and the breakdown of her most recent romantic relationship a
year earlier. However, she was most distressed by the loss of her work colleagues following
the redundancy. She missed having relationships that were situational and required no effort
to sustain.
Looking at what she wanted from relationships revealed that Marie had unrealistic
expectations and was therefore often disappointed. She did not discriminate regarding
her expectations of relationships, wanting them all to provide high levels of intimacy and
confiding as well as practical help and social contact. Marie had a negative thinking style
that impacted on her appraisal of the quality of her relationships – for example, if she
could not confide in someone she felt rejected by them and concluded that she was
unwanted.
Asked how her depression impacted on her relationships, Marie said that she did not tell
people when she was depressed. Instead she withdrew socially; when this was not possible
she ‘toughed it out’.
Formulation: there was clinical evidence that Marie’s attachment style was insecure.
This was associated with low self-esteem, the belief she could not ask for support at times
of stress and unrealistic expectations of relationships. Redundancy faced her with the loss
of an important part of her social network – one that was consistent and undemanding.
The impact on her self-esteem of losing her job increased her anxieties about being
wanted by others and led to social withdrawal; the consequent lack of contact with family
and friends reinforced her fear of being a burden and became a maintaining factor in her
depression.
Marie relied on her role at work to create a structure and purpose in her life that helped her
to cope with pervasive feelings of loneliness and low self-esteem. Although at retirement age,
she had planned to carry on working until she was 70 and had no plans to manage the transition

into retirement. The pattern of previous depressive episodes indicated vulnerability at times of
role transition; this unplanned transition was experienced as an entirely negative event and
reinforced her feelings of low self-esteem.
We agreed that role transition was an appropriate focus for therapy and that we would
address the specific transition from being employed into being unemployed. Marie did not
want to work on making the transition into retirement and still hoped she would be able at
find work.
Goals of therapy: As well as relief from her depressive symptoms, Marie wanted to feel
better about not working and to find replacement activities that would increase her social
contact. She also wanted to feel more supported by her social network.

Interpersonal strategies included helping Marie re-evaluate her relationships, for example
discovering the value in friendships that weren’t confiding, but which provided opportuni-
ties for pleasurable activities and an attendant improvement in her mood. She was initially
resistant to the idea of having friends in whom she did not confide but could nevertheless
value; however, over time, she discovered that more realistic expectations of her relation-
ships resulted in increased satisfaction with them. A pivotal moment in therapy occurred
when she arrived home from staying with her son to discover that her neighbours had called
the police, anxious that she had not answered her front door while appearing to be at home.
Although initially annoyed at what she considered an intrusion, Marie came to realise that
her neighbours had cared sufficiently to take action. This helped her re-evaluate how others
felt about her.
Communication analysis revealed the extent to which Marie was unclear in communicat-
ing her needs; consequently those close to her, particularly her children, were unsure what
she needed. Marie used this understanding to change how she asked for her needs to be met
and her relationships with her children became more open and rewarding.
Affective strategies included facilitating Marie in becoming aware of and expressing
anger about her redundancy. She was helped to express her distress at the loss of her old
role and its associated social permissions as well as her anxiety about structuring her new
life in a meaningful way. The expression of strong affect was cathartic and she gradually
oriented herself away from her distress about her lost role into thinking about her new
one.
Behavioural techniques included role-plays. Marie practised making her needs more
explicit in intimate relationships and initiated repair techniques with friendships where disap-
pointment in what the friend could offer had led to rupture. We undertook a decision analysis
to evaluate her options when she considered applying for a job junior to her previous role. I
employed directive techniques to help Marie consider how to undertake activities that
increased social contact, were fulfilling and structured her time.
Cognitive strategies were aimed at helping her see how her negative thinking style
impacted on her engagement with her social network. We also considered how her negativity
might be experienced by those in her network.

Marie was anxious and sad about ending therapy. I worked to normalise her feelings: firstly
by distinguishing appropriate sadness at losing a valued relationship from the re-emergence
of depression; secondly by reinforcing her current independent competence. Ending also
involved another role transition – this time from being a client in therapy to managing her
mental health by herself. We constructed a relapse prevention programme which highlighted
the importance of maintaining contact with her social network and the wish to withdraw as
an early-warning sign of relapse.

I saw Marie for 16 sessions over a period of five months. Her PHQ-9 score was 8 at session 15,
indicating ongoing mild depression. Although she did not experience complete remission,
Marie felt that she had largely met her therapeutic goals. She experienced significant sympto-
matic relief; her relationships were more rewarding and she felt much less alone. Although she
had not reconciled herself to retirement, her continued search for work was within the context
of knowing she was no longer totally dependent on work for everyday social interaction.
Speculating on the sources of therapeutic change, I think that four factors were central to
her improvement. Firstly, the experience of empathic attunement and validation so that she
felt heard and understood. She had previously felt invalidated when those around her
regarded her as fortunate to have the choice to retire. Secondly, cathartic release associated
with expressing her distress about the redundancy and feeling alone and unwanted. This freed
her up to be more in touch with positive affects and to be able to think about what she wanted
in making the transition into not working. Thirdly, behavioural experiments in which she took
risks in relationships by stating her needs more clearly; the outcome was mostly positive and
when it wasn’t she learned about her impact on others and the limitations of different rela-
tionships. This helped to generate more realistic expectations and appraisals of relationship
and social situations so that she was less disappointed and more satisfied with them. Lastly,
through being mentalized by me her own capacity to mentalize increased, which meant that
she was better able to negotiate her relationships.
Reflecting on our work, had Marie been referred to me now I would have encouraged her
to bring a significant other to at least one of her sessions. At the time I confined having sig-
nificant others in sessions to the disputes focal area, as recommended in the IPT manual.
However, since then I have come to recognise the value of significant others attending at least
one session in all focal areas as it brings the network into therapy and reinforces the role of
significant others post therapy.
5.1 Developments
As noted earlier, developments in IPT have almost exclusively involved adaptations of the
original protocol to new client groups or conditions. The adaptations described at the end of

this section (for bipolar disorder and borderline personality disorder (BPD)) are ones in
which there has been a more significant reworking of the model.
IPT for eating disorders: Fairbairn and his colleagues adapted IPT for this group (IPT-BN,
Fairbairn, 1998; IPT-ED, Murphy et al., 2012). The basic IPT principles are adhered to
although there are adaptations in all phases of therapy. During assessment attention is paid to
the history of the eating disorder and weight fluctuations; the relationship between interper-
sonal functioning and the disorder; the client’s difficulties with self-esteem and depression.
During treatment clients are restricted in how much time they spend discussing their eating
symptoms, and are instead required to discuss the stressors and interpersonal factors that
maintain the eating disorder. One of the criticisms of this adaptation has been that the cogni-
tive elements of IPT were largely eliminated in order to make the comparison with CBT more
defined.
Recently the Leicester group (Whight et al., 2011) published a manual for modified
IPT-BN (m), which is, in many ways, more true to the original IPT model in that the cognitive
elements of IPT remain. They promote clear discussion of the food diaries which clients keep
throughout therapy and clients focus on their interpersonal relationships and the link between
their eating disorder and social interactions.
IPT for adolescents: In IPT-A (Mufson et al., 2004) the basic structure of the IPT protocol
is adhered to with its emphasis on thorough assessment and ending phases and the four
identified problem areas. However, the overall length of therapy is reduced to 12 rather than
16 face-to-face sessions. The IPT-A protocol includes adaptations specific to the needs of
adolescents including telephone contact between sessions and the greater inclusion of par-
ents or an alternative significant other in sessions.
IPT for perinatal depression: The best evidenced is Stuart’s adaptation for PPD (Stuart,
2012), which follows the IPT protocol with minor modifications in the assessment and
treatment phases. It is important that reported physical symptoms such as sleep disturbance
are clearly caused by depression rather than the result of having a young baby. The
Interpersonal Inventory needs to emphasise the client’s relationship with her baby as well
as her partner, her family of origin, her partner’s family and her friendships. Although the
therapeutic techniques are those generally used in IPT, Stuart emphasises the importance
of psycho-education and other directive techniques such as advice-giving, particularly in
the early stages of therapy.
IPT for dysthymia: Markowitz (1998) developed IPT-D for people with chronic
depression. Dysthymic clients often view their depression as part of their personality
rather than as a condition; IPT-D while following the IPT protocol, aims to separate the
diagnosis from the person, recognising that the long-term nature of the illness distorts
interpersonal skills over time. The client is encouraged to see his difficulties as an ill-
ness, rather than part of his personality structure, and the treatment period as an ‘iatro-
genic role transition’ into health. The therapist pays particular attention to those times of
relative euthymia – when the client did not feel so bad – as evidence that he has the
capability to feel better.

IPT for bipolar disorder: Frank and her colleagues (Nusslock and Frank, 2012) have
developed a hybrid therapy (IPSRT) combining social rhythm therapy (SRT) and IPT
which adds managing symptoms by regulating social rhythms to IPT’s interpersonal
focus. SRT seeks to stabilise the client’s biological rhythms through regulating his life-
style, thus avoiding triggering the onset of a bipolar mood episode in vulnerable indi-
viduals. Therapy takes place over a much longer period than normal; although initially
sessions are weekly, once the client understands the principles of IPT, therapy moves to
bi-weekly then monthly sessions.
IPT for BPD: is often part of a comprehensive range of interventions for these clients
with complex needs. Therapeutic adaptations include increased use of the therapeutic rela-
tionship (Bateman, 2012), particularly in the early sessions, with an emphasis on repairing
ruptures with clients who are highly sensitive to feeling criticised and undervalued.
Bateman includes an additional (fifth) focus area of ‘how interpersonal interaction moder-
ates and influences experience of the self’, so that this core component of BPD pathology
is openly addressed. Therapeutic input is increased to 24 sessions, with the first 16 taking
place weekly and the remainder fortnightly and then monthly. Because of pervasive feel-
ings of abandonment, adaptation of the model to these clients requires even greater atten-
tion to the end of therapy.
5.1.1 Brief therapy

Weissman and her colleagues have developed two forms of brief IPT aimed at primary
care clients with mild depression in the context of a medical disorder. The first – IPC is a
6–8 session intervention (Weissman et al., 2000). IPT-EST (evaluation, support, triage) is
a new, three session, adaptation manualised for non-mental-health specialists (Weissman
and Verdeli, 2012). IPT-EST is designed to provide guidance, management and support to
the client with the aim of guiding those who need it into more intensive treatment for
depression.

IPT is acutely aware of the need to adapt to the needs of diverse populations. Minor
modifications are introduced for each new group treated by IPT. For example the treat-
ment of older adults (IPT-LL – Later Life) recognises the subtle changes in approach that
are required in treating older people, while IPT-HIV acknowledges the particular needs
of those with HIV.
At the level of cultural diversity, an intervention in Uganda addressed the losses people
experienced as a result of the AIDS epidemic using village leaders. Working cross-culturally
in IPT requires taking into account norms and beliefs about illness as well as recognising
different expectations about how we communicate and function in relationships. Horjus et al.
(2011) have developed a protocol for treating minority populations in the Netherlands, which
offers a blueprint for enhancing cultural relevance.


IPT has demonstrated limited efficacy as a treatment for anxiety disorders or drug and alco-
hol abuse, and there is no evidence base for its use with psychosis or personality disorders
other than BPD. IPT could have a role in the treatment of psychosis, particularly at the stage
of early intervention in helping clients to manage the transition into having a major psychi-
atric diagnosis. Similarly it has potential in the treatment of physical and psychological long-
term conditions, where secondary depression associated with having the condition can under-
mine the primary treatment.

A criticism from the psychoanalytic community is that IPT does not address underlying psy-
chological structures, despite its psychoanalytic inheritance. For example, there have been no
adaptations specifically aimed at increasing security of attachment. At one level this is a
legitimate criticism, since the lack of structural change may contribute to future relapse. Yet
if IPT is judged on its own terms – that it is an effective short-term treatment for depression
and eating disorders that does not aim to rework underlying structures – it is a successful
therapy that ‘does what it says on the tin’.
5.4 Controversies
Although IPT has not been riven by the schisms so often seen in other therapies it is not
without controversy. The major one involves the place of theory and whether IPT will
continue to focus on outcome research with minor modifications to the original protocol.
The founders of IPT argued for many years that research addressing how IPT works should
only be pursued once its efficacy had been established. This position was maintained in
spite of a substantial evidence base demonstrating that it works and has arguably resulted
in a stultification of IPT. As a result those who wanted to explore process and theoretical
issues have felt marginalised within the IPT community. Consequently, after more than
forty years of outcome research, we are still not much clearer as to what the active ingre-
dients in IPT are. There has also been antagonism to critically examining and elaborating
the theoretical basis of IPT.
However, there are signs that this position is no longer seen as tenable. In their recent book
Markowitz and Weissman (2012) proposed that ‘it now makes sense to further explore how
and why it works’, while Scott Stuart continues to make headway in grounding IPT in attach-
ment theory.
Another emerging area of controversy is how to manage the growth of IPT. The chal-
lenge is to maintain adherence to the model while retaining its therapeutic essence, par-
ticularly its humanity and attention to affect. Understandably, there is concern that the
broader dissemination of IPT will result in a dilution of the quality of IPT training and

thus the therapy itself. The challenge is to maintain therapeutic standards and integrity
without demanding strict adherence to overly-rigid protocols. There is concern within the
wider IPT community that a rigid approach will result in a ‘tick-box’ therapy that over-
values the demonstration of discrete competencies at the expense of broader therapeutic
aims and the needs of the client.
6 RESEARCH
Given IPT’s beginnings as a research condition, it is not surprising that it has built its
reputation around its research efficacy. It has an impressive research record for every
adaptation, which I cannot do justice to in this summary. Instead I will select a few semi-
nal studies.
The National Institute of Mental Health Treatment of Depression Collaborative Research
Programme was undertaken in the 1980s (see Weissman et al., 2000) and confirmed IPT as
an effective treatment for depression. 250 depressed outpatients were randomly assigned to
IPT, CBT, pharmacotherapy and a placebo condition; the latter two conditions also included
clinical management. IPT was found to be superior to CBT for severe depression; it also had
the lowest drop-out rate of all the interventions – a finding that has been repeated frequently.
Patients treated with IPT were less likely to relapse within eighteen months than those treated
with CBT (33% for IPT, 36% for CBT).
These findings highlighted the problem of relapse in major depression following all
interventions. In response Ellen Frank and her colleagues developed Maintenance IPT
(IPT-M) extending IPT for clients who had recovered during the acute phase of treatment
but were at risk of relapse (Frank, 1991). They developed a protocol based on monthly
follow-up sessions. 128 acutely depressed patients with a history of recurrent depression
were initially treated with imipramine and weekly IPT. After they met the criteria for
remission and had remained stable for four months they were randomly assigned to one of
five conditions: imipramine with IPT-M; imipramine with clinical management; IPT-M
alone; IPT-M with pill placebo; clinical management plus placebo. Although the combined
imipramine/IPT condition was the most effective in delaying relapse, IPT-M alone delayed
relapse to a mean of 54 weeks. As Weissman et al. (2000) point out, this is sufficient time
for a woman to complete a pregnancy and nurse her baby without medication.
Good outcomes have been found for using IPT with older people. Frank and her colleagues
(see Hinrichsen and Clougherty, 2006) established the Maintenance Therapies in Late-Life
Depression study. 180 people over 60 years with an acute episode of recurrent major depression
were treated with combined IPT and nortriptyline. 78% achieved remission and were randomly
assigned to one of four maintenance treatments. 20% of those receiving combined pharmaco-
therapy and IPT relapsed in the next three years, compared with 43% pharmacotherapy only,
64% IPT only and 90% placebo only. Hinrichsen and Clougherty argue that IPT is the treatment
of choice for older depressed adults where there is an interpersonally relevant problem.

Recently there have been attempts to produce indirect evidence about the mechanisms
underlying change through identifying those patient characteristics associated with
response to IPT. Carter et al. (2011) randomly assigned 177 participants over 18 years of
age with a principle diagnosis of major depressive disorder to either CBT or IPT. Although
much of the variance in outcome was unaccounted for, clients’ initial perception of the
logicalness of the intervention was a predictor. In both therapeutic conditions those who
expected treatment to be effective engaged more constructively with it, leading to symp-
tomatic change.
In terms of process research, as already stated there is a paucity of published findings. An
example is Connolly-Gibbons et al. (2002) finding that IPT therapists used significantly more
statements linking thoughts, feelings and behaviour to early life events than did CBT thera-
pists. A later paper found that IPT therapists who made interpersonally accurate statements
had better outcomes (Crits-Cristoph et al., 2010).
As Champion and Power (2012) note, this is an exciting time for IPT; this applies not only
to its increasing penetration as a therapy, but for the opportunities to research a therapy that
is known to work but is still poorly understood.
7 FURTHER READING
Hinrichsen, G. and Clougherty, K. (2006) Interpersonal Psychotherapy for Depressed Older Adults. Washington:
American Psychological Association.
Markowitz, J. and Weissman, M. (eds.) (2012) Casebook of Interpersonal Psychotherapy. Oxford: Oxford University
Press.
Mufson, L., Dorta, K., Moreau, D., Weissman, M. (2004) Interpersonal Psychotherapy for Depressed Adolescents
(2nd edn). New York and London: Guilford Press.
Stuart, S. and Robertson, M. (2003) Interpersonal Psychotherapy: A Clinician’s Guide. London: Hodder Arnold.
Weissman, M., Markowitz, J., Klerman, G. (2000) Comprehensive Guide to Interpersonal Psychotherapy. New
York: Basic Books.
8. REFERENCES
Bateman, A. (2012) Interpersonal psychotherapy for borderline personality disorder. Clinical Psychology and
Psychotherapy 19: 124–33.
Bowlby, J. (1973) Separation: Anxiety and Anger. London: Penguin.
Champion, L. and Power, M. (2012) Editorial: special Issue on interpersonal psychotherapy. Clinical Psychology and
Carter, J., Luty, S., McKenzie, J., Mulder, R., Frampton, C., Joyce, P. (2011) Patient predictors of response to cogni-
tive behaviour therapy and interpersonal psychotherapy in a randomised clinical trial for depression. J. Affective
Disorders 128: 252–61.
Connolly-Gibbons, M.B.C., Crits-Christoph, P., Levinson, J., Gladis, M., Siqueland, L., Barber, J.P., Elkin, I. (2002)
Therapist interventions in the interpersonal and cognitive therapy sessions of the treatment of depression col-
laborative research program. American Journal of Psychotherapy 56(1): 3.

Crits-Cristoph, P., Gibbons, M., Temes, C., Elkin, I., Gallop, R. (2010) Interpersonal accuracy of interventions and
the outcome of cognitive and interpersonal therapies for depression. Journal of Consulting and Clinical
Fairbairn, C. (1998) Interpersonal psychotherapy for bulimia nervosa. In J. Markowitz (ed.), Interpersonal
Psychotherapy. Washington D.C.: American Psychiatric Press.
Frank, E. (1991) Interpersonal psychotherapy as a maintenance treatment for patients with recurrent depression.
Hinrichsen, G. and Clougherty, K. (2006) Interpersonal Psychotherapy for Depressed Older Adults. Washington:
Holmes, J. (2010) Exploring in Security: Towards an Attachment-Informed Psychoanalytic Psychotherapy. London:
Routledge.
Howard, S. (2010) Skills in Psychodynamic Counselling and Psychotherapy. London: Sage.
Horjus, M., Gumbs, P., Zirar, D. (2011) IPT-Cross-cultural; Practical Aspects Treating minorities. Paper presented at
4th ISIPT Conference, Amsterdam, June 24–25, 2011.
Klerman, G., Weissman, M., Rounsaville, B., Chevron, E. (1984) Interpersonal Psychotherapy of Depression. New
York: Basic Books.
Markowitz, J. (1998) Interpersonal Psychotherapy for Dysthymic Disorder. Washington DC: American Psychiatric
Press.
Markowitz, J. and Weissman, M. (eds.) (2012) Casebook of Interpersonal Psychotherapy. Oxford: Oxford University
Press.
Miller, M. (2009) Clinician’s Guide to Interpersonal Psychotherapy in Late Life: Helping Cognitively Impaired or
Depressed Elders and Their Caregivers. New York: Oxford University Press.
Mufson, L., Dorta, K., Moreau, D., Weissman, M. (2004) Interpersonal Psychotherapy for Depressed Adolescents
(2nd edn). New York and London: Guilford Press.
Murphy, R., Straebler, S., Basden, S., Cooper, Z., Fairbairn, C. (2012) Interpersonal psychotherapy for eating dis-
orders. Clinical Psychology and Psychotherapy 19: 150–8.
Nusslock, R. and Frank, E. (2012) Interpersonal and social rhythm therapy (IPSRT): a review and case conceptualiza-
tion. In J. Markowitz and M. Weissman (eds), Casebook of Interpersonal Psychotherapy. New York: Oxford
University Press.
Ravitz, P., Maunder, R., McBride, C. (2008) Attachment, contemporary interpersonal theory and IPT: an integration
of theoretical, clinical, and empirical perspectives. Journal of Contemporary Psychotherapy 38:11–21.
Slade, A. (1999) Attachment theory and research: implications for theory and practice of individual psychotherapy
with adults. In J. Cassidy and P.R. Shaver (eds), Handbook of Attachment: Theory, Research and Clinical
Applications. London: Guilford.
Stuart, S. (2012) Interpersonal psychotherapy for postpartum depression. Clinical Psychology and Psychotherapy
19: 134–40.
Stuart, S. and Robertson, M. (2003) Interpersonal psychotherapy: a clinician’s guide. London: Hodder Arnold
Weissman, M. and Verdeli, H. (2012) Interpersonal psychotherapy: evaluation, support, triage. Clinical Psychology
and Psychotherapy 19: 106–12.
Weissman, M., Markowitz, J., Klerman, G. (2000) Comprehensive Guide to Interpersonal Psychotherapy. New
York: Basic Books.
Whight, D., Meadows, L., McGrain, L., Langham, C., Baggott, J., Arcelus, J. (2011) IPT-BN (m): Interpersonal
Psychotherapy for Bulimic Spectrum Disorders: Treatment Guide. Leicester: Troubador.
Wilfley, D., MacKenzie, R., Welch, R., Ayers, V., Weissman, M. (2000) Interpersonal Psychotherapy for Group. New
York: Basic Books.

PART V
Broader Developments in
Individual Therapy

17
Mindfulness in Individual
Therapy
Jody Mardula and Frances Larkin
1.1 Historical origins

The current interest in mindfulness in individual therapy can, in part, be credited to the work of
Kabat-Zinn (1990) who developed group-based mindfulness based stress reduction programmes
in response to the needs of his patients at the University Medical Center, Massachussetts, who
were not improving through conventional medical protocols. Jon Kabbat-Zinn, a molecular
biologist with a Buddhist meditation background, had been influenced in his own life and work
by Eastern wisdom traditions such as Buddhism and yoga. Participants in these initial courses
were taught a combination of formal and informal meditation practices, drawn from Buddhism
and yoga, which developed into an eight-week taught mindfulness based stress reduction pro-
gramme (MBSR). These early programmes have since been developed and adapted for a wide
range of issues and health populations, in the United States, Europe and further afield.
Although secular in its applications, mindfulness based approaches (MBAs) have their roots
in ancient wisdom traditions developed over centuries. In particular Buddhist psychology,
which offers what De Silva (1979: ix) has described as ‘an extraordinary astute and penetrat-
ing analysis of human nature and the human condition’. Classical Buddhist texts, for example
the Sattipatthana, which has influenced many Buddhist traditions, emphasise, meditation
practices such as mindfulness of breathing, of the body and of sensations, emotions and

446 PART V: BROADER DEVELOPMENTS IN INDIVIDUAL THERAPY
thoughts (Thera, 1965). These are underpinned by the attitudinal foundations of mindfulness,
non-judging, patience, beginner’s mind, trust, non-striving and acceptance. These practices,
delivered in a secular format, form the basis of what have come to be known as mindfulness
based approaches (MBAs).
Since the early work of Kabat-Zinn, MBAs have been adapted for use with a wide range of
clinical issues, such as depression, anxiety, stress, addiction, chronic pain, cancer, ME, and the
list is growing. Given that these are the kinds of issues that psychotherapists regularly work
with, it is not surprising that its potential for clinical work is increasingly recognised. A further
attraction is the growing empirical research base that has consistently shown significant bene-
fits for participants. It is this combination of applied Eastern wisdom traditions, alongside
Western scientific scrutiny, that has no doubt helped MBAs find a place in Western healthcare
structures and applications, including, more recently, its application to psychotherapy.
1.2 How it finds its way into individual therapy

Mindfulness currently finds its way into therapy via several different routes. Two of these
have been described as mindfulness-based therapy, and mindfulness informed therapy
(Germer et al., 2005: 19). Although in practice, these tend to weave in and out of each other,
for the purposes of this chapter we will give a brief outline of each. Later sections will
develop and explore these in more detail.
With mindfulness-based therapy, practices and techniques from MBAs may be taught to clients
in the course of the clinical session or as home practice. The main focus is inviting clients into
mindfulness practices, arising from what is happening for the individual client in the clinical work.
With mindfulness informed approaches, although mindfulness practices and techniques may be
incorporated, the approach informs the therapy in more subtle ways, and arises from therapists’
own personal practice and understanding of mindfulness, rather than solely techniques, skills, or
interventions. There is an emphasis on the therapist stance within the therapeutic relationship.
Emerging research indicates that when therapists have some background of training and
practice in mindfulness, their clients show improvements. This process is not yet fully
understood. However it would appear that therapists with a regular ongoing mindfulness
practice can come to embody relational qualities important to a good psychotherapy out-
come, such as presence, positive regard, empathy, non-judgment and acceptance. Since the
benefits of a therapeutic relationship that include these kinds of qualities for good clinical
outcomes is at this stage well documented, it would seem logical to infer that therapists with
a regular ongoing mindfulness practice may bring these qualities into their clinical work,
with beneficial results. However further research is needed in this area.
1.3 Mindfulness in psychotherapy is not a theoretical model

It is worth noting that mindfulness approaches have not developed to a point where they
could be described as a theoretical model. However, they are fast emerging as an important

MINDFULNESS IN INDIVIDUAL THERAPY 447
area for discussion, development, and research. Mindfulness is not only an innate human
capacity, but also a way of being, and a foundation for the core conditions of presence and
non-judgmental acceptance that many therapists value. ‘Due to the universal and fundamen-
tal nature of mindfulness it seems reasonable to claim that the attitudinal framework and
personal stance – the way of being – developed during mindfulness practice is potentially
useful to any and all therapists regardless of orientation’ Crane and Elias (2006: 31). In this
broader sense, its influence may extend well beyond the areas described above. As well as
its potential to inform therapy through a mindfulness based or mindfulness informed
approach, it also has the capacity to transcend models, and a potential role in informing the
next wave of developments in psychotherapy.
Mindfulness is essentially moment-to-moment awareness, a state of mind accessible to,

and experienced by all humans. In a healthcare context, it has been described as non-
judgmentally and purposely paying attention to the present moment (Kabat-Zinn, 1990). In
the context of individual therapy Siegal (2010: xiv) further describes it as: ‘intentionally
focusing attention on moment-to-moment experience without being swept up by judgments
or preconceived ideas and expectations’. Many psychotherapists will recognise the kinds
of qualities this definition implies as a central element in their clinical work no matter what
theoretical background they come from, and part of the core conditions, such as uncondi-
tional positive regard, genuineness, non-judgmental acceptance that psychotherapists gen-
erally offer their clients.

To get a flavour of some of the underpinning assumptions of the approach about the person
and human nature, it is useful to draw on Buddhist psychology, and its view of the human
condition. We outline below some of the more relevant aspects of these.
2.1.1 Present moment awareness

At the heart of the MBA approach is an emphasis on the importance of present moment
awareness, and this is what the approach seeks to access. As mentioned earlier, although
this is a universal human capacity, for various reasons we humans often live in a non-
mindful world made up of perceptions of past experiences or imaginings about the future.
A mindfulness approach points out that when we are not in touch with the present moment
our potential for wholeness, and therefore healing is correspondingly limited.
A mindfulness approach works on the basis that many of the ways we use to avoid the
present moment only add to our problems in the long run. When, for example we try to
avoid experiences we perceive as undesirable, or try to make permanent experiences we

want more of, we are setting ourselves up for mental, physical, physiological habits that can
lead to psychological disturbance. People avoid experiencing the present moment through
all kinds of ways that including body tensions, stuck or blocked thoughts, or shutting down
feelings with mental and/or physical defences. It is not hard to see how the kinds of mental,
physical and emotional habits we create can lead to increased stress, depression, anxiety,
self-harm and increased suffering in the long run. In this regard Baer (2006) argues that
many forms of psychopathology are to do with the ways we try to avoid negative internal
experiences, by developing behaviours such as substance abuse, dissociation, binge eating,
or avoidance of people, places and situations.
2.1.2 Gap between experience and perception

A mindfulness approach draws attention to the fact that much of our lives are spent on auto-
matic pilot; there is a gap between what we actually experience through the senses, and how
we perceive that experience. This gap, although often outside of awareness, tends to overlay
our actual experience with layers of automatic conscious and unconscious thinking, feeling,
sensing, and behaving, that may have very little to do with what is actually being experienced
in the present moment. This territory is ripe for projections, introjections and other kinds of
delusional thinking, feeling and behaving. This can contribute and add to a process of ongoing
suffering, or dissatisfaction with life, or a deeper sense that we may be missing out on some-
thing important in our lives.
The degree or size of the gap between experience and perception is highly individual, the
result of a combination of a person’s particular life experiences, psychological make-up, and
genetic inheritance.
2.1.3 Impermanence
A mindfulness-based approach emphasises that human experiences are by their very nature
fleeting and often unsatisfactory. The natural and human wish for positive experiences, rela-
tionships, and possessions to be permanent sets up a tension between what we experience in
the moment and how we would like that experience to be. It could be argued that Western
capitalism, with its focus on the good life, instant gratification, and wanting more than we
already have, exploits this human tendency to the full. However, even without this influence
a mindfulness-based approach points out that humans have an inbuilt tendency to want to
hold onto experiences perceived as good, avoid those perceived as bad, and to be bored, rest-
less or indifferent with experiences perceived as neutral. This creates a resistance to the flow
of life as it is in the moment and its impermanence.
2.1.4 The self

A further point is that Western psychology and Buddhist thinking differ on how the self
is viewed. Whereas Western culture tends to place a huge value on the sense of an indi-
vidual self, Buddhist psychology regards the self more as a dynamic system continually
unfolding and changing (Germer et al., 2005). A mindfulness approach argues that

regarding oneself as separate and completely self-reliant is a delusion which gives rise
to suffering (Bien, 2008). Not only can it contribute to a sense of isolation and loneli-
ness, but it can lead to mental health issues, such as low (or inflated) self esteem; a
preoccupation with self and a dissatisfaction with the self we perceive ourselves to be. It
is no surprise that narcissistic disorders are so prevalent in Western culture, and almost
absent in many other cultures. As Bien notes: ‘the fallacy of the self as separate gives
rise to insecurity, competition, aggression, jealousy, and defensiveness, all to protect and
aggrandise the self’ (2006: 61). Buddhist psychology tells us this activity is pointless,
because the self we seek to defend is no more real than a shadow. From a mindfulness
point of view, acceptance, compassion and kindness towards this fleeting self is crucial,
and can be developed through regular mindfulness practice.

A mindful approach views psychological disturbance as essentially a rupture in our rela-
tionship with ourselves and, by extension, with others we come into contact with. This
rupture is often the result of a combination of life events, the socialisation process, and
our individual genetic or biological predispositions. Whatever the cause, some are able to
ride the constant uncertainties and vicissitudes of life and maintain a sense of connection.
Others are more vulnerable. For example the presence or otherwise of a secure base, or
secure childhood attachments, may interact with an individual’s biological tendency
towards anxiety. Subsequent life events, when perceived through the lens of prior experi-
ences, may reinforce this biological set point, which can then create the conditions for
psychological disturbance.

From a mindfulness perspective, psychological health is the extent to which we are able to be
present, accepting and in contact with the present moment rather than distorting it through the
lens of preconceptions, ruminative, or delusional thinking. A mindfulness approach works on the
basis that although we have a tendency towards dissatisfaction, given the right conditions, we
also have the capacity to accept the way things are, find compassion for ourselves and find a way
to be, even with difficulty. When we are able to open to our experience, in the present moment,
free of judgments and the desire for things to be a certain way, and can bring an attitude of kind-
ness, equanimity and acceptance to what is, then we are free to use all our resources to respond
to whatever is occurring in the present, which, after all, is the only moment we have.

Drawing on neuroscience Siegel (2010) points out that the ability to be present or connected
to experience depends on a basic sense of internal and external safety, which is continually

being monitored through a process called neuroception. One way humans have of dealing
with an unsafe environment is to suppress or avoid it (fight, flight, freeze). However this can
create and set down psychologically unhealthy habits that are self-reinforcing; the more we
suppress the present moment, the more we strengthen neural pathways that increase the like-
lihood of suppressing these similar moments in the future. Over time we internalise and
embody these often rigid or chaotic habits, often to the extent that we no longer notice we are
doing it. From a mindfulness perspective, attempting to avoid or escape aversive internal
experiences only serves to perpetuate those very experiences, which can lead to psychologi-
cal difficulties and unhappiness.

A further, related way psychological disturbance is perpetuated is through neuroceptive
evaluation. According to Siegel (2010), our interpretation of events is driven by an assess-
ment of previous similar experiences. This is particularly true of past experiences of per-
ceived danger or lack of safety. For example, experiences of past unresolved trauma can
restrict, bias or compromise, our ability to openly assess our present moment experience.
Given these human tendencies it is not hard to see how we may spend much of our time in a
non-mindful state that is continually being reinforced and strengthened as we perceive and
filter new experiences. In these kinds of ways, not only do we run the risk of perpetuating
psychological disturbance, but we also end up living a life that falls short of what is poten-
tially possible.
2.4.1 Intrapersonal mechanism

Psychological disturbance occurs to the extent that we turn away from self-engagement at
various levels. When, for whatever reason, the ability to be present, attuned and connected to
ourselves in an empathic way is diminished, we may fail to notice what our body, mind or
senses are experiencing. For example, we may tell ourselves we feel calm, while remaining
unaware that our shoulders and jaw are tense. Or we may maintain a sense of inner calmness
and equilibrium by avoiding experiences that create feelings of anxiety.

A mindfulness approach views the self as interconnected to everything else including other
people. In addition most of our life experiences, either good or bad, happen in relation to other
people. Therefore, the stories we create about who we are and what the world is like also
impact on our relationships with others and become reinforced by the ways we perceive our
relational experiences, and how we invite people to be with us. Germer and Siegel (2012)
point out that the defences we create to ward off our experiences make it difficult to see others
clearly as they are. For example, our minds may be continually stereotyping, judging, idealis-
ing, denigrating others in positive and negative ways that relate to previous experiences, or

how we wish them or us to be, rather than how they actually are and this impacts on our rela-
tionships with ourselves and others.

The combination of biology and an invalidating environment can contribute to the develop-
ment of psychological disturbance. To take just one example (Baer, 2006): if a person with a
biological tendency towards anxiety then experiences an invalidating or unsafe early environ-
ment, this may lead to the development of a heightened sensitivity to mental, physical and
emotional cues. In this way their present moment experience may be influenced by the lens
of both their inherited biology and social conditioning.
Through a combination of biology and social conditioning, we construct a map of the
world, and our place in it as we grow to adulthood. This map, although mostly unconscious,
is often maintained, in the face of a very different present moment reality. As Gilbert (in
Germer and Siegel, 2012) state: ‘We have to make sense of this extraordinarily short, painful
reality of being born from genetic material that has evolved over millions of years, with a
brain capable of creating a sense of self with a desperate wish to continue to live free of suf-
fering and to find meaning – yet knowing we are destined to decay and die’ (2012: 252).
2.5 Change
2.5.1 The concept of change in therapy
Most clients come into therapy because they are unhappy with aspects of their lives and seek
some kind of change. However, at the heart of a mindfulness based approach there is a para-
dox; the more we can be open to and accepting of our current experience without the usual
distorting lenses and habits, the more we are in a position to change it. A mindfulness
approach, therefore, is about a radical non-judgmental acceptance of things as they are in the
present moment. This involves letting go of the resistances, avoidances, grasping, and other
habitual self-perpetuating cycles described earlier, and turning towards and accepting experi-
ences just as they are. It is only through this different more compassionate acceptance that
any kind of meaningful change can happen. ‘The deepest transformations in therapy arise out
of a person’s capacity to hold his or her own inner life with a loving wise awareness’ (Brach,
in Germer and Siegel, 2012: 36).
What can support the client in this journey is both the attuned presence and attention of the
therapist, and the client’s development of mindful present moment awareness through atten-
tion to the mind, body, and senses. A mindfulness approach to therapy therefore emphasises
two main routes to the kinds of acceptance and change described here. Firstly, through the
kind of therapeutic relationship offered by a therapist with their own regular ongoing mind-
fulness practice. Secondly, through incorporating mindfulness based techniques or practices
into therapy. As outlined earlier, these are not mutually exclusive; a mindfulness approach
often comprises both.

Relationship informed by therapist’s own regular ongoing mindfulness practice The

practice of mindfully paying attention to what the mind is doing in each moment helps us
discern the ways conditioning from previous events overlays the present, making it difficult
to see things clearly as they are. With the kind of close mindful attention fostered by regular
practice, we become better at distinguishing an event from our relationship to it. As we pay
attention to our inner world in this way we can experience the arising of a sensation, thought
or feeling, and also how this is followed by the urge to react or respond, and are therefore
strengthening the ability to respond non-reactively.
One of the benefits of regular mindfulness practice is the development, over time, of a
heightened awareness of conditioned patterns of thought and response. Through this process,
Crane and Elias (2006) point out, ‘the grip of the conditioned self is spontaneously slackened’
(2006: 2). A therapist who practises mindfulness is therefore less likely to be acting auto-
matically out of their own conditioning and blind-spots.
In these kinds of ways the therapist, with a regular mindfulness practice, helps bring clar-
ity of awareness, presence, and non-judgmental acceptance to the layers of automatic con-
scious and unconscious thinking that overlay the present moment. This and other insights
gained from practical experience has potential for freeing ourselves from mental habits and
ways of being, that do not serve us or the clients we come into contact with.
3 PRACTICE

As observed earlier, although clients often come to therapy seeking change, it is only
through acceptance of the way things are that it is possible to for change to happen. The
aim with a mindfulness approach therefore is to help the client develop a more open,
accepting and compassionate relationship to their present moment experience. Arising
from this, the goals of a mindfulness approach to therapy are twofold. Firstly to offer a
therapeutic relationship characterised by attuned presence, attention, non-judgment, and
compassion, as a container for building trust and safety. Secondly, to support clients’
capacity to turn towards more aspects of their experience through helping them develop
skills in mindful awareness of the body, thoughts, senses and feelings, and a kinder more
compassionate relationship to these.

In our experience there are very few clients who would not benefit from the addition of
some elements of a mindfulness approach, particularly the qualities of attuned presence,
attention, non-judgment, and compassion offered by a mindfulness oriented therapist.
However there are some caveats that will be explored in this section. When considering if a

mindfulness approach to therapy is suitable it is important right from the start that clients
know what it is being offered to them, so they can make an informed decision on whether
or not to work that way. This will include an open and transparent explanation of what the
elements of such an approach might be, and that mindfulness involves paying attention and
being present to aspects of their lives, including aspects they tend to avoid.
It is important to ascertain if they are open to exploring their experience in this way,
because although appearing simple mindfulness practices and techniques can be extremely
powerful; the approach may awaken deeply held feelings, thoughts, and sensations for some
clients, and they need to be made aware of this. At this early stage it is important also that
the therapist gets a sense of the client’s inner resources and vulnerabilities so they can both
decide if and when this approach is appropriate. Seen in this light, selection, or de-selection,
is a process arrived at jointly. Clients are involved in their own selection or de-selection, with
some guidance from the therapist.

There are very few clients who will not benefit from some elements of a mindfulness
approach. However, although there is, as yet, very little research on mindfulness in individual
therapy, research into meditation in general has shown adverse effects for some. Both authors
want to emphasise the point that the therapist needs to have an in-depth understanding,
through their own practice, of the ways that mindfulness has the potential to cut through
defences, that may be too overwhelming if not approached sensitively, and in a way that suits
the individual client.
Rather than it being unsuitable it is more likely that the teaching of mindfulness practices
and skills may need to be substantially modified for some clients and some conditions. A
therapist who has an in-depth personal experience to draw on is likely to discern what aspects
of the approach may need to be modified for the particular client, and when to defer until
other kinds of therapeutic work is undertaken. For example, for clients who have experienced
trauma it is helpful to discuss the possibility that painful memories may surface during mind-
fulness practice as awareness of disturbing, distracting thoughts and sensations can be any-
thing but relaxing. However, according to Germer and Siegel (2012) even those who are very
vulnerable may benefit from mindfulness practices that develop attentional stability or safe
exposure to inner experience. Short relaxation practices, or meditations of the senses, such as
hearing, seeing, tasting, or the breath, may help stabilise and resource such clients. In addi-
tion, the period of meditation should be time-limited – perhaps as short as a few minutes
(Miller and Schmidt, 2004).
However, even for clients who may be vulnerable in the ways described above, mindful-
ness meditation may be a useful adjunct to psychotherapy as it has the potential to lead to an
awareness and freedom, and increased inner resources not ordinarily experienced in therapy.
The important thing here is the combination of the therapist’s experience and their own ongo-
ing practice, together with feedback and open discussion with the client on how they are
experiencing the practices, and adapting and changing course when necessary.


As noted later in the chapter there is currently very little research on mindfulness in indi-
vidual therapy. Most of the research to date has focused on short taught mindfulness based
stress reduction or mindfulness based cognitive therapy groups. However, since the benefits
of these kinds of groups is now well established, its suitability for individual therapy looks
promising.

We have emphasised throughout the chapter that a mindfulness approach informed by a
therapist’s own regular ongoing mindfulness practice is more useful than one based on a
set of skills or techniques. The therapist’s emotional growth and depth of understanding
are crucial. Mindfulness-based skills and practices have limited value unless embedded in
a therapeutic relationship where the therapist has a personal understanding of their
strengths and limitations. When practised at this level mindfulness becomes much more
than a set of skills or techniques. It becomes embodied in a clinicians’ sense of self. As
one such therapist put it in a recent interview: ‘Mindfulness is not separate from how I
view the world, how I view myself, how I work with clients ... It’s how I live my life
(Larkin, 2012: 34). When practised at this level, an inner wisdom informs the work, guid-
ing the healing process, and letting the therapist know how fast or slow to go, when to
speak, and when to remain silent.

A mindfulness approach emphasises the kinds of personal characteristics useful in build-
ing and sustaining relationships with self and others such as presence, empathy, warmth,
understanding and acceptance (Siegel, 2010). All of these are developed and sustained by
the therapist’s own regular mindfulness practice. In addition, therapists who practise
mindfulness have been shown to have enhanced level of attention, awareness, love and
compassion, all of which are known to benefit clients (Baer, 2006). The mindfulness prac-
tice of the therapist can strengthen acceptance and tolerance of a broad variety of internal
states. All of this has potential to provide a holding presence for the internal states of
clients.

The skills shown by effective therapists can be more to do with how their own mindfulness
practice helps to increase their awareness of their own internal process, making it more likely
that they can be open rather than defended or reactive with clients. This, according to Siegel
(2010), allows for a more accurate internal sense of what is going on in someone else, with-
out over-identification. With these kinds of conditions in place, according to Siegel the client
is more likely to experience a sense of ‘feeling felt’ by the therapist which can contribute to

a sense of feeling safe, seen, affirmed and connected. There is more of an emphasis on rela-
tional rather than skills based interventions.

In bringing sustained mindful attention to the therapeutic dyad, the therapist fosters a deep
appreciation of the client. This relational approach involves the therapist in opening to the
client while at the same time staying open to their own present moment experience as it arises
and changes moment by moment. The core conditions of presence, empathy, congruence and
trust, and a sense of not being judged that are common to many therapeutic orientations are
important features of a mindfulness approach in individual therapy.

The therapeutic style arises from this relational approach and is fostered through the therapist’s
embodiment of the therapy within a container of mindfulness. This includes a process of mind-
ful enquiry intended primarily to further the client’s direct, present moment understanding of
their experiences of their sensations, emotions and mind states. Through this the client can
begin to see themselves as someone whose experience matters. This relationship and therapeu-
tic style, added to the therapist’s existing theoretical model, helps the client to open towards
what is feared or unacceptable in themselves and to find that this can be tolerated. This can
lead to a shift of perception, and ultimately to being able to bring new awareness and choices
to the arising of experience, and particularly the issue in hand.

3.5.1 Assessment
Although assessment can be seen as somewhat at odds with a mindfulness approach with its
stance of acceptance, it is necessary for the therapist to have a clear sense of the therapeutic
issues this client is bringing, their suitability for a mindfulness approach at this time, and of
how they will integrate this with their own therapy approach. The therapist would be likely
to employ a relational style, to both introduce the client to mindful breathing and make use
of this as an assessment tool. Through teaching a short mindfulness practise and enquiring
into what the client noticed during this practice the therapist will gain information on the
nature of the difficulties that arise for this client when invited to go towards their experience,
and of how they interpret and respond to that experience.
Through this process the therapist will be able to assess whether a mindfulness approach
is indicated and in discussion with the client, the nature of the approach to be adopted. The
integration of mindfulness with their clinical therapeutic approach will depend on the context
of working, each particular client, and the style of the therapist. This is a skillful integration,

arising from the therapists practise and supported through supervision from a supervisor who
is familiar with a mindfulness approach to therapy, and ideally has their own mindfulness
practice.

This will differ with whatever therapy approach each therapist is working from, and one of
the skills of a mindfulness-orientated therapist is the weaving of mindfulness into their
approach. This will be impacted on by the context of delivery, whether this is a short- or
long-term piece of work, the constraints of time or any requirements of outcome from the
delivery.
The relational stance of a mindfulness informed therapy can be integrated into most thera-
peutic approaches and may be the only way that the therapist employs mindfulness. Or the
therapist may decide to use a mindfulness based approach teaching mindfulness practices to
foster the development of mindfulness qualities of curiosity, compassion and bringing atten-
tion to their own unfolding processes, of the mind the body and the senses. Where the thera-
pist decides to put emphasis will arise from the ongoing relationship, and be informed by the
assessment and therapeutic issues in hand.

Strategies and techniques, when used, are drawn from the kinds of practices taught on
MBSR or mindfulness-based cognitive therapy (MBCT) programmes which in turn are
based on Buddhist mindfulness meditation practices adapted for secular use. In MBSR
and MBCT programmes participants are taught a mixture of formal and informal mind-
fulness practices. The learning from the direct experience of these practices is supported
by a group enquiry and discussion process. When adapted for individual therapy there is
more of an emphasis on the development of the therapeutic relationship as a vehicle
through which to explore mindfulness. There is also an emphasis on individual enquiry
and client feedback so that the practices are tailored to an individual client’s needs,
wishes, and developing felt sense. Through experiencing a relationship where the client
can feel deeply met and accepted as they are a safe base becomes established. From this
base, the introduction of mindfulness techniques and practices help to foster a safer more
embodied present moment experience that can begin a process of safely turning toward
and befriending a self that may previously have been experienced as the source of dis-
tress, pain, and difficulty.

Depending on what is presented by the client the therapist might teach, and invite the client
to practise, mindful awareness of the breath, of sounds, of tastes, or images. The body-scan,
that is, paying attention to different parts of the body, or mindful movement might also be

incorporated. The aim of these kinds of practices is to help clients develop skills that enhance
their ability to shift the focus of attention to different aspects of experience (emotions,
thoughts, sensations, sounds, textures, tastes etc.). This can lead to enhanced awareness of
more aspects of present moment experience. Clients can learn to pay attention and respond
to experience with more acceptance and less judgment. Segal, Williams and Teasdale (2002)
point out that the ability to redeploy attention, developed by, for example, the body-scan, is
particularly useful for clients with extremely intense or reactive emotional experience.
Paying attention to the body in this way can reduce the likelihood of getting caught in loops
of negative rumination that are known to lead to depressive relapse. According to Siegel
(2010) breath awareness practices help integrate the nervous system and promote a sense of
calmness. Clinicians from diverse theoretical orientations or backgrounds can use these kinds
of mindfulness techniques and practices to benefit their clients, and help them establish a
ground of inner resilience, fluidity of experiencing, and calmness, at various stages of therapy
when appropriate.

As the therapy unfolds and trust and awareness of themselves and their process deepens cli-
ents may begin to open to old memories or begin to experience feelings or sensations they
previously avoided or blocked out. At this stage the therapist needs to pay close attention to
the unfolding process of the client, tracking how are they managing this new awareness. The
therapist needs to monitor and teach the client to monitor, the intensity of their experience.
There is an ongoing exploration of the edge of experience, and of bringing in wise and com-
passionate choices – both for the therapist in their choice of intervention, moment by
moment, and for the client, as they learn how to ride the tide of their emotions, thoughts and
sensations. The client learns that they can tolerate the present moment, and stay safe, that
feelings pass, that thoughts pass. They learn that they can turn away from their familiar strug-
gles, and that they can open to acceptance and change, letting go of their old patterns of
avoidance and change (Crane, 2009).
Clients often report a sense of empowerment from gaining a new perspective, and the
confidence that comes from recognising that all things pass, and that they can turn to them-
selves, to their own breath and body to support and steady themselves through the ups and
downs of their lives. They become more attuned to themselves, and to their own wisdom and
compassion.
4 CASE EXAMPLE
4.1 The client

Adam was a 54-year-old professional British man. He had several short-term relationships
but never married or had children. His father had died some years ago and he visited his

elderly mother in a care home nearby. He was the oldest of three brothers. Adam reported
a history of anxiety and panic attacks, particularly in social situations, and spoke of a
sense of dread. He had done some meditation before and thought a mindfulness therapy
might suit him.
Adam wanted to be more comfortable in social situations, understand the feeling of dread,
engage more with other people, and develop his mindfulness practice. We agreed to use a
combination of therapy and mindfulness and for him to practise mindfulness between
sessions.
4.2 The therapy

Adam reported being calm when he arrived, although he appeared tense and agitated. I
noticed that a lack of congruence between what he expressed and what I observed resulted in
my feeling a sense of uneasiness, and I wondered if this might be familiar for him in relation-
ships. The therapy took the form of inviting him to talk about whatever came up as we sat
together while I responded when I noticed or experienced an inconsistency (e.g. myself
becoming distant) to help him explore thoughts and feelings as they arose. I would then invite
him to practise a short mindfulness practice, bringing attention to his breathing, what was
arising in his body and his mind, and enquiring with him into what he had noticed. I also
introduced a mindfulness approach to working which was to track his experiences with him,
fully attending and bringing in the qualities of curiosity and kindness and developing a sense
of embodied presence.
The focus of the work was to help Adam become aware of the thoughts and feelings that
led him to move away from contact, and develop a way of settling and connecting to
himself and with me as we sat together. Initially this was uncomfortable for him. As he
became more aware and familiar with settling himself in the therapy, he began to notice
that he found it easier to be with me. Through this process he gradually became aware of
the level of anxiety he felt, and the sense of dread that accompanied it, and began to be
less worried as he became familiar with the breathing practice. After several sessions of
therapy we moved in to a more integrative therapy approach where my strategy and inter-
ventions were influenced by a combination of transactional analysis, person centred and
psychodynamic approaches.
I became aware that both his story, and a tendency I noticed for me to feel disconnected
when he talked, indicated that he had a distant relationship with his mother. As I enquired
about his relationship with her he said that he would like to find a way to talk to her now,
particularly about memories from his childhood. I asked him what stopped him from doing
that and he said that her reply would be to dismiss his request, as this was her response to
most things. I felt sad as he said this and chose to share my feelings. We explored what he
was experiencing, which was the sensation of dread in his chest.
At this stage in the therapy Adam had developed sufficient sense of safety in the thera-
peutic relationship and in the mindfulness practices to begin to open towards the arising

intensity of his emotion as he talked. We worked together in this way, engaging in mind-
ful breathing while gradually coming up closer to the difficult feelings with an attitude of
curiosity and gentle kindness and exploring the edge of the intensity, with the option
always of going further in or moving back to the anchor of the breath in the belly.
Gradually Adam was able to turn towards his experience, and find that this could be toler-
ated, and that, rather than staying the same, or increasing, he noticed that the intensity
often softened and changed.
At this point in the work Adam began to explore his history. Mindfulness had enabled him
to find a way to be with his discomfort and to open up to the painful recollections. He recalled
his father as being prone to unpredictable rages, particularly if the children made a noise or
moved too quickly. He knew that his father had had a terrible time in the war and that for
much of Adam’s childhood hardly seemed to leave the house. His mother seemed not to
notice and if they spoke of it she would was say ‘Shh some things are best left alone.’ Every
so often men would come and take his father away, but there was never any discussion about
this in the home. I asked him how he felt about that now and after a pause, he said he felt
angry. I invited him to speak about his anger and as he spoke I noticed that I felt sad. Adam
was expressing anger for the lack of information on behalf of his dad, who was so damaged,
and with his mum for still not letting him talk about it. I affirmed his feelings whilst being
aware that I was still sad and, holding that, chose to give Adam the permission he seemed to
need and said ‘It’s time for you to speak about this now, it will not hurt anyone, it’s time to
leave it in the past.’ This gave a direct permission that was counter to the ‘best left alone’ that
had been how to respond in the past. He began to sob, getting in touch at last with the depth
of sadness.
After this session Adam talked about having a new sense of empowerment. I told him
that I experienced him as more connected in sessions, and noticed his voice was firmer and
louder, as if he had just found it. There was a new sense of closeness and mutuality as we
talked, and I began to look forward to our sessions in a way I had not before.
Later he told me that when he next went to see his mother, he practised focusing on his
breath and decided to bring kindness in to his breathing, the way that I had done in our ses-
sions and to bring his attention to thinking about his Dad as they sat there. He said, ‘And then
I felt a strong urge to speak to Mum and I said, “Mum, I have been talking about Dad, and it
feels good, I feel much better for that.” And she did not say anything for a while, and then
she reached out and took my hand, she never does that, and we just sat there, and somehow
since then I have felt different, and the lump is not there in my chest, and mum and I have
begun to talk more than we ever did.’

The relationship was characterised by my intention to bring the attitudes of mindfulness,
curiosity and compassion into the relationship itself. This enhanced my ability to be
present, open to myself and my client, and to foster my client’s ability to open to himself
and his experience (mindfulness plus a person-centred, integrative approach). In the

early stages of the relationship with Adam, I often experienced myself as uneasy (dis-
owned feelings projected from the client). At these moments I became aware that I had
a tendency to move to doing, intellectualising, and away from fully attending to myself
and to him. I would find myself glancing at the clock. My own use of mindfulness sup-
ported me in maintaining awareness of these reactions. I responded by breathing, con-
necting to my body sitting here, and deliberately widening my attention so that I was
opening to the felt sense of the client. From this connected place I would invite Adam to
pause and to breathe and feel the connection of his body with the chair, and we would
engage in this practice together. This helped me to connect back to him, and for him to
connect to me.
I realised that his mother had probably kept an emotional distance from her children, as
she struggled to deal with her own and her husband’s difficulties. I understood this through
my experience of moving in and out of being present as I sat with Adam, and within this
mindfully informed relationship I was able to stay present and Adam to develop a sense of
his impact on me, and in that to strengthen his sense of himself.

I engaged in an ongoing assessment of the client’s moment by moment changes, choosing,
through dialogue and reflection, when and how to respond. This process was informed by
my own mindfulness practice, and by our contract, the changes Adam wanted to make,
and my assessment of his presenting issues. Adam had been able to make initial contact
with others, but this evoked anxiety. This resulted in him being uncomfortable to be with,
and had made it difficult for him to maintain close relationships. Feelings of sadness and
anger seemed to have been pushed away leaving him with fear understood and experi-
enced as anxiety and dread. This had indicated that a mindfulness style would be helpful.
Through developing mindfulness techniques and using them within the experience of an
accepting and attending relationship, he could begin to find a way to turn towards himself,
to allow himself to feel what was there, and to feel confident in his ability to respond, to
settle himself.
As he gained a new perspective on his story, he perceived it with the knowledge and insight
of the here and now, rather than through the lens of a young child. As he turned towards
himself, and myself in the therapy, he also began to relate differently to others, and to find it
more comfortable to relate to others.
4.2.3 Therapeutic strategies and technique

My main strategy was integrating mindfulness with my therapeutic approach by bringing it
into the therapy through the relationship and in teaching the client a simple breath and body
focus mindfulness practices. A further strategy was for Adam to develop a habit of regularly
pausing in whatever he is doing in his daily life, and to do this practice. The aim was to bring
in the qualities of curiosity about what is it he is experiencing, to build his confidence in his
ability to do this, and to bring in the compassionate, non-judging approach fostered in the

therapy. Together these strategies began the process of Adam being able turn towards emo-
tions previously blocked off, and finding a way to be with them, himself and others.

At this time Adam had engaged in 15 sessions of therapy and developed his mindfulness
practice to support the changes that he was making. This resulted, together with the insights
and new perspectives gained, in him noticing and responding when he began to feel anxious,
and to no longer have anxiety attacks. Through being kinder to himself he was more able to
let go of his judgmental thoughts and he no longer experienced the feeling of dread he had
reported initially. By the end of the sessions Adam was confident enough to go and attend an
8-week mindfulness class and become a member of a weekly follow-up group. He later
returned to therapy with me bringing a very different goal of having a close relationship and
finding a partner.
5.1 Developments
The current interest in mindfulness in individual therapy developed from the work of
Kabat-Zinn and colleagues at the Centre for Mindfulness in Medicine Health Care and
Society in the United States. Kabat-Zinn and colleagues continue to develop and deliver
MBSR and to train others to use this approach throughout the world. From these founda-
tions programmes have developed that combine the essence of this approach with population
groups and issues in the United States, Europe, and further afield. As psychotherapists
have become interested in using it in their own lives and in their work, the development
of a range of different psychotherapy approaches that incorporate mindfulness in various
ways has increased.
5.1.1 Brief therapy

The approach works well within a brief therapy format. The original mindfulness based stress
reduction programmes developed by Kabat-Zinn and his associates are based on a short term,
eight week model. The various therapies such as MBCT, DBT, and ACT, described later, are
short-term, structured approaches and interventions that combine elements of group and
individual therapy at different points in the treatment.

The stance of acceptance, non-judgment and compassionate warmth towards self and
others is an egalitarian stance that lends itself to working with diversity. In developing
mindfulness based approaches Kabat-Zinn (1990) envisaged these as a more egalitarian,
less costly, shorter form of intervention than traditional therapies. Seen as part of an

ideological difference to the usual medical model, it has always emphasised the sharing
of expertise between client and therapist. The importance of the facilitators having had
an in-depth engagement with the practices was seen as fundamental to its success. The
model of the ‘wounded healer’, rather than ‘expert’ has been emphasised (Santorelli,
1999). This approach lends itself to respecting diversity and difference within the wider
arc of our shared humanity as vulnerable human beings. As health-care professions,
including psychotherapists, develop this, it remains to be seen if this egalitarian stance
will remain.
(a) Mindfulness-based cognitive therapy Mindfulness based cognitive therapy

(MBCT) based on Kabat-Zinn’s work is an integration of the kinds of mindfulness based
stress reduction programmes outlined earlier, with cognitive behavioural therapy (CBT).
It was developed by Segal, Williams and Teasdale (2002) to help people suffering from
depression and anxiety. Its benefits have at this stage been well documented (Segal,
Williams and Teasdale, 2002; Crane, 2009). It has, for example, been shown to be benefi-
cial for clients with depression through teaching them skills to disengage from habitual
‘automatic’ unhelpful cognitive ruminative patterns that can make people vulnerable to
depressive relapse.
One of the main differences between MBCT and CBT is that rather than changing belief
in the content of thought, the focus in MBCT is on a systematic training to be more aware,
moment by moment of physical sensations, thoughts and feelings as passing events, rather
than who a person is. This facilitates a ‘decentred’ relationship to thoughts and feelings,
where they can be perceived as aspects of the flow of experience, which move through our
awareness and not necessarily reality in any given moment.
(b) Other therapies influenced by mindfulness Mindfulness ideas and practices also
inform other therapies such as dialectical behaviour therapy (DBT) and acceptance and com-
mitment therapy (ACT). Germer and Siegel (2012) point out that attitudinal qualities of
mindfulness and acceptance permeate both the stance of the therapist and the interventions
used in these kinds of approaches. The former, which seeks to develop a dialectical balance
between acceptance and change, has been used for clinical populations such as borderline
personality and severe suicidality. The latter, used for anxiety based conditions, encourages
a stance of turning towards and accepting experiences as they are as a way of befriending
oneself and reducing anxiety. The programmes that have emerged from this initial work have
been well documented and researched, and have been described as part of a new wave of
mindfulness and acceptance based treatments that are developing in psychotherapy (Germer
and Siegel, 2012).
(c) An emerging new therapy/model? Mindfulness approaches in psychotherapy are an

emerging development that, unlike many other contributions to this book, cannot be
described as a model with its own clearly defined maps and theories. According to Germer

‘We will have developed a new model of psychotherapy if the out-come literature further
confirms its usefulness, when we elaborate and refine relevant aspects of mindfulness for
different settings and diagnostic categories, when we specify the limitations of the approach,
and when different areas of scholarly investigation are brought under a consistent theoretical
umbrella’ (in Germer, Siegal and Fulton, 2005: 20).
In some ways we are not too far off from this. As well as being developed into the kinds
of therapies described above, treatment strategies based on mindfulness both as technique
and as a way of being are increasingly being incorporated into the repertoire of experienced
therapists with an established mindfulness practice. Many psychotherapists have a natural
interest and leaning towards some kind of meditative stance in their work. Although research
into mindfulness in individual therapy is in its infancy, taught programmes based on mindful-
ness offer therapists a well-researched and documented avenue to bring aspects of this into
their clinical work. Such an approach can integrate seamlessly with traditional therapeutic
techniques by fostering attention, awareness, and a quality of presence to the clinical issue at
hand. Therapists can then build on this from their own theoretical orientation and training.
Mindfulness can help clients and therapists develop the tools they need to make the best use
of therapeutic interventions that require in-depth awareness of the present moment. Seen in
this broader context mindfulness has the potential not only to link different models of psy-
chotherapy, but also to bridge clinical research and practice, and to integrate the personal and
professional lives of psychotherapists.

One limitation that has been emphasised in this chapter is that a mindfulness approach is not
yet a model with its own background of scholarly research and investigation. There are, as
yet, no agreed definitions of what mindfulness orientated therapy actually is, how its use can
be refined for different diagnostic categories, or what the limitations are. It does not have an
agreed developmental model of the person.
Therapists bringing mindfulness into their work need to be clear about the contraindica-
tions to the use of mindfulness with certain clients. Generally clients presenting with person-
ality disorder, current substance misuse, eating disorder, current and recent bereavement and
trauma, and who have a tendency to disassociate need a therapist who is fully trained and
supervised in the application of a mindfulness-based approach with these issues if they are
going to introduce them. Bringing mindfulness to working with clients with psychosis would
be contraindicated unless carried out by a clinician experienced in working with this group
and would generally be delivered in a clinical setting.
Research for mindfulness in individual therapy is at a very early stage. All of this makes it
hard to form an objective view of its benefits. At this point in time, as we have stressed in
this chapter, rather than seeing it as a standalone model, it needs to be viewed more as an
adjunct to existing models of therapy that some therapists may find useful, and an emerging
development that can influence psychotherapy in different ways.


In a sense mindfulness has become a victim of its own success. Although attracting huge
interest from psychotherapists, recommendations and guidelines for its use are only in the
very early stages of development. Recommendations for mindfulness teachers are now in
place and protocols for a mindfulness supervision model are currently being developed.
However, at this point there is nothing similar in place for mindfulness in individual therapy.
This current lack means that anyone with minimal practical experience or knowledge can
set themselves up as an expert. Part of the guidelines for good practice for mindfulness
teachers is that they are required to have supervision from a recommended mindfulness
supervisor in place. In our view this needs to extend to psychotherapists, who may need
supervision on how they are engaging with their own mindfulness practice, and how it
informs their clinical work.
A criticism sometimes directed at a mindfulness approach can be that it may be perceived
as Buddhism by the back door, and a suspicion that this is a spiritual or religious approach.
Mindfulness-based approaches are delivered in a secular format, and the increase in provi-
sion of excellence in training and supervision of mindfulness practitioners ensures the skills
to deliver a secular intervention that nevertheless embraces the teachings from Buddhist
psychology.
A further related criticism is that there is a blurring of the line between teaching a mindful-
ness based course such as MBSR or MBCT, and practising mindfulness oriented therapy
using elements from mindfulness approaches. This situation is likely to change as mindful-
ness in individual therapy becomes more established, with its own research base, and its own
recommendations and protocols for practice.
5.4 Controversies
The points raised as limitations also have the potential to be controversial. For example, there
are differing views in the practice literature on the relevance and importance of the therapist’s
ongoing meditation practice, when seeking to use it in their work in the kinds of ways
described earlier.
5.4.1 The importance of the therapist’s personal ongoing mindfulness practice

This debate has parallels to the long-running debate on how much personal therapy a
therapist needs to have undertaken in order to be a good therapist. On the one hand there
is the argument that the therapist’s own regular practice is crucial not only in fostering
qualities that make for good therapeutic relationship but also in discerning the ‘fit’ of mind-
fulness techniques and interventions for each individual client. On the other, mindfulness-
based techniques such as breath and body awareness can, at a more superficial level, be
easily learned and incorporated into treatment strategies known to be helpful to clients. We
see the regular ongoing mindfulness practice of the therapist as important. Without it the

depth and complexity of what mindfulness can offer, both to therapist and client, may be
lost. There is the danger, as Kabat-Zinn observed, of it being reduced to ‘just another dime
store technique that will be good for practitioners to know about so they can offer it to their
patients’ (in Pointon, 2005: 7). As the interest in mindfulness approaches develops, no
doubt this debate will continue.
6 RESEARCH
As emphasised throughout the chapter mindfulness in individual psychotherapy is a rela-

tively new development. At this stage there is a solid research base supporting the benefits of
taught MBCT and MBSR courses. However, research into mindfulness in individual therapy
is only just emerging. Given that MBSR and MBCT are of benefit to the same kinds of issues
that psychotherapists encounter in individual therapy it would be logical to infer that a mind-
fulness approach here would also be beneficial. Research into therapies influenced by mind-
fulness within a combined individual and group therapy format, such as ACT and DBT, are
a promising area of development (Germer and Siegel, 2012).
In our experience for a mindfulness approach to have any kind of lasting or meaningful
influence on the client the therapist needs to have a regular ongoing meditation practice
from which to draw on; an embodied sense, from the inside as it were, of mindful pres-
ence. This view has been supported by recent research that indicates that the regular
mindfulness practice of the therapist fosters and develops attitudinal qualities including
presence, positive regard, and non-judgmental acceptance, all of which have been proven
to enhance the therapeutic relationship and benefit clients in individual therapy. For
example studies by Shapiro et al. (2006), Shapiro, Brown and Siegal (2007), and
Christopher and Dunnagan (2006) found that healthcare professionals taking MBSR self-
care programmes reported greater self-compassion and a greater capacity for empathy,
and other relational qualities.
Christopher and Maris (2010) have summarised several qualitative research projects
conducted over the past nine years on taught mindfulness self-care programmes for
therapists. They found that the therapists in the studies experienced positive physical,
emotional, mental, spiritual and interpersonal changes. Interestingly, the therapists also
reported substantial positive effects on their counselling skills and therapeutic relation-
ships (Christopher and Maris, 2010). This kind of research is important as it makes links
between therapists’ personal mindfulness practice and positive influence in their clinical
work.
Research by Grepmair et al. (2007) considered the influence of taught mindfulness courses
on trainee therapists, and found these had a significant positive influence on their clinical
work, mainly through enhancing the therapeutic relationship. Although further research is
needed to understand how and why this happens, these kinds of studies appear to indicate that
it is relational rather than technique driven factors that lead to the positive changes described.

This finding is also supported by the strong body of psychotherapy research citing the thera-
peutic relationship as a better indicator of successful therapy than any particular therapy
orientation or technique (Cooper, 2008; Hubble, Duncan and Miller, 1999). However, since
at this point in time there is very little research into using mindfulness-based techniques in
individual therapy caution is required when interpreting findings from these studies.
6.1 Researching the interior of mindfulness and psychotherapy

Researching the benefits of mindfulness approaches in psychotherapy is an onerous task. For
a start mindfulness is just one of many meditation practices rooted in Buddhist and other
Eastern psychologies. In addition the number and kinds of psychotherapeutic orientations
have grown exponentially over the past century. This means that mindfulness combined with
psychotherapy is just one drop in an almost limitless pool. A further difficulty is that the kinds
of transcendent experiences evoked by mindfulness practice (and some psychotherapies) can
be ineffable, hard to pin down and verbalise, not easily accessed by traditional quantitative
methodologies alone. It is interesting therefore to examine some of the smaller practice based
qualitative studies that explore in-depth the experiences of a small number of therapists.
These kinds of studies give a flavour and some insights into how a mindfulness approach
may be woven into individual therapy.
One such example is a qualitative study carried out by Bazzanno (2010). Faced with the
depth and breadth of the topic (hundreds of therapeutic orientations, hundreds of meditation
practices over millennia), his small-scale study was based on a personal wish to reflect on his
own practice and clinical use of one kind of meditation (Zen meditation), and that of col-
leagues. His research found that ‘The regular practice of meditation can make a therapist a
better instrument, more finely tuned to empathic awareness and congruence, one who can
better assist a person in distress or a person exploring issues in his or her life’ (Bazzanno,
2010: 36).
One of the authors of this chapter carried out a small qualitative exploration into the ways
a therapist’s personal ongoing mindfulness practice may influence the self of the therapist
and their clinical work. Using interpretative phenomenological analysis this study found
that mindfulness influenced participants’ sense of self by fostering qualities and attitudes
including an enhanced sense of presence, awareness, mental clarity, openness to experience,
non-judgment, compassionate warmth, and a fluidity of experiencing (Larkin, 2011). As
these qualities developed through their own regular mindfulness practice, therapists
observed they were increasingly able to extend these to clients. Although results from small
qualitative studies such as these cannot be generalised they give an insight into the experi-
ences of practitioners seeking to combine meditation and psychotherapy. As Bazzanno
observed, the few research studies so far ‘represent merely the beginning of many possible
connections still to be made between Eastern contemplative practices and Western psycho-
therapy’ (2010: 33). Given the current interest in mindfulness approaches in healthcare, and
its potential benefits for individual psychotherapy, research in the area looks set to increase
over the coming decades.

7 FURTHER READING
Crane R. (2009) Mindfulness Based Cognitive Therapy. London: Routledge.

Germer, C. and Siegal, R. (eds) (2012) Wisdom and Compassion in Psychotherapy. New York: Guilford Press.
Germer, C., Siegel, R., Fulton, R. (eds) (2005) Mindfulness and Psychotherapy. Abingdon: Guilford Press.
Kabat-Zinn, J. (1990) Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and
Illness. New York: Dell.
Segal Z., Williams, J., Teasdale, J. (2002) Mindfulness Based Cognitive Therapy for Depression: A New Approach
for Preventing Relapse. Abingdon: Guilford Press.
8 REFERENCES
Baer, R. (ed.) (2006) Mindfulness Based Treatment Approaches: A Clinician’s Guide to Evidence Base and
Applications, MA: Academic Press.
Baer, R. (2003) Mindfulness training as a clinical intervention: a conceptual and empirical review. American
Psychological Association 10: 125–43.
Bazzanno, M. (2010) Mindfulness in context. Therapy Today: 21(3): 32–6.
Bien, T. (2006) Mindful Therapy: A Guide for Therapists and Helping Professionals. Boston: Wisdom.
Chambers, J. and Maris, J. (2010) Integrating mindfulness as self-care into counselling and psychotherapy training.
Counselling and Therapy Research 10(2): 114–26.
Christopher J. and Dunnagan, T. (2006) Teaching self-care through mindfulness practices: the application of yoga,
meditation, and qigong to counsellor training. Journal of Humanistic Psychology 46(4): 494–509.
Christopher, J. and Maris, J. (2010) Integrating mindfulness as self-care into counselling and psychotherapy train-
ing. Counselling and Psychotherapy Research 10(2): 114–26.
Cooper, M. (2008) Essential Research Findings in Counselling and Psychotherapy: The Facts are Friendly. London: Sage.
Crane, R. (2009) Mindfulness Based Cognitive Therapy. London: Routledge.
Crane, R. and Elias, D. (2006) Being with what is: mindfulness practice for counsellors and psychotherapists.
Psychotherapy Today 17(10): 31–3.
De Silva, P. (1979) An Introduction to Buddhist Psychology. London: Macmillan.
Germer, C. and Siegel, R.(eds) (2012) Wisdom and Compassion in Psychotherapy: Deepening Mindfulness in
Clinical Practice. New York: Guilford Press.
Germer, C., Siegel R., Fulton P. (eds) (2005) Mindfulness and Psychotherapy. Abingdon: Guilford Press.
Grepmair, L. Mitterlehner, F., Loew, T., Bachler, E., Rother, W., Nickel, M. (2007) Promoting mindfulness in psycho-
therapists in training influences the treatment results of their patients: a randomized, double-blind, controlled
study. Psychotherapy and Psychosomatics 76: 332–8.
Hick S. and Bien T. (eds) (2008) Mindfulness and the Therapeutic Relationship. London: Guilford Press.
Hubble M., Duncan B., Miller S. (1999) The Heart and Soul of Change: What Works in Psychotherapy. Washington:
The American Psychological Association.
Kabat-Zinn, J. (1990) Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and
Illness. New York: Dell.
Larkin, F. (2010) Mindfulness as psychotherapy intervention. In To a Life That Shines: NCS Ten Years Transforming
the Shadows, Ireland, National Counselling Service.
Larkin, F. (2011) Mindfulness and Psychotherapy: An Exploration of the Influence of Mindfulness Meditation on
the Self of the Psychotherapist and Their Clinical Work. MA Thesis, for Centre for Mindfulness Research and
Practice, School of Psychology, Bangor University.

Miller, J. and Schmidt, A. (2004) Healing trauma with meditation. Tricycle, Fall: 40–3.
Pointon, C. (2005) Mind-body medicine. Therapy Today (16): 4–6.
Santorelli, S. (1999) Heal Thyself: Lessons on Mindfulness in Medicine. New York: Bell Tower.
Segal, Z. Williams, J., Teasdale, J. (2002) Mindfulness Based Cognitive Therapy for Depression: A New Approach
for Preventing Relapse. New York: Guilford Press.
Shapiro, S., Austin, J., Bishop, S., Cordova, M. (2005) Mindfulness-based stress reduction for health care profes-
sionals: results from a randomised trial. International Journal of Stress Management 12(2): 164–76.
Shapiro, S., Carlson, L., Astin, J., Freedman, B. (2006) Mechanisms of mindfulness. Journal of Clinical Psychology
62(3): 373–86.
Shapiro, S., Brown, K., Siegal, G. (2007) Teaching self-care to caregivers: effects of mindfulness-based stress
reduction on the mental health of therapists in training. Training & Education in Professional Psychology
1(2): 105–15.
Siegel, D. (2010) The Mindful Therapist: A Clinician’s Guide to Mindsight and Neural Integration. New York:
W.W. Norton.
Thera, N. (1965) The Heart of Buddhist Meditation. New York: Buddhist Meditation Society.
Wellwood, J. (2000) Towards a Psychology of Awakening. Boston: Shambhala.

18
Narrative Therapy
Martin Payne
Narrative therapists share certain philosophical positions, and use similar practices, but like
all therapies this is a developing way of working. Although this chapter attempts to present a
consensus, inevitably there are omissions and simplifications.
I have followed the practice of Michael White, one of the cooriginators of narrative ther-
apy, by referring to ‘persons’ rather than ‘clients.’
‘Narrative’ in this therapy refers to self-stories, the many-stranded and often inconsistent
images and conceptualisations of our past, present and future that we continually build
throughout life. Narrative therapists propose that people’s frequent, repeated and explora-
tory accounts of their experience are the most important factors influencing their sense of
themselves and how they view their lives and relationships. The way we select out, under-
stand and give meaning to our remembered experience is powerfully influenced by many
factors, including the values and assumptions of the culture and subcultures within which
we exist. We ruminate in internal monologue, but when we talk to other people, including
therapists, our memories, and the thoughts and feelings they incorporate and evoke,
become organised, even if the account is back-and-forward rather than strictly sequential.
Assisting persons to explore, expand and revise their self-stories is the basis of narrative
therapy.

Narrative therapy originated in Australia and New Zealand in the early 1980s. It is
informed by European theoretical positions of post-modernism, and in particular post-
structuralism. The post-structuralist tradition proposes that assumed knowledge is always
influenced by limiting factors of socially constructed language; questions the possibility of
achieving objective knowledge in human affairs; defines much assumed ‘expert’ knowledge
as the means by which social institutions perpetuate their power; and sees people as princi-
pally influenced in their identity and behaviour by cultural and social norms rather than by
universal psychological processes. Michel Foucault, the French historian of ideas, is a major
influence on this therapy’s theoretical base. Narrative therapy also draws on the ‘cognitive
turn’ intellectual tradition in America, which places conscious understandings of life at the
centre; sociologist Erving Goffman, psychologist Jerome Bruner, anthropologists Gregory
Bateson, Glifford Geerz and Barbara Myerhoff, and social psychologist Kenneth Gergen
have been influential.
Narrative therapy’s originators are Michael White, who before his death in 2008 was
Co-Director of the Dulwich Centre for family therapy and community work in Adelaide,
South Australia, and David Epston, Co-Director of the Family Centre in Auckland, New
Zealand. In family therapy circles White is recognised as one of the most important
therapists of our time. He began his career in the 1960s as a hospital social worker, but
soon questioned the taken-for-granted ‘truths’ of social work training and practice in
Australia at that period. These included the assumption that practitioners choose to work
with distressed people because of their own suspect and unacknowledged psychological
motives; that ‘clients’ are influenced by hidden factors in their past lives producing short-
comings of personality and of skills in living; and that social and political factors imping-
ing on people’s lives are of no concern to the therapist. White’s reaction against these
assumptions led to ways of assisting troubled people which are in striking contrast to such
pathologising positions.
Initially White worked within the Australian public health system, but he found greater
freedom by becoming Co-Director of the independent Dulwich Centre. In 1981 he met
David Epston. They recognised common values and purposes, as they had independently
developed similar approaches to community work, counselling and family therapy. The
Dulwich Centre Press published a Newsletter, collections of papers by White and Epston,
and books by therapists who found White’s and Epston’s ways of working exciting. In 1989
Epston and White jointly wrote ‘Literate Means to Therapeutic Ends’, a key account of the
theoretical basis of their work and its practical application to therapy. In 1990 a very slightly
modified version (White and Epston, 1990), significantly with ‘Narrative’ replacing
‘Literate’ in the title, was published by Norton, which brought their work to the attention of
a wider audience.
Articles by White, Epston and other narrative therapists have proliferated in family therapy
journals, and books on the subject have been published by international firms such as Norton,
Guilford, Jossey-Bass and Sage. The Dulwich Centre Newsletter has evolved into the
International Journal of Narrative Therapy and Community Work. Centres offering narrative
therapy and/or training, and well-attended annual conferences, are now established in many

NARRATIVE THERAPY 471
countries. Over the past twenty years or so, narrative therapy has increasingly been discov-
ered and used by counsellors who work with individuals.

Narrative therapists conceive people as socially and individually complex; never fully know-
able or explicable to themselves or others. Events selected from memory can be combined to
make up accounts of life in innumerable ways – ‘I find it helpful to conceive of life as multi-
storied’ (White, 2004: 60). Since life is perceived as a movement from past to present to
imagined future, a sense of temporal sequence underpins and gives an overall structure to
selective memories even if these are often recalled and told in a non-sequential or kaleido-
scopic fashion. Personal narratives, ‘self-stories’, have emotional resonance. The continual
process of self-storying actively feeds back into, and influences, people’s attitudes, actions,
relationships and sense of identity.
Narrative therapists recognise that people are born with inherited mental potentials, such
as a predisposition for understanding and developing language. However narrative therapists
do not call on psychological dynamics to define what makes people tick, what produces dis-
tress and confusion, and what is needed to improve life. People’s own perspectives as
revealed through their told narratives are the focus. McLeod (1997) accurately calls narrative
therapy ‘post-psychological’.
Sociocultural influences, including family of origin, social class, significant relation-
ships, and wider subgroups inform people’s sense of what constitutes normality and how
life should be lived. Correspondingly, self-stories embody socially and culturally derived
assumptions, values and beliefs, which form lenses through which people perceive and
give meaning to their lives. The provisional nature of these norms is frequently unrecog-
nised because they have been absorbed as assumed ‘truths’. They form a framework of
‘canonical life styles’ – stereotypical templates of living, current in the immediate and
wider social circles to which people belong. Failure to correspond to these stereotypes can
produce self-devaluation and stress. To give examples: one canonical life style in the
contemporary Western world, particularly applied to middle class men, is of moving up
through status-level stages of a career so as to gain a high income with which to provide
for a family originating in a romantic heterosexual attachment. In certain strata of Indian
society an otherwise similar canonical story includes the norm of parents advertising for
suitable marriage partners for their adult children. A Western middle-class man who chose
to follow a low-paid vocation while living with a male partner, or an Indian woman in a
traditional community who chose her own husband independently of her parents, would
be stepping outside the canonical stories by which others in their social context expect
them to live. They might, however, gain validation in these choices through allegiance to
non-conforming subgroups.

Self-stories also incorporate and are expressed through culturally formed, value-laden,
unrecognised and unexamined linguistic meanings, such as when a woman identifies herself
as insufficiently ‘feminine’, a young man drawn into criminality says he wants to keep the
‘respect’ of his peers, or a person conversant with pop psychology identifies his problem as
‘lack of self-esteem’. Such terms not only embody cultural attitudes and meanings; their use
embeds those attitudes and meanings.
Narrative theorists therefore propose that since people’s identities, values and beliefs are
culturally and linguistically derived, and provisional, there is no bedrock of innate, essential
or universal self; no psychology common to all people at all times; and no extra-cultural and
unchanging human nature. Identity and beliefs are ‘negotiated’ between people, in a huge
variety of social and historical contexts. There is no universal common meaning to superfi-
cially similar institutions, actions and belief systems. However, narrative therapists’ view of
the person is not relativist or determinist. People may largely live according to the culturally
influenced meanings they give to their experience, but narrative therapists believe that people
are fully capable of examining their assumptions, making conscious choices, and basing their
lives on those choices. They can to a significant degree escape sociocultural and interper-
sonal influences; they are not inescapably moulded by them. They can evaluate their self-
stories and revise them (metaphorically ‘re-write’ them) and in so doing loosen the grip of
previously fixed ways of conceptualising their lives, opening up possibilities for moving into
new ‘territories of life’ (White, 2004: 60) which differ from their past in significant ways but
which also embody continuity with it.
White suggests that if therapists abandon the generalised idea of assisting people to
‘become more truly who [they] really are’ this opens up the possibility for paying a more
specifically focused attention to the concrete details of people’s lives; a ‘fascination with
… how people’s management of the predicaments, dilemmas and contradictions of their
lives contribute to possibilities for them to think outside of what they otherwise thought’
(2000: 106–7).

Narrative therapists do not define human distress in terms of deficit, so ‘psychological
disturbance’ is not a concept found in this therapy. Binary concepts labelled ‘psychological
disturbance’ versus ‘psychological health’ would not be seen by narrative therapists as
actual elements possessed by or internal to troubled people; rather, they would be seen as
linguistic constructs of the therapy culture that unintentionally pathologise people, and that
narrative therapists strive to avoid. The use of professional-psychological language for
reactions to distress and confusion is seen as an example of a medicalised discourse imply-
ing that the therapist has access to specialised knowledge in people’s motives, lives and
relationships that is superior to their own, and a correspondingly superior expertise in
addressing their problems.


Because people’s distresses and dilemmas have, in much of Western professional practice,
come to be expressed in the language of physical illness, metaphors such as healthy,
unhealthy, symptoms, dysfunction and so forth have become reified as psychological reali-
ties. Narrative therapists aim to step out of this tradition. They do not conceptualise the per-
son’s changes of thought, feeling, attitude and action as ‘recovery’ (meaning a return to
‘health’). Rather, they see persons’ potential for moving towards a wider grasp of possibilities
for problem resolution as obscured by dominant self-stories. The taken-for-granted norms in
a person’s subculture and/or in wider society are internalised, and so, powerfully influence
their self-stories. Re-examination and revision of these stories assists persons to free this
potential.
Narrative therapists working with people whose reactions have been medically defined
ask them whether or not they find these terms helpful, since some persons find such defini-
tions helpful whereas others do not. The therapist asks direct questions such as ‘Is it helpful
to call your problem “obsessive-compulsive behaviour”, like in your doctor’s referral, or
would you prefer us to use something like “relying on comforting daily rituals?”’
Locating the source of distress in factors beyond the ‘bounded individual’ certainly does
not deny the reality of anguish, disorientation and confusion that bring people to counselling.
Nor does it deny that people feel, think, behave and relate in ways that may be counter-pro-
ductive, dissatisfying, chaotic or reinforcing of their problems. Narrative therapists also
acknowledge a physiological aspect to distress and that in some instances medication can
play a useful part in alleviation. Nevertheless narrative therapy is allied to a movement of
re-evaluation and re-definition of psychological or psychiatric concepts. An example is
White’s work with people diagnosed as schizophrenic (White, 1989: 47–58; White, 1995:
112–54). Psychological and psychiatric definitions like those in the Diagnostic and Statistical
Manual of Mental Disorders (DSM) are critiqued on three grounds: firstly because they con-
vey an authoritative stamp of expert and proven knowledge to a range of human distress
which has wide, multiple and never fully knowable aspects; secondly because such defini-
tions (such as the former DSM definition of homosexuality as illness) are unacknowledged
reflections of the thinking and values of a particular society, and a particular, powerful group-
ing within that society, at a particular historical time; and third because they pathologise
persons’ reactions to distress without taking into account multiple factors outside the assumed
bounded individual, including family and peer interaction and the effects of social and
political power on lives and relationships.

Narrative therapists conceive confusion, sadness and despair as reactions to be expected
when circumstances are distressing, rather than as indications of something awry in the
person seeking assistance. They pay close and detailed attention to the social, political and
cultural origins of much distress, and the ways in which institutional and professional

discourse can feed into and exacerbate it. Where such factors are involved, this is the
emphasis of therapy. If a man is affected by depression because his boss is setting him
impossible tasks, that is the reason for his distress, not an inability to work hard enough,
a failure to be assertive, or the depression produced by the situation. He would be invited
to consider the culture of overwork linked with the emergence of ‘hard management’. He
would be invited to consider how that culture arose and whose interests it serves. The
therapist would elicit the precise nature of his boss’s expectations and pressures, their
effects on his life and the lives of people he cares about, and the extent to which the situ-
ation is outside his power to control – and in this light, would encourage him to examine
what his options might be. If a woman is insistently told by her male partner that she
should welcome intercourse every night, that is the reason for her confusion and unhap-
piness, not a lack of libido, nor a lack of affection leading her to resist her partner’s
demands. A narrative therapist would encourage her to consider the well documented
wide variations of sexual behaviour and of frequency of intercourse. She would be invited
to think about how men are encouraged by peers and the media to glorify and normalise
frequent intercourse, and how they take on the belief that they have both a need for its
frequency and the right to demand this. The power-based techniques used by the man to
make the woman feel it is ‘her’ problem, rather than an issue needing respectful discus-
sion between partners with differing wishes, would also be raised.

Narrative therapy focuses more on sociocultural and systemic explanations for distress than
on individual psychological theory. Metaphors derived from mechanical processes are
avoided, as these are seen as expressions of an over-individualistic therapy culture that stands
in the way of a broader, more accurate and respectful view of the causes of human unhappi-
ness. White identified ‘repression’ as one of these metaphors, as well as criticising what he
called ‘the will to truth’ and ‘the emancipation narrative’ (1997a: 220–35). Rather than base
their approach on such metaphors, narrative therapists question them, especially when they
appear to negatively influence a person’s self-view.
Should there be no clearly identified, continuing, external factors perpetuating the person’s
problem, a narrative therapist would hypothesise that the main perpetuating factor is likely
to be embedded negative or limited self-stories, which have come to represent the person’s
experience, the power of which restrains them from seeing beyond those stories. A self-
reinforcing pattern of distress leading to a dominant, problem-saturated story, leading to
increased distress, is seen as the main intrapersonal process perpetuating the problem.
2.4.2 Interpersonal mechanism

Although the term ‘mechanism’ is avoided in narrative therapy, narrative therapists are alert
to how a person’s negative self-stories may be reinforced and perpetuated by their belief that

they have not lived up to the norms and standards of influential significant others such as
parents and partners. A person’s account of their experience, and their overt or implicit self-
view, frequently incorporate self-condemnation, guilt and inadequacy derived from the actual
or assumed judgements of others, but which the person attributes to their own faults or limi-
tations. The person is invited to recognise these influences, describe them in detail, and to
explore how they have affected, and are affecting, their view of the problem, and of them-
selves in relation to the problem.

The person’s distress may be directly perpetuated by their social circumstances. Someone
who is trapped in a job where they are overworked, expected to achieve impossible targets,
bullied by managers, and perpetually at risk of dismissal, is likely to have distress perpetu-
ated until they can resolve the situation. A woman continually denigrated by an unpredictably
violent partner may be in a similar position. More subtly, unhelpful social norms and expec-
tations of the person’s subculture or of wider society may have been interiorised and be the
source of self-condemnation. Persons are constrained by these influences from seeing a
broader picture which might incorporate, for example, their resistance, resilience, courage,
and refusal to accept received ideas and standards. Since grasp of the unfamiliar depends on
how persons make sense of events or notions by relating them to their existing stock of ideas,
the environmental factors will continue to reinforce the negativity of their perceptions unless
brought fully into awareness and explored.
2.5 Change
Since perceptual change must mesh with preconceptions, ‘new information’ has to be
absorbed at a pace which will allow reconfiguration. A past/present/future framework is
inherent to and facilitates this. In other words, storying; gradually extending the pre-existing
framework of time-structured memories into versions which incorporate different images and
possibilities out of the person’s past, present and future. Such storying occurs in everyday
life, as people scan and explore their experience through internal monologue and in discus-
sion with others such as concerned friends, and it is central to narrative therapy. Previously
untold stories of persons’ lives, by their richness and variety, have the potential to allow
movement towards change without disconnection from the past and without minimising or
dismissing the initial, painful account.
In moving towards a narrative understanding of change White and Epston have found
recent literary theory helpful in its considerations of how storied representations of life
impact on the teller and the reader or listener. From this has come an emphasis on the
importance of an audience as a vital contribution to the person’s creation of new self-stories.
The active response of an audience facilitates the stories becoming enriched, confirmed
and remembered. In narrative therapy the therapist is not seen as the most important audi-
ence, and one of the therapist’s tasks is to discuss with the person to whom else she might

like to tell the ‘new story’. In addition, where acceptable, the therapist may organise an
in-session audience of one or more people significant to the person, or colleagues of the
therapist, or both.
Re-storying in everyday life, and in a more focused way in therapy, is not so much a pro-
cess of talking about problems or distress more hopefully, although this may occur. Rather,
it is a means of conceptual reorientation or re-positioning in relation both to the problem and
to the person’s wider life and relationships. It is the embedding of this re-positioning that
enables possibilities for change to emerge. Forgotten, unnoticed or undervalued actions, feel-
ings and thoughts are identified, and expanded through conversation; and by means of
exploring their implications, unforeseen possibilities emerge.
3 PRACTICE

Narrative therapists do not set preconceived goals for their work, since these would con-
stitute external impositions on the person rather than allowing a sensitive, always revis-
able response to the unique story the person brings to therapy. Nor do narrative therapists
encourage persons to take part in goal-setting. As therapy begins, people are likely to be
dominated by preconceived positions around their lives, identities and relationships, so if
they were to set specific goals at that point they would be locked into the conceptualisa-
tions they have brought to therapy rather than open to processes of perceptual change
through re-storying. A man who defines his marital problems as ‘poor communication’
and ‘constant nagging by my wife’ might set goals of their talking together more, and of
his wife keeping her temper, which would then act as constraints on considering the
implicit verbal and non-verbal signals the couple may in fact be clearly exchanging, what
these might mean, and whether ‘nagging’ might be a word used by men to describe
women’s attempts to get through to them. As therapy progresses the discoveries and per-
ceptions achieved by the person are tentative, provisional and subject to further extension,
the dominant story only partly revised, the unrecognised subplots only partly told. Goal-
setting at these later points would constitute a constraint on further, as yet unimagined
possibilities.
A wholly future perspective would also disallow the exploration of personal history, and
the discovery and elaboration of helpful elements from that history. Narrative therapists may
invite persons to envisage a ‘preferred future’ where the problems they brought to therapy
will be absent. But unlike for example in solution-focused work, where the therapist would
ask what small steps might now be taken towards this future, a narrative therapist would tend
to leave the images to settle and to create their own momentum and meaning for the person
as part of their revised past/present/possible future story. If the future images have resonance
the person will discover their meaning and will discover, rather than anticipate, what actions
might be taken to move towards this preferred future.


Since narrative therapists wish to avoid taking up ‘expert positions’ they do not have cri-
teria as to whether any particular individual, couple or family might benefit from this way
of working, or whether any specific issues brought to therapy might be inappropriate for
narrative work. Judgements about appropriateness are based both on the therapist’s assess-
ment of their own competence and on choices made by the person seeking assistance. Is
the therapist experienced and skilled enough to take on this particular person and the issues
brought to therapy or would it be best to refer on? Would there be a preference for someone
of the same gender, sexuality, ethnic group, culture or religious affiliation? Are there other
sources of assistance that might be more useful than counselling, either now or later?
Throughout counselling such questions would be borne in mind, with the therapist check-
ing out whether the person is finding counselling useful, and whether it might end soon or
continue.

Persons may be referred to narrative therapy as individuals, couples or families. When it
becomes clear that the problems and dilemmas brought to counselling by individuals
derive from, or are intertwined with, the actions or inactions of others, a narrative thera-
pist may float the possibility of joint or family work rather than, or in addition to, one-
to-one counselling. A man who is distressed because he cannot recover from the effects
of his wife’s sexual affair despite her regrets and apologies may benefit from a combina-
tion of joint and individual sessions; a mother who is being driven to despair by her
teenage sons’ loutish and disrespectful behaviour while her husband stands back from the
problem, may benefit from some sessions with her husband, and possibly some with her
husband and their sons. Narrative therapists do not consider individual, couple and fam-
ily therapy to be distinct – indeed the traditional counselling focus on the bounded indi-
vidual is seen as often masking wider social and political aspects of people’s lives and
as imposing the whole weight of responsibility for change on one person’s already
bowed shoulders.

The narrative therapy literature contains little explicit definition of personal or professional
qualities necessary to be an effective therapist, although it contains much implicit ethical
positioning; for example its moral base and resultant practices imply respect for cultural
diversity, and for the beliefs of others where these beliefs are not harmful. Examples of nar-
rative work in books, articles and teaching videos show narrative therapists demonstrating
empathy and respect for the persons consulting them, and a genuine interest in their lives.

The overall ethical position of narrative therapy is not to pathologise but always to separate
the problem from the identity of the person.
Narrative therapy does not work unless the therapist consistently maintains this post-
structuralist position. This means the effective narrative therapist needs to hold to a genuine
belief that distressed persons are not intrinsically deficient. They are struggling, always with
unrecognised or potential elements of success, to cope with the issues they bring to therapy,
while defining themselves negatively or acting harmfully under the influence of powerful
interpersonal and sociocultural influences woven into their self-stories. Since post-structur-
alist thinkers question the concept of essential, fixed ‘qualities’ for anyone, including thera-
pists, the nature of the therapist’s speech, actions and revealed attitudes in his interactions
with persons are the relevant considerations. Although narrative therapy incorporates many
specific practices, White saw it as essentially an ethical position, or attitude towards human
life, rather than an ‘approach’ (1995: 37–8).

An effective narrative therapist will have rehearsed narrative practices in initial training, and
subsequently will have used them when counselling a wide variety of persons and problems.
Supervision and further training will have refined and consolidated competence. The choice
and use of practices developed by White, Epson and others will have become instinctive;
creatively chosen and implemented according to the nature of the problem. In effective nar-
rative sessions persons are engaged by the therapist in respectful and concerned conversa-
tions where they are unobtrusively assisted to describe, review and revise how they see their
problems and their identity. The more a narrative therapist develops effectiveness, the more
the practices become invisible to the person, as they are subsumed into a subtle, purposeful
series of friendly interchanges.

The nature of the relationship between the therapist and the person has a different emphasis
in narrative therapy than in many other therapies. It is taken for granted that the therapist
will be respectful, engaged and open, but this way of relating is not defined as promoting
some kind of special relationship which is itself the key to the therapy’s success. In other
words, the relationship with the therapist is not seen as the means by which change is
effected. White emphasises a quite different idea – the deliberate aim of de-centring the
therapist, of maintaining a persistent orientation toward putting the person’s own skills and
knowledge of living at the centre of the therapy with the therapist following a little behind,
together with acknowledgement and enhancement of the part played in the person’s life by
his own significant relationships in the present and in the past (White, 1997a: Chapter 10).
It is the person’s relationship with these people, not with the counsellor, that is considered
therapeutic.

Therapist de-centring is an ethical position at the core of narrative therapy, and it is

promoted by specific practices. These include including ‘taking-back practices’ when the
therapist acknowledges the resonances from, and effects on, their own personal and pro-
fessional life coming out of conversations with the person, and ‘transparency and account-
ability’ when the therapist invites the person to bear in mind the counsellor’s limits and
constraints of understanding. Therapist de-centring makes it clear to the person that
therapy is a two-way process. The therapist learns from persons as well as assisting them
to review and extend their self-stories. De-centring counteracts therapist mystique and
any assumptions that the therapist wishes to, or can, take an expert position in relation to
the person’s experience.

Observation of White and other leading practitioners in training sessions, workshop dem-
onstrations or on videos reveals some of the values and attitudes implicit in good narrative
practice. The atmosphere is purposeful but relaxed. People are treated with respect and
acceptance, taken seriously, and consulted on whether the session is proving fruitful for
them. Strong feelings are often present, both in the person and in the therapist. Sometimes,
even if the matter under discussion is very serious, a spontaneously light-hearted moment
or sequence may occur, creating a less constricting atmosphere around the problem when
discussion continues. The person’s statements are checked out for understanding, and the
therapist’s verbal summaries are given in the person’s own words. Within these generali-
ties there are many different personal styles. Epston tends to be more immediately chal-
lenging in his mode of speech than was White, and White’s manner was exceptionally
informal compared, for example, with that of the US narrative practitioner team Jill
Freedman and Gene Combs.

3.5.1 Assessment
There is no place in narrative therapy for ‘expert’-based assessment of persons and their
problems, though during the process of therapy persons, at appropriate junctures, are
encouraged to consider for themselves the ways and extent to which they are developing
more helpful perspectives and actions in resolving the issues brought to therapy.
Narrative therapists also keep alert as to whether the therapy is working, by consulting
the person on this.

The term ‘case’ is avoided in narrative therapy as this way of defining a person and the prob-
lems they are facing is seen as an example of disrespectful, distancing language. It is inap-
propriate for a therapy that emphasises equality of role between the therapist and the person,

with the person always acknowledged as the expert in their own life. ‘Example of therapy’ is
the preferred term. Formulating a way of working with a particular person is not determined
before therapy begins or even at the first session. The content, sequence and length of therapy
depend upon moment-to-moment openness both to possibly significant nuances in the per-
son’s initial problem-narrative, and in the developing narrative. In this respect narrative
therapy resembles the person-centred approach. A difference between the two therapies is
that the narrative therapy literature, especially White’s books and articles, offers several
‘maps’ of therapy. These are outlines of session structure, to be used flexibly according to the
person’s problems and circumstances, always with the aim of assisting them to recall experi-
ence more fully and accurately and to consider the possibly helpful significance of unnoticed,
forgotten or ignored elements of that experience. Some of these maps are outlined below in
Section 3.6.2.

Narrative therapists are careful to avoid metaphors which derive from military activity, sales-
manship, or other areas which imply predetermined plans, unknown to the other person, by
which they may be moved towards ends decided by the therapist. ‘Strategy’ is such a term,
and it is not found in the narrative therapy literature.

‘Techniques’ is a term generally avoided by narrative therapists as it conveys a sense of a
rather impersonal and mechanical way of working. The preferred term is ‘narrative prac-
tices’. Narrative counsellors tend to hold standard 50–60 minute sessions, but practices such
as definitional ceremony may best be undertaken in sessions of around 90 minutes or more.
The number of sessions, and the intervals between them, vary according to the nature of the
issues brought to therapy. One session may be enough, but sometimes many more may be
appropriate, although narrative work tends to be completed in significantly fewer sessions
than some traditional therapies.
(a) Maps of narrative practice Sessions are usually organised according to what White
called ‘maps of narrative practice’, which might equally be called ‘session frameworks’.
He published these over a number of years then drew them together in his final book,
published shortly before his death (White, 2007). Like geographical maps, maps of narra-
tive practice comprise an overview of possibilities for moving from a starting point to a
final destination, but without pre-determining the exact journey – that will be negotiated
according to what is discovered on the way, sometimes with unexpected or un-anticipated
directions being taken.
The overall pattern of these maps is to begin by inviting the person to describe the prob-
lem in considerable detail, including how it is affecting their thoughts, feelings, health,

work, relationships and other aspects of life. While listening to the problem-narrative the
therapist is alert to clues which suggest the possibility of helpful elements in the person’s
experience such as personal capacities, values, beliefs, actions and relationships, that have
slipped out of their awareness under pressure from the dominant, problem-based story.
White called these elements ‘unique outcomes’. The therapist asks detailed questions
around these previously unrecognised elements. By answering, the person begins to modify
the original narrative and to open up previously blanked off possibilities for re-conceptual-
isation of the problem and of the self. The therapist avoids an interrogatory stance and
attempts to establish a genuinely egalitarian and conversational ambiance. Later sessions
focus on assisting the person to extend and enrich the modified narrative, and to explore the
changes brought about by this wider and more accurate view of the problem, its context, and
the person’s relationship with the problem.
In his later writings White called extensively on the ideas of the educational theorist Lev
Vygotsky in order to formulate very precisely graduated maps of practice, called scaffolding
conversations (2007: 283–90). These conversations, led by therapist questions, encourage
persons to move from their initial perception of the problem to a more ‘distanced’ or devel-
oped position in relation to it compared with their initial account. Although White’s descrip-
tion of this practice is more complex and detailed than his more generalised earlier accounts,
it could be argued that it essentially comprises an elaboration of the therapeutic maps outlined
above.
Narrative therapists draw on White’s maps creatively, according to how the conversation
develops, in sensitive response to the person’s emerging story. Sometimes the maps merge
or elements of them are combined. The maps need to be learned and practised, so that as
with any other skill involving response to the unpredictable they can then be underplayed,
extended, shortened or modified. Within their overall structures there is the possibility to
introduce a range of specific narrative practices geared to certain kinds of problems and
concerns.
The externalising conversations map codifies one of White’s most original practices: the
use of language which implies a distinction between the identity of the person, and that of the
problem brought to therapy. The intention is to counter the assumption that life’s distresses
and difficulties are caused by innate deficits. This assumption is widely held in society, and
is often assumed by persons themselves. Such assumed deficits are embodied in the language
of many therapies (‘out of touch with feelings’, ‘depressed’, ‘anxious’, ‘repressed’, ‘dam-
aged’, and so forth). The use of such terms encourages self-blame, and fails to acknowledge
the multiple external factors involved in human misery, or to honour the efforts made by
distressed people to deal with their problems. Externalising language assists the person (and
the therapist) to escape this trap. A narrative therapist might refer to ‘feelings you can redis-
cover’, ‘sadness that has invaded your life’, ‘the worries affecting you’, ‘emotions you have
managed to defend yourself against’, ‘the severe limitations imposed on your life’.
Externalising conversations also emphasise the social, cultural and political (in the widest
sense) factors which have contributed to the problem and to the person’s difficulties in deal-
ing with it.

Externalising is not always used – for example if the person is abusive or violent, this is
directly and unequivocally stated – ‘the abuse you have committed’, ‘your violence towards
her’. The Statement of Position Map, often used at the beginning of therapy, encourages
persons to describe the problem in considerable detail, to commit to change, and to consider
the significance of this commitment. A name for the problem is agreed (usually in external-
ised terms) which encourages them to view the problem in a more objective light and to
decide whether they wish to take steps to deal with it. A conversation is developed around
times when the person was able to find ways of coping, even in quite small ways, and the
significance of these ‘unique outcomes’ is explored, leading to discoveries about their skills
and capacities.
The re-authoring conversations map focuses in greater detail on the identification and
exploration of ‘unique outcomes’ – occasions when the presenting problem, or similar prob-
lems, were absent, or were dealt with successfully. It incorporates questions around such
occasions in the person’s present, past and possible future, weaving back and forth between
questions about actions and events, and about thoughts and feelings.
The failure conversations map invites consideration of sociocultural norms that are
influencing the person’s self-condemnation, and asks questions around apparently minor
successes which reveal the person’s own values and how they have put these into practice,
usually in ways which they have undervalued. The aim is to assist persons to revise the
negative conclusions they have reached about themselves – conclusions derived from oth-
ers’ views which have become embedded in the self-story. This map is particularly appro-
priate for overcoming the effects of trauma arising from abuse and violence, when the
focus of therapy is upon recovery of a sense of identity. By the therapist externalising
‘failure’ and asking questions around the person’s acts and thoughts in relation to it, this
map assists the person to move from a sense of ‘I’m a failure’, implying a permanent
innate deficit, to a sense of ‘I believe in and have done these things’, implying achieve-
ment. Questions invite persons to identify the norms and standards by which they have
been judging themselves, to consider when these come from others and society, then to
define their own values and standards and the origins of these values and standards in
their personal history. Finally they are asked how their newly recognised values might
sustain them in the future.
The re-membering conversations map encourages the person to draw on their memories of
significant persons in their past as a source of example, inspiration and advice with regard to
the difficulties being faced in the present.
(b) Therapeutic documents Since the spoken word is easily forgotten, narrative therapists
may create permanent records of counselling to confirm and record persons’ thoughts, dis-
coveries and achievements. Unlike the ‘secret file’ documentation of much officialdom, these
documents are always fully in the open, shared with the person, and embody the person’s own
thoughts and discoveries rather than the therapist’s ideas. They may be in written form,
including letters from the therapist reminding the person of salient points of discovery; copies
of the therapist’s notes sent for verification and comment next time; or reminders of unique

outcomes, written as brief notes by the therapist in the person’s own words, and given at the
session’s end. Sometimes documents have a light-hearted tone, especially when the person is
feeling rather better – examples include end-of-counselling certificates, produced to look like
formal documents and presented ceremonially. The written word is not the only medium
used. Sessions may be tape- or video-recorded (with permission) and the recordings given to
the person to take home, possibly sharing them with a relative or friend who can comment
on and discuss them.
The therapist sometimes encourages persons to create their own therapeutic docu-
ments, either to show to the therapist or to record experiences and thoughts privately,
including their ideas about what is coming out of counselling. Narrative therapists do not
encourage the uncontrolled outpouring of feelings as a means of assumed catharsis, but
an expression of feeling in persons’ writing may assist them to understand themselves
and the situation better, and poetry as well as prose may be appropriate if the person is
comfortable with this. Sometimes persons whose experiences have been embarrassing
find it easier to describe them to the counsellor through writing rather than in speech.
Diaries and other records of progress are particularly useful, with the person noting
instances when the problem is more under control, or absent, which can then be dis-
cussed in subsequent sessions.
(c) Calling on the assistance of others Narrative therapists bear in mind that we are
born with certain in-built potentials, and that the form these take in life is constructed via
social interaction. We can be made miserable by criticism, condemnation and marginalisa-
tion, and our lives can be made happy and satisfying by support, understanding and
acceptance. In addition we live in a wider culture where socialisation has led us to accept
certain beliefs, norms and behaviours as ‘given’, and we can feel failure or inadequacy if
we do not match up to society’s expectations. When people come to counselling they often
feel rather isolated. They have often lost access to sources of assistance. Friends and
relatives may have tried to help but perhaps without much success, and the person may
feel a nuisance.
Sometimes the source of pain is the very people who might otherwise be expected to be
helpful – an unfaithful or abusive partner, a bullying boss, cold and uninterested parents.
Sometimes people close to the person have died, resulting both in grief, and in the loss of the
dead person’s support. Narrative therapists have developed various means of calling on a
wider range of people than the therapist to play a part in assisting the persons, as described
below. This is another aspect of therapist de-centring.
(d) Re-membering practices In an early paper White proposed that rather than assisting
a grieving person to say a final goodbye, and to accept the finality of loss so as to get on
with life without the dead person, therapists would do better to acknowledge and promote
the lost person’s continuing to play a part in the grieving person’s life. By the person’s say-
ing ‘Hullo again’ in imagination rather than ‘Goodbye’, and through discussing what the
dead person would appreciate about them at this point of life, the person tells a story-line of

the relationship continuing rather than ending. Thus grieving persons can in imagination
take lost others with them rather than leave them behind. White stresses that this is not to
deny the pain or reality of loss but rather to assist the person to position themselves differ-
ently in relation to it.
In contexts other than grief, the calling on the ‘voices’ of others to contribute to the
person’s developing self-story has proved fruitful. This is known as ‘re-membering,’ a pun
implying both the activation of memory around a lost other, and that other’s rejoining the
person as a member of her ‘club of life’. Persons who have received little or no useful help
from others immediately available to them are asked who in their past might have had
something helpful to say about the situation, and what this might have been. Sometimes
the imagined other might have died and sometimes the person might simply have lost touch
with them, for example wise and supportive grandparents or a helpful teacher. Where per-
sons lack belief in their own worth, the therapist may ask them to name someone in their
past who thought well of them, following with questions such as, ‘What was it about you
that she appreciated? What would she say about how you contributed to her life and hap-
piness? What qualities in you did she recognise that others including yourself might not
see? How did these qualities show themselves in action? What would she see you doing or
not doing today that would tell her you are the same person with the same qualities she
valued?’ If the person is unable to identify a known significant other to re-member, they
may be encouraged to call on an imagined relationship with someone well known, whom
they admire – ‘If you could tell Nelson Mandela about your struggle at this point, what
might he say to you?’
(e) Bringing ‘outsider witnesses’ into the therapy room White and Epston have always
stressed the importance of an actual recipient, or ‘audience’, for the person’s developing
story, in the belief that unless it is told to people in addition to the therapist, and commented
upon by them, it may fade in the memory. Questions such as, ‘Who might you like to tell
about the discoveries you have made?’ and ‘Can you think of anyone who would appreciate
hearing about how you are feeling now compared to a couple of months ago?’ are asked in
later sessions. Narrative therapists sometimes go to considerable lengths (with the agreement
of the person) to make contact with named people to invite them to attend one or more ses-
sions. Similar questions to those quoted in the previous section may be asked, but White has
also developed a map for a more systematic sequence of team questioning, known as ‘defi-
nitional ceremony’ (1995: 172–98). In these sessions outsider witnesses may be friends or
relatives of the person, or they may, with the person’s consent, be therapists and/or therapist
trainees.
(f) Definitional ceremony Definitional ceremony consists of a sequence of ‘tellings and

re-tellings’. The therapist encourages the person to tell their story, prompting with ques-
tions where necessary, while the outsider witnesses listen. The outsider witnesses then
comment on the story in response to questions by the therapist. The person responds to the
outsider witnesses’ comments, and then everyone including the therapist discusses the

experience and what it has meant for them. As the person tells their story, hears the
responses of the outsider witnesses, and then responds to their responses, the story takes
on further dimensions of meaning and significance. Not only will the person remember it
more fully and completely, but interwoven with the story will be carried its meaning and
significance for others.
The role of outsider witnesses is not to take an expert position by hypothesising, advising,
analysing motives or sources of action and feelings, or congratulating. The focus is on a
response to the ‘more neglected aspects’ of the person’s life (White, 1995: 180) – those
aspects which have, through the therapist’s exploration of unique outcomes, become woven
into the initial self-story but which may still be rather fragile. The therapist also includes
questions around aspects of the person’s story that may have resonance in the lives of the
outsider witnesses themselves, so as to create a sense of commonality between the lives of
the person, the outsider witnesses and the therapist.
The responses of outsider witnesses are elicited by specific and purposeful questions from
the therapist. The therapist focuses on the words, phrases and images used by the person,
asking what these convey about their beliefs, values, purposes and commitments. The out-
sider witnesses are asked about resonances in their own lives evoked by the person’s words,
what images and feelings these resonances produced for them, and what difference hearing
the person’s account of their history will make to the outsider witnesses’ own lives, percep-
tions and understandings. The therapist asks the person a similar sequence of questions
around what the outsider witnesses have said, continuing to focus on verbal expressions that
carry significance.
Counsellors working in constrained circumstances which make it difficult or impossible to
organise definitional ceremony sessions with a team may invite a colleague to take an out-
sider witness role, and return the favour in the colleague’s sessions. Sometimes the person is
invited to bring a partner or trusted friend to the session. The definitional ceremony sequence
is then followed: asking the visitor definitional ceremony questions, inviting the person to
respond, asking the visitor to respond to the person’s response, then discussing the session
with both.

Narrative therapists do not aim to produce change in the person, if by this is meant cure,
improvement, fixing of problems, or personal growth. It is a resource-based rather than a
deficit-based therapy. The resource it assists the person to discover is the previously veiled
richness of their actual experience in all its diversity and contradiction, including its pain
and confusion but also its elements of coping, hope, skills of living, personal values and
lost relationships which have the potential to play a renewed part in actuality or in imagina-
tion. The telling of richer accounts of life together with hearing others’ responses to the
emerging story enables the person to gain what White calls a more ‘experience-near’ per-
spective on their life and problems than the previously restricted perspective embodied in

and expressed by the original, problem-saturated or despairing story. The apprehension of

this new position, not only as a cognitive restructuring but also as a wholly felt, emotional
and releasing experience, frees persons to make conscious choices and commitments which
were previously blocked by the fogged, enveloping and constraining self-story which had
come to represent life to them. Narrative therapists become familiar with such key
moments of revelation and self-discovery, and to the sense of relief, hope and renewed
prospects which they embody, and they attempt to become skilled in reinforcing and con-
solidating them.
Those aspects of narrative therapy which encourage persons to recognise the negative
power of sociocultural norms and expectations often have a major role in this opening up of
viewpoints and re-positioning. Lack of progress would be attributed to the therapist’s inex-
perience or misjudgement, rather than to any assumed shortcomings in the narrative
approach, or the intractable nature of the problem, or ‘resistance’ on the part of the person.
A narrative therapist will in these circumstances consult a supervisor, and/or refresh his
memory of the relevant literature. If progress remains blocked, referral on to a colleague
would be considered.
4 CASE EXAMPLE
4.1 The client

David, aged 39, was a scientist who spent long periods in remote Antarctic stations with
periods of leave back home. While away, telecommunication with his family was sporadic
and difficult. David’s doctor reported that he appeared highly stressed, anxious, and possibly
mildly clinically depressed.
4.2 The therapy

Narrative therapists believe that genuinely therapeutic relationships are those between the
person and supportive significant others. By promoting this perspective, narrative therapists
aim to de-centre themselves, so I did not see my relationship with David as therapeutic in the
sense by which that term is generally used in more traditional therapies. I attempted to promote
a respectful, purposeful, friendly and open atmosphere, always explaining the reasons for my
questions and tentative suggestions, and by inviting his wife to some sessions I encouraged
recognition that the couple’s relationship would sustain David during and after our sessions.

I accepted David’s own description and definitions of his problems. He was unsure that his
doctor was right in suspecting depression, but he had certainly become stressed and anxious

much of the time, had lost his appetite, was sleeping badly, and had developed an irrational
dread at the prospect of social contacts with friends and colleagues. He was worrying, then
worrying about the worrying, characterising these anxieties as ‘unlike me’. His father had a
history of depression, and although this had been overcome, David worried about whether
there might be a genetic factor which would be difficult to counter.
He had found some relief in fast walks in the countryside, and was seeking strategies for
stress control in self-help books. He believed that the quality of his work had not been
affected, but he felt frustrated, anxious and trapped because he was newly promoted to be in
charge of a research team, bringing a changed emphasis from being largely ‘hands on’, to an
unfamiliar supervisory role.
Another concern was his difficulty in coping with his eldest, eight-year-old daughter.
Rationally, he could see that her defiant naughtiness was within the norm of childish misbe-
haviour, but he fretted about it, veering between anger at her, and suspicion that his parenting
skills were inadequate. Overall he wondered if his job was largely to blame for his anxieties,
partly because it meant regular periods of several weeks cut off from his family. However, it
would be difficult to change this job. He was well paid and needed to be, as he had many
financial commitments, and his specialist knowledge was in little demand outside the organ-
isation that employed him.

These may also be known as ‘narrative practices’. In David’s first session I encouraged him
to give a full description of how anxiety was affecting him, including his health, his relation-
ships with friends, family and colleagues, his sense of himself, and his general outlook on
life. I noted down the distressing, ‘problem-saturated’ elements of his story. I also noted
down a number of ‘unique outcomes’ – overt or implicit elements which stood apart from
David’s taken-for-granted, problem-saturated narrative, and that might constitute starting
points for a more accurate and potentially helpful account of his experience:
• he felt his present reactions were unlike his normal self;

• he had found a technique for diminishing stress – fast walking;
• he was actively seeking help, through counselling and reading;
• he was performing his job competently, and knew this;
• he valued family life and was a conscientious parent;
• his work superiors thought highly of him, as he had been promoted to team leader.
We agreed to define the problem, simply, as ‘anxiety’. This had a relatively unthreatening,
non-medical, feel to it. David called himself ‘anxious’, but my own phrasing, throughout
our counselling, implicitly characterised anxiety as external to David rather than as part of
his identity. I spoke of ‘anxiety invading your life,’ ‘your strategies to deal with anxiety’ and
so forth. Before long David had taken up similar externalising language, and I believe that
this played a part in helping him to observe his problem with increasing objectivity and
sense of agency.

At the second session David reported mixed experiences. He had continued fast walk-
ing and found this helpful and relaxing; he had spent enjoyable times with his parents and
his wife and daughters; and he had phoned a friend and arranged to meet despite some
unease. However he had experienced ‘down’ periods which made him wonder if his doc-
tor was right to suspect clinical depression. It was important to maintain a balance
between validating David’s more hopeful perceptions, and acknowledging the reality of
the continuing difficulties and setbacks. I asked him to describe his more positive experi-
ences in some detail, and to consider what they might indicate about his ability sometimes
to keep anxiety at bay; I spent time exploring the pros and cons of anti-depressant medica-
tion. Since David continued to be reluctant to consider medication, I moved to other
practical possibilities.
I floated an idea that had been found useful by several other persons I had counselled. If
he kept a day-to-day record in the form of a graph, he would see the ups and downs of his
moods, could identify what events and circumstances might be linked to these lower or
higher moods, and could monitor his progress. Over the rest of our counselling David pro-
duced mood-swing graphs, beautifully prepared on his computer, and they proved a valu-
able resource. Rather than relying on memory and the imprecision of language, they dem-
onstrated in concrete form his developing ability to cope with anxiety, with higher scores
gradually coming to predominate, and with recovery from low points becoming swifter.
The graphs also gave David a sense of agency, by his actively observing anxiety and noting
its patterns.
David’s self-help texts had mixed blessings. Early on he became overloaded with
ideas, and frustrated, as he sought for some definitive solution. However, he came to see
that such intensive searching and fretting was by its nature counter-productive, and he
became more selective in his reading. Meditation based on ‘mindfulness’ gradually
became important to him, playing a major part in his increasing ability to deal with
anxiety, and to accept that controlling its effects was perhaps a more realistic aim than
trying to eliminate it. Meditation was an independent discovery on his part, and a good
example of how, once a person begins to move away from a problem-saturated outlook,
he will come to recognise thoughts and ideas that are useful for him. My role here was
to invite David to give detailed descriptions of exactly how meditation was of assistance,
and to encourage him to relate these discoveries to his values, his history and his sense
of self. He said he had always enjoyed problem-solving. Discovering meditation, then
putting it into practice, combined David’s problem-solving skills with his long-estab-
lished vein of spirituality.
Our discussions increasingly focused on the ‘up’ periods, shown by his graphs, which
despite occasional dips became relatively frequent and long lasting. At my suggestion he
invited his wife to attend a session, when she testified to the positive changes she had noticed
in him, and when I asked him to comment on her comments. Her observations confirmed that
David was more relaxed in his relations with his daughters, was sleeping far better, and was
enjoying the company of friends. He had renewed pleasure in his work, and overall was hap-
pier and much less affected by anxiety.

We were thinking that counselling might end, and David willingly agreed to being
called on as a volunteer ‘outside witness’ for other persons affected by Anxiety.
However he then hit a serious obstacle. He was unexpectedly invaded by immense guilt
about when his wife had a termination of pregnancy, twelve years previously, and was
overwhelmed by a suspicion that by agreeing to this termination he had committed
murder.
Therapy over the next few sessions took two forms. I invited David to revisit in memory,
and to narrate in precise and full detail, the events and circumstances surrounding the termi-
nation. In so doing he re-connected with the complex past rather than staying in a present
fogged by partial memory; and by so doing he recognised that although he now felt regret,
he need not feel guilt, as his decision had been inevitable.
The second aspect of therapy took place elsewhere than in my consulting room. David saw
his local priest to discuss the moral issues involved, and received assurances that the decision
had clearly been made on good, ethical grounds. At his eleventh and penultimate session with
me he described having experienced an ‘epiphany’, when all the factors allowing him to
forgive himself had come together with total conviction.

Counselling ended with David recognising and accepting that anxiety would probably always
accompany him to some extent, and might have temporary victories. However, he had found
effective ways to limits its attacks, and to enjoy his life despite these attacks. A year or so
later, when giving permission for his story to be told in this chapter, David said that he was
still keeping anxiety at bay, and intended to create a web page outlining his discoveries, to
help people affected by similar problems. Scanning his memory of what was helpful, and
formulating it into a web page, will comprise the creation of a further therapeutic document,
initiated and created by David himself.
When reflecting on David’s therapy I realise that I could have introduced an element of
re-membering, had it emerged that there was a significant figure from his past who fitted this
role. It might also have been fruitful to invite his priest to a ‘telling and re-telling’ session.
However not all narrative techniques are used with all persons, and perhaps David’s progress
shows that the therapy was ‘good enough’.
5.1 Developments
From its beginning in the early 1980s as an obscure, local and specialist strand of family
therapy, narrative therapy has evolved into a philosophy and methodology increasingly
acknowledged and practised worldwide, with therapists who discover it frequently attest-
ing to a revelatory sense of engagement and excitement. White’s principal texts have
been translated into many languages, and books on the subject increase yearly. Narrative

therapy organisations such as the UK Institute for Narrative Therapy have been set up,
and training in the approach is established in the UK, Europe, USA, Canada and the
Middle East. Teams from the Dulwich Centre give courses and workshops all over the
world, and facilitate many community projects based on narrative ideas.
White’s writing and teaching were continually surprising and sometimes dismaying, as
his restless and creative energy sought ever more effective ways of characterising and
expanding narrative practices, and of relating them to an ever wider range of philosophi-
cal ideas. In the 1980s he had emphasised the work of the anthropologist Gregory
Bateson, with its proposal that we selectively ‘interpret’ our experience and can only
absorb new ideas into pre-existing conceptual frameworks. In Narrative Means to
Therapeutic Ends, the 1990 text co-authored with David Epston, he acknowledges the
importance of Bateson’s ideas, but gives more emphasis to Michel Foucault’s writings,
which propose that persons create and perpetuate their own negative views of themselves
through the internalisation of socially constructed ideas, values and beliefs which derive
from, and serve to perpetuate, personal and political power systems. This book also
describes in detail the identification and exploration of ‘unique outcomes’ (elements of
experience ‘not accommodated by the dominant story’), which became a core aspect of
narrative therapy. An appealing and influential chapter is devoted to ‘externalising the
problem’, including an account of a child’s soiling being characterised as ‘Sneaky Poo’.
For many therapists attempting to use narrative ideas and practices, externalising came to
be seen as the essence of this therapy, though White was careful to say it was not always
appropriate. A chapter by David Epston explains therapeutic documents, with examples
which by their length, detail and complexity set a standard that lesser therapists have
sometimes found hard to emulate.
Narrative therapy since 1990 has built on this seminal publication. In the wider world
of counselling, the term ‘narrative’ has become quite fashionable, and White often found
his proposals were misunderstood, distorted or sometimes used to justify ends he found
mistaken or even abhorrent, such as ‘therapy’ to ‘cure’ homosexuality. Partly to counter
these misrepresentations, he increasingly developed very precise practices, such as the
‘maps’ of therapy outlined earlier in this chapter. Towards the end of his life he called on
Lev Vygotsky’s educational theories as a basis for the most elaborate structure of thera-
peutic questioning he ever formulated. Other narrative therapists have expanded White’s
earlier ideas and have built on them. Hedtke and Winslade (2004) enlarged a short paper
by White on resolving delayed grief into a whole book. Therapeutic documents have
received much creative elaboration, such as Stephen Madigan’s practice of inviting a
person’s friends and relatives to send supportive letters and other documents (Madigan,
1998: 220–2). David Denborough’s concept of the ‘Tree of life’ presents an engaging
metaphor for narrative description of experience over a lifetime (1998). Duvall and Béres
(2011) have identified specific turning points in narrative therapy interaction; they, Jane
Speedy (2008) and others, through qualitative research, have published precise observa-
tions of how, and how well, this therapy works.

5.1.1 Brief therapy

Although White and Epston never defined narrative therapy as ‘brief’, their descriptions of
their own practice clearly indicate that persons were seldom seen for long, and this is
matched by other narrative therapists’ accounts of their own work. Although the atmosphere
of sessions is relaxed and exploratory, this is a purposeful, focused way of working with
sometimes surprisingly swift outcomes. When training under White I saw persons find a
single session with him transformative. My own experience, working in contexts with a lim-
ited number of sessions imposed by the employing organisation, has shown that narrative
therapy can be effective in about three to eight sessions.

Narrative therapy has always had a central philosophy of respect for local and minority cul-
tures. The social consciences of its originators meant that therapy and political action were
seen as inseparable, especially as White and Epston lived in societies where Aboriginal and
Maori peoples are subject to bigotry and discrimination. Basic narrative therapy practices
need little modification when counselling persons belong to social or cultural groups differ-
ent from that of the therapist, but the therapist attempts to be alert to cultural difference and
will adjust the specifics of these practices so as to take account of persons’ cultural positions.
Sometimes this can lead to dilemmas for the therapist, as for example when a team from the
Dulwich Centre undertook a major counselling project with Aboriginal people. The team had
to put aside their own beliefs in gender equality and to follow the aboriginal cultural norm
that men should have separate, higher status-based sessions than women. The work of the
Dulwich Centre in Adelaide and of the Just Therapy team in Wellington, New Zealand, has
united therapy and community work in significant ways.
Feminism had a great influence on White and Epston, and has remained a significant strand
in narrative philosophy. Male narrative therapists attempt to be continuously alert to how
culturally derived, internalised gender assumptions may be influencing their language and
attitude to women who seek their assistance. Whatever the therapist’s gender, when it is sus-
pected that a person’s distress or negative self view may be influenced by culturally derived
ideas about male or female role and identity, this is openly addressed in sessions.

For therapists who have been trained to work with individuals, the perceived limitations of
narrative therapy perhaps mostly derive from its origins in family therapy. Some of the theo-
retical assumptions and working conditions of family therapy differ considerably from those
of the traditional individual counselling culture. Family therapists focus on several or all
family members as interactively affected by their problems, rather than on family members
as individuals. Systemic family therapists also consider family problems in the context of
society and culture. Family therapy is often undertaken by a team, comprising an interviewer

and one or more observers. The observers may join the interviewer and the family members
part-way through the session, and reflect on what they have seen and heard.
This needs considerable resources, and more time than the ‘fifty-minute hour’ conven-
tion for individual counselling, and White’s practice of definitional ceremony takes this
mode of working even further. Counsellors with restricted time and facilities, and who are
unable to call on colleagues to form teams, may conclude that narrative therapy is imprac-
tical for them. They may also feel unease because the confidentiality of one-to-one sessions
may seem irreconcilable with a team approach, and this way of organising sessions may
also be thought incompatible with development of the traditionally valued one-to-one
‘therapeutic relationship’. Writing therapeutic documents is another possible stumbling
block, as it is very time consuming, even if the documents are relatively short. These and
similar issues can be resolved with imagination and flexibility (Payne, 2006: ch. 7), but for
therapists meeting narrative ideas for the first time they may seem alien and daunting.

White claimed that many accounts of his work ‘totalise’ and oversimplify his ideas, or simply
miss the point. Perhaps this is not altogether surprising, as White’s writing style is sometimes
compressed, tortuous and difficult, and in his later writing he tends to assume prior knowl-
edge of narrative concepts rather than explaining them. Since his ideas often implicitly chal-
lenge rooted assumptions of the therapy culture, many readers are likely to react with dismay
or even hostility. In interviews and essays White was at pains to rebut many criticisms,
including for example that this is a cold and distancing approach; that it rejects the use of
psychotropic medication; that it is directive; that it is either constructivist (focusing primarily
on the bounded individual), or its opposite, social constructionist (focusing exclusively on
social pressures and socialisation).
Critiques of narrative therapy have largely been voiced within the family therapy commu-
nity rather than by counsellors who work with individuals, possibly because this therapy has
yet fully to make its mark in the traditional counselling culture. The occasional articles on
narrative therapy that have appeared in established counselling journals have tended to be
introductory and advocatory.
There have been attempts to challenge some of White’s theoretical positions, such as a
paper by Fish which claims that in important ways White misunderstood Foucault (Fish,
1993). Many narrative therapists see considerable common ground between narrative and
solution-focused therapies, especially since both explore occasions when the problem was
not present. In an interchange with Steve de Shazer reproduced in Gilligan and Price (1993),
White suggests strong links between his and de Shazer’s ways of working, but this is imme-
diately denied by de Shazer, who suggests that White’s view of the nature of problems is, in
contrast to his own, ‘very traditional’ – to which White responds that De Shazer’s account of
narrative therapy is mostly unrecognisable to him. De Shazer’s irritation is palpable. White
finally agrees that the differences are greater than the similarities.

Hayward (2003) discusses a number of papers that criticise narrative therapy for exclusiv-
ity, lack of consistency, moral posturing, insufficiently systemic thinking and practice, and an
excessive focus on individual functioning rather than on family dynamics. He concludes that
although narrative therapists might do well to give more careful attention to the language
they use when promoting this therapy, so as to avoid conveying a sense of disrespect for other
modalities, advocacy of any new approach implicitly criticises others, leading to resentment
and misunderstanding. He suggests that criticisms of narrative therapy are largely attributable
to this factor.
5.4 Controversies
Compared with more established therapies, there appear to be few or no controversies preoc-
cupying narrative therapists. At this stage of narrative therapy’s development, practitioners
and theorists are building on White and Epston’s ideas rather than challenging them. Perhaps
this lack of debate is regrettable, as it can add to the impression of narrative therapists as
uncritical and insular, and of White as a revered and not-to-be questioned guru, certainly the
last thing he himself ever wanted – he always claimed he was ‘still learning how to do this
therapy’ (1997b).
6 RESEARCH
The research model of comparative randomised controlled trials for the treatment of physical
illness is the expected methodology for providing evidence of the relative effectiveness of
different counselling approaches. At a time when providers are under pressure to provide
research-based evidence that their approach works, therapies which cannot be reduced to
repeatable protocols of practice for comparison with others are at a disadvantage. If research-
ers reduce counselling practices to standard protocols, the selectivity, flexibility and creative
moment-by-moment response essential to all good counselling is lost, so the approach is not
really being assessed; but if the research is based on observation of good counselling being
performed in all its subtlety, sensitivity, variety and complexity then no precise comparisons
between approaches are possible – or even between sessions of the same modality. Perhaps
for these reasons, narrative therapists have taken a rather critical attitude towards compara-
tive research, and as late as 2000, Etchison and Kleist could suggest that research on the
effectiveness of this therapy was in its infancy. Documenting what persons themselves find
helpful is called ‘co-research’ by narrative therapists, many of whom strongly prefer it to
researcher-led methods (Epston et al., 2004).
Comparative research may run the risk of being unrealistic, but qualitative research, the
method preferred by narrative researchers, runs the risk of remaining self-referential. The
‘evidence’ is in the responses of the persons counselled, and the perceptions of the research-
ers. The researcher writes protocols of method, observes them in practice, tabulates positive

change in persons’ position in relation to the problem, and then attributes this change to the
aspects being observed. It is rare for such research to discover unexpected and significant
factors not previously assumed. An exception in the case of narrative therapy is found in
Duvall and Béres (2011), who note some significant and previously unreported factors in
observed narrative practices, such as ‘pivotal moments’. White endorsed their book as pro-
viding an evidence-based foundation for the effectiveness of narrative therapy.
At the time this chapter is being written the Dulwich Centre website describes a number
of recent research papers on narrative therapy. Two of these, concerning adult depression,
compare outcomes with other modalities, concluding that a narrative approach was
equally as (NB not more) effective as established methods, and/or was effective compared
with no therapy at all. A similar result was obtained in a study of narrative therapy for
childhood soiling. Other reported results are impressive (for example an 88–98%
improvement in child/parent conflict, an 80% improvement in children’s habit of steal-
ing). Success is attributed to externalising, reflexivity, and other narrative therapy prac-
tices. These papers are valuable, but their authors did not seek to demonstrate that narra-
tive therapy works better and/or is more cost-effective than other approaches; or that
certain practices of narrative therapy are more effective than others, or more suitable than
others for addressing specific problems.
As with many narrative practitioners, my own commitment to this therapy did not come
from being convinced by research findings. Its values and assumptions match my own, and
persons whom I have counselled over the 16 years since discovering it have consistently and
emphatically testified to its helpfulness.
7 FURTHER READING
Morgan, A. (2000) What is Narrative Therapy? An Easy-to-read Introduction. Adelaide: Dulwich Centre
Publications.
Payne, M. (2006) Narrative Therapy: an Introduction for Counsellors (2nd edn). London: Sage.
White, M. (1995) Re-Authoring Lives. Adelaide: Dulwich Centre Publications.
White, M. (2007) Maps of Narrative Practice. New York: W.W. Norton.
8 REFERENCES
Denborough, D. (1998) Collective Narrative Practice: Responding to Individuals, Groups and Communities Who
Have Experienced Trauma. Adelaide: Dulwich Centre Publications.
Duvall, J. and Béres, L. (2011) Innovations in Narrative Therapy. New York: W.W. Norton.
Epston, D. et al. (2004) From empathy to ethnography: the origin of therapeutic co-research. International Journal
of Narrative Therapy and Community Work 2: 29–35.
Etchison, M. and Kleist, D.M. (2000) Review of narrative therapy: research and utility. The Family Journal 200(8): 1.

Fish, V. (1993) Poststructuralism in family therapy: interrogating the narrative/conversational mode. Journal of
Marital and Family Therapy 19: 221–32.
Gilligan, S. and Price, R. (1993) Therapeutic Conversations. New York: W.W. Norton.
Goffman, E. (1961) Asylums. London: Penguin.
Hayward, M. (2003) Critiques of narrative therapy: a personal response. Australia and New Zealand Journal of
Family Therapy 4: 183–9.
Hedtke, L. and Winslade, J. (2004) Re-membering Lives: Conversations with the Dying and Bereaved. New York:
Baywood.
Madigan, S. (1998) Praxis. Vancouver: Yaletown Family Therapy.
McLeod, J. (1997) Narrative and Psychotherapy. London: Sage.
Payne, M. (2006) Narrative Therapy: an Introduction for Counsellors (2nd edn). London: Sage.
Payne, M. (2009) ‘Thanks, Michael’ Context 105:15–18
Speedy, J. (2008) Narrative Enquiry and Psychotherapy. Basingstoke: Palgrave Macmillan.
White, M. (1989) Selected Papers. Adelaide: Dulwich Centre Publications.
White, M. (1991) Deconstruction and therapy. Dulwich Centre Newsletter, 3 Reprinted in D. Epston and M. White
(1992) Experience, Contradiction, Narrative and Imagination. Adelaide: Dulwich Centre Publications.
White, M. (1995) Re-authoring Lives. Adelaide: Dulwich Centre Publications.
White, M. (1997a) Narratives of Therapists’ Lives. Adelaide: Dulwich Centre Publications.
White, M. (1997b) Personal communication.
White, M. (2000) Reflections on Narrative Practice. Adelaide: Dulwich Centre Publications.
White, M. (2002) Addressing personal failure. International Journal of Narrative Therapy and Community Work 3:
33–76.
White, M. (2004) Narrative Practice and Exotic Lives. Adelaide: Dulwich Centre Publications.

19
The Transpersonal in
Individual Therapy
John Rowan
Transpersonal psychotherapy comes from transpersonal psychology, which has been developing
over the past fifty years or so, as I have described in detail elsewhere (Rowan, 1996), and is
now well known. It maintains that human beings are spiritual beings, with a soul and a spirit,
and that this is something essential and basic, rather than something added on as a mere grace
note. This means that even the most downtrodden worm of a person has the divine within,
and that this needs to be acknowledged if we are to do justice to this person in front of us.
Roberto Assagioli (1975) is one of those who has recognised this, and he speaks of the super-
conscious, the source of creativity and morality and truth, as just as important as the lower
unconscious so well dealt with by the psychoanalysts.
This, of course, raises huge challenges for the transpersonal psychotherapist, because in
the current climate of opinion spirituality is not widely accepted or recognised, although
the tide has turned since the 1950s, when it was anathema to use such terms. Nowadays
people do not usually turn away or blush when such words are used, but they are rightly
suspicious of the New Agery which is everywhere, and which says that we must never be
negative, but always be positive. Real spirituality recognises the importance of the nega-
tive just as much as the positive, and actually draws attention to the dialectical character
of our encounters with the world. It is important to make a clear distinction between

transpersonal psychology and the more recent discipline of positive psychology. The latter
goes in for tests, and tables, and quantitative research, all of which are regarded with some
scepticism by the transpersonal theorists. On the other hand, there is now a spiritually
organised group within the Royal College of Psychiatrists, which is something new but
perhaps predictive of a wider trend.
And so we are now getting books coming along which deal well with the spiritual side of
therapy, and do not fall into the trap of mixing it up with religion. Some of them (Matteson,
2008) also do real justice to questions of religion and prejudice, concerning homosexuality
and so forth. One of the permanent difficulties of working in this field, of course, is the per-
sistent attempt (conscious or unconscious) of many people, some of whom should really
know better, to confuse spirituality and religion. The distinction is simple: religion is an
organisational matter, replete with sacred texts, sacred buildings, sacred practices, sacred
stories and so forth, some of which are quite questionable; spirituality is a personal search,
not a question of something you join. Of course, religion is not to be dismissed: Ken Wilber
holds that it can actually be a useful escalator, leading people from the most prejudiced prac-
tices to the heights of mysticism.
When therapy meets spirituality, we get transpersonal psychotherapy. I think the term
‘transpersonal’ is better than the term ‘spiritual’ because it is unambiguous, in a way that
spirituality is not. There are all kinds of spirituality, some of them primitive, or demeaning,
or dangerous, or ignorant; the term ‘transpersonal’ means that which is above and beyond
such errors.

As we just saw, the image of the person is of a spiritual being with eternal life and a spir-
itual destiny, as well as all the normal features of body, emotions and intellect. The image
of society, however, is of a regime which systematically blocks our awareness of this, and
diverts our attention into practical matters on the one hand, and inadequate philosophy on
the other. So it is often the image of society which is the prime issue, rather than the image
of the person.
It needs to be said that we systematically reject any suggestion that events in the past of
the client operate in a deterministic manner on the present well-being of that person. We
would rather say that in the past we made certain decisions, often made in haste and with
minimal evidence, which we are still acting on. It is possible to remake those decisions, with
the knowledge and ability that we have now.
Our interest in such things as attachment theory, the Oedipus complex and ‘the mirror
stage’ is therefore quite limited. It may be that such things as the trauma of birth are extremely
important, but they are well dealt with in the more popular forms of therapy, where the whole
question of the Shadow is so important. The people who come to transpersonal therapy are

THE TRANSPERSONAL IN INDIVIDUAL THERAPY 499
almost invariably people who have done all or most of the work in dealing with their Shadow,
and who are therefore ready for the more advanced work in the transpersonal realm.

Psychological disturbance is not being aware of the truth that we all spiritual beings with
infinite resources and an infinite history. Most people are psychologically disturbed by this
lack of awareness. However, it is not just lack of awareness: it is active rejection of awareness
because of too much attention to immediate matters, and because of adherence to false
assumptions. All the way through, it is false assumptions that are seen as the problem, and so
the task is always to see through more of these.
One classic example of this is the desire to be right. Most people adhere to the view that it
is possible to get things right. This may be in the field of parenting, it may be in the field of
work, it may be in the field of sport, or all the other fields that we live in and work through.
This is a potentially crippling false assumption, which leads to the saw – ‘Most people would
rather be right than be alive.’ This is one of the major assumptions that clients come to ques-
tion in the course of the work.
Another classic assumption that currently is even more prevalent than it used to be is that:
(a) all our actions come from our brains; and (b) that the brain is in the head. To anyone who
takes literature seriously, whether in novels, in poetry or any other genre, it is obvious that
our actions spring from our hearts and our bodies just as much as from our brains. The
research, which has been done on neural networks by people like Panksepp, Damasio and
Varela has now demonstrated without any possibility of error that our brains are distributed
throughout our bodies, and not just located neatly in our heads.
One of the most important aspects of the transpersonal approach is this scepticism about
deterministic solutions. Spiritual beings are not at the mercy of their genes, their traumas,
their early struggles, their cultural background and so forth. As soon as we start to get in
touch with our spiritual heritage we realise this.

Psychological health consists in the full ownership of all our levels and faculties. It means
full awareness of our authentic self (where we wake up to the possibility that we are in charge
of our own worlds as well as our own minds and bodies), of our Subtle self (where we wake
up to the understanding that we are spiritual beings, with a spiritual origin and a spiritual
destiny), and our Causal self (where we wake up to the truth that we are ultimately not limited
by our bodies or our minds), at least. If we have achieved this, we are then healthy in the full
sense of the word. This means, of course, letting go of all that which holds us back. One of
the problems then is that society continually tries to hold us back and accept that the status
quo is all that there is. It rewards us for being psychologically unhealthy – for looking outside
for guidance rather than seeing the world through our own eyes.

Not only that, society actively dissuades us from making some of the necessary moves, by
telling us that we must not be arrogant or prideful, we must not be pretentious, we must not
lay claim to insight or intuition, we must not be superior or egregious. On the contrary, we
must be modest, and say within the limits accepted by the people around us. And we get
punished if we go outside these commonly accepted limits. The idea that psychological
health consists in the full acceptance and full development of our highest aspirations is not
only questioned, it is actively opposed, for the most part. There is a cost involved in moving
into the spiritual levels, the land of the transpersonal.
But if, as I believe, psychotherapy is a dance of soul-making, then we can lay hold of the
nourishment that comes with that, and use it to strengthen the client against the insults that
come from the social milieu.

Virtually everyone acquires psychological disturbance because of the early and continuing
adoption of false assumptions. These are given to us by society, firstly in the person of our
parents, and then later in the fact of education. Most of what we learn in such situations con-
tains falsities that disturb and unbalance us. We also learn inadequate ways of thinking about
the world and ourselves, such as, for example, the positivist view that the world is divided
into one and zero, yes and no, either/or and in general the logic of Aristotle, Newton, Boole
and mathematical logic. These logics, while very suitable for computers, are crippling when
applied to human beings.
It has often been noted that education impedes creativity and demands conformity. It
does not matter whether it is a state school in a deprived neighbourhood or a private
school for the rich and famous – conformity is demanded in any case. And even when
creativity is apparently allowed, it is generally examined in the same way as more mun-
dane subjects, with grades, and stages, and demands for performance according to a
standard.
These are the ‘conditions of worth’ noted by Carl Rogers as the main focus of psycho-
logical problems (Barrett-Lennard, 1998). All through our childhoods most of us are faced
with the demand to measure up to other people’s standards and other people’s perceptions of
what is right and what should be happening, with due penalties for failure. These then get
internalised as injunctions for how we are to be and behave, most of which are nothing to do
with our own perceptions and our own growth.

Our psychological disturbance is perpetuated by the media, by our families, friends, teachers,
and so forth, which systematically lead us away from our own spiritual development and our
own self-realisation.


Intrapersonal mechanisms are many and various, but they all add up to self-deception in one
form or another. Freud and his followers identified about 24 ‘defences of the ego’, but really
the number is infinite. Once we abandon self-deception, which may be quite a long process,
these problems disappear.

Interpersonal mechanisms are the pressures to conform. Society provides a multitude of such
pressures, all designed to make us better role-players for the benefit of others. Even when we
escape from the position of being a mere role-player for the benefit of others, and become an
authentic person, it is hard to exist in a society which has no place for such things. It is even
harder if we wish or need to move into the transpersonal sphere.

Environmental factors include the social system, the monetary system, the system of
trade and international intercourse and so forth, all designed to make us conform and
submit to the usual thing, the regular diet. It also includes prejudices like sexism, homo-
phobia, racism and so forth. And of course it includes the food we eat and the liquids we
drink – all of which hold us in thrall to the whole system, and help to prevent us from
knowing who we are. This has been particularly well described by the proponents of the
Integral (AQAL) system described by Ingersoll and Zeitler (2010). This system, origi-
nated by Ken Wilber, advocates taking account of intimate social factors, objective body
factors and broad social factors in every attempt at therapy – not only the individual
consciousness. The theory says that these four quadrants are fundamental to understand-
ing human experience, and that any form of therapy that leaves them out must be to that
extent inadequate. Not only that: within each one there are a number of levels that need
to be taken into account. This is quite a comprehensive theory which is being explored
more and more today.
2.5 Change
The change we are aiming at in transpersonal psychotherapy is development onwards
from the conventional state of mind, which has been called ‘the consensus trance’, into
self-discovery and self-awareness. It is also towards the adoption of dialectical logic or
vision-logic, as it has also been called. This is the logic of paradox and contradiction,
where opposite positions can both be true at the same time. Formal logic has as its basic
statement ‘A is A’, while dialectical logic has as its basic statement ‘A is not simply A’. It
now becomes clear that the transpersonal approach is a radical one, which does not accept
the current view of society as just the way things are. Society is actively discouraging
people from discovering themselves, because it prefers biddable functionaries who do not

question their roles. Transpersonal approaches all question this and refuse to accept it.
They work best when the person is already aware of the importance of authenticity and
being a whole person.
We can then help the client to develop further into the Subtle realm of being, where
we discover our soul and begin to open up to the whole divine realm. Other therapies
do not envisage the existence of the higher self, of the superconscious, and so forth,
and so cannot help the client emerge into this kind of new awareness. For most people,
the Subtle realm is little known, in spite of the efforts of authors, composers, poets,
musicians and other arts practitioners to enlighten us about it. In psychotherapy our
most helpful guides start with Jung, who made the most exciting inroads into this
realm, followed by von Neumann, Hillman, Ponce, von Franz, Edinger, Schwartz-
Salant, Hannah, Dieckmann and so forth. Just recently we have been allowed to see
The Red Book, an amazing creation of Jung himself (Jung, 2010), full of fascinating
images, prose and poems. The other school which has pioneered the exploration of this
realm is that of Assagioli, and his schools of psychosynthesis are now spread world-
wide. The website (www.two.not2.org) contains a wonderful compendium of psycho-
synthesis worldwide, which is well worth consulting, as is the work and website of
Will Parfitt (www.willparfitt.com).
Still less do other therapies envisage the possibility of entering the Causal state of con-
sciousness, or the Nondual. In fact, the explorers of this realm tend to be rather isolated and
idiosyncratic, such as Robert Rosenbaum, Amy Mindell, Mark Epstein, Michael Eigen,
David Brazier, Wilfred Bion, Nathan Field and so on. As we shall see later, this is a severe
deprivation. Fully radical therapy demands that these later territories be opened up. In prac-
tice, work at the Causal level turns out to be surprisingly productive, giving original and
highly specific insights into what is going on.
3 PRACTICE

The goals of therapy are unspecified. The work we do is completely open-ended, because in
the end each person faces the mystery alone. As soon as we name a goal we limit the work.
Even if we name the goal as the absolute, that is still just one name, just one story, just one
tradition. Perhaps we can name the goals of therapy in negative terms as the destruction of
all false assumptions – but of course this may be an endless task, and if so perhaps there is
no goal of therapy at all.
This is most important. I have argued elsewhere (Rowan, 2002) that there are three dif-
ferent ways of doing therapy: the instrumental; the authentic or relational; and the
transpersonal. Of these three, the transpersonal is the most insistent that therapy is not an
instrumental task.


A client is unsuitable if they have a goal. It has often been noted that the client’s goals are
very often just as neurotic or dubious as anything else about the client. What the client needs
to work on emerges most fully and truthfully in the course of the action, not at the beginning.
If therapy is a voyage of discovery into vast realms of the unknown, to have goals is to limit
the voyage to known destinations, familiar shores. If we want to make real discoveries, open
up new vistas, go all the way to the horizon, we do not want to be prematurely limited by our
existing knowledge, our familiar rounds.

A client is suitable if they have been thrown into a situation where they have to change, and
do not know the scope and limits of that change. Common situations of this kind are the loss
of a partner, the loss of employment, deep problems with children, loss of faith, serious injury
and so forth. A crisis of some kind seems to be necessary, leading to dissatisfaction with the
whole conduct of one’s life. This often seems to happen around the age of 30. This leads
them, hopefully, into some humanistic form of therapy, where they can discover their real
self, their authenticity.
When they have worked their way through the implications of all this, they will be ready
for the transpersonal approach. We can then start the movement into the Subtle by using
suitable techniques such as guided fantasy, work with chakras, spiritual chairwork and so
forth. It is true to say, however, that we do not work with methods such as hypnosis, which
seem to us basically instrumental in their whole thrust and assumptive structure. We believe,
on the contrary, that everything that can be done using trance states can be done just as well
without a trance.

The therapist should have gone quite far into the development of his or her own conscious-
ness. This means losing all or most of their own false assumptions. This would normally
entail a good deal of work at lower levels, dealing with their own Shadow material; a good
deal of work at the Subtle level, losing their fear of deities, angels, devils, archetypes and so
forth, and gaining much knowledge of symbols and images; and sufficient work at the
Causal, having dropped their fear of the absolute, having experienced the usual mystical
states of the Void, and so forth. Some experience of the Nondual would be an advantage.
They would of course have acquired the usual skills of the therapist, such as the ability to
relate openly at a deep level, the ability to confront with elegance and care, the perceptiveness
to see where pressure would be most effective and acceptable, and so forth.


Such skills would include the creative use of imagery, the strength to use direct challenges,
the ability to work with transcendental empathy when appropriate, the ability to work without
empathy when appropriate, the ability to use materials such as art materials, music, film and
so forth, and in general to keep up with social trends. The development of the essential skill
of intuition is very important. In transpersonal psychotherapy intuition is the main way of
thinking, and it has to be cultivated by the therapist in great depth.
Today it seems also necessary for any therapist to be aware of emails and the social media,
and to be able to use methods such as Skype. It is by no means impossible to use such meth-
ods in the pursuit of transpersonal psychotherapy. To have clients in various countries may
often be very educative for all concerned.

The therapeutic relationship is totally open. There are no arbitrary constraints, though the
usual formalities are usually observed, such as a time slot, a fixed payment, mutually under-
stood holiday arrangements, and so forth. Once in the room, the Jungian mode of the vas bene
clausum is usually observed, using confidentiality and privacy. But either party may ask
questions, make observations on process, probe beneath the surface, and so forth.
‘Communication is only possible between equals’ is one rubric which has been used, and
which I personally would endorse.

Therapeutic style is again open, active, informal, self-disclosing, humorous, all as appropri-
ate for the day, the time, the persons involved and so forth. There is no mystery except the
Mystery. The physical distance from the client should not be too close or too distant, and
the distance and angle of the seating arrangements are often negotiated with each client. The
whole question of the way the room is furnished is relevant here, and I have written about
this in some detail elsewhere. The practice of Freud of having a number of symbolic objects
in the room seems very good, though it seems that he was very conservative in the way he
used such stimuli.

3.5.1 Assessment
Assessment is not undertaken in any formal way, except to ascertain suitability along the
lines outlined in Section 3.2. There is the question of matching here, whereby certain cli-
ents and certain therapists are not good together. Sometimes this is obvious from the start,
but sometimes it only emerges after some time, which may mean referral on to someone
more suitable. There is no assumption that the transpersonal therapist can necessarily deal

with every client who comes along, and reference to another therapist may sometimes be
required.

Case formulation is not used at all, because the person is not seen as a case. The danger,
which has often been pointed out, is that the therapist may try to deal with the label rather
than with the person. That is the reason why there will never be a protocol in the transper-
sonal system. However, if forced to use some kind of formula, we would prefer the psycho-
logical approach of someone like Barbara Ingram (Ingram, 2006), rather than the psychiatric
approach of diagnostic manuals. Psychological therapy is clearly distinct from any psychiat-
ric assumptions.

The major therapeutic strategy is presence, or as Laing used to put it, co-presence. If the
therapist is genuinely there in the room, that is the major factor. The emphasis is rather on
the person of the therapist, who should be an exemplar for where the client is expected to
move. Not in the sense of copying the therapist, but in the sense of using the therapist as a
benchmark.
This of course puts the emphasis on the relationship, and this is much better understood
today, because of the widespread adoption of the idea of intersubjectivity. In the transpersonal
approach the relationship starts off very often as a sort of expert/student type of thing, but
this continually moves in the direction of equality.

All the creative techniques can be used, and new ones invented on the spot. Imagery is used
a great deal, and the transpersonal therapist trusts images more than words. Chairwork is also
used a great deal, bringing the topics to life in the present. Art materials are always present,
and the Winnicott squiggle method (Winnicott, 1971) is often used. Guided fantasy is used
from time to time, and carefully distinguished from pathworking, which is not used at all.
Dream work is important, and may be explored in a variety of ways, including transcendental
work at the Subtle level. Some beautiful techniques are laid out in the excellent book by
Gordon-Brown and Somers (2008).
In general, an active approach is used, because there is really a lot for the client to learn,
and practise. However, in my experience the use of homework is very small, simply because
this is not an instrumental approach. Because there are no problems, there are no aims.
Intuition is greatly relied upon, particularly in the Subtle realm, where it is a major resource.
The development of intuition is one of the great discoveries of the Subtle, and in this realm
it becomes the main method of thinking.

It seems clear that there are several different types of intuition, which are really rather dif-
ferent from one another. Let us look at six of them, recognising that there may well be more.
Each of them seems to entail a different notion of the self, such that we cannot have that form
of intuition until we have developed to that level of the self. In all of them we may be faced
with unusual ways of discovery or prediction.
The child self: This is a level of consciousness where fantasy and reality are not always too
well distinguished. Fantasies may be very vivid and emotional, and the person may come to
conclusions about what is going on in the real world which are really more to do with private
fantasies. But the young child may be very perceptive, knowing that something is wrong
without knowing exactly what it is.
Intuition may become very intense at this level, because there are few inhibitions due to
knowing what must logically be the case; there is a wider sense of possibility than we have
later. It is possible to get back into this level of intuition by lowering our barriers and being
childlike, and many creative people use this method.
The magic-mythic-membership self: At this level we use intuition to avoid our loneli-
ness and isolation. It has to do with the denial of separateness to ward off fear and anxi-
ety. It consists of techniques, often of a ritual kind, which give or restore connection and
communication with others. These are tied up with a group, and it is the needs of the
group which are the key to intuition at this level. This happens a lot in close families.
What the intuitive person does is, as it were, to tune in to the group, and to realise its
fears (and answers to them) in concrete form. Sometimes trance is used for this purpose:
a trance in which the individual becomes more part of the group and can speak out in
terms of the group’s obsessions. Cases of apparent possession or poltergeist phenomena
may be expressions of this level of being. This is the participation mystique which is
found in primitive tribes and still in certain communities such as some of those in Sicily,
for example. In our own culture the production of good graffiti, spellbinding speeches,
popular music, popular badges and T-shirts, and successful advertising may occasionally
take this form.
The role-playing self: At this level intuition is turned towards being used or exploited, in
order to give the person a niche in society. Intuition is used to get social rewards of one kind
and another. The whole emphasis seems to be on problem-solving. Fantasy for its own sake
is disapproved of and suppressed. There may be a notion of intuition as regression back to
the unconscious, in the service of the ego. Or it may be seen as psychic, sensitive, an unusual
skill. But somehow intuition is regarded as something which is fully tamed and at the service
of society. Many scientific discoveries come from this level of intuition. There is a lot of
emphasis on techniques, amounting eventually to a technology of intuition which can be
packaged and sold for a price. Intuition is simply another skill to be learned, another role to
be played.
The autonomous self: At this level intuition is seen as the expression of the most central
self. It is something which can be fully identified with and in that sense owned – ‘I am my
intuition’. At first, the emphasis on problem-solving may be kept, but often this gives way
to a more spontaneous approach. This means that we can see this as the beginning of a

transpersonal approach to intuition. It is, as it were, on the borderline between the everyday
world of the previous self, and the fully transpersonal world of the one next to be described.
There may sometimes be a negativistic tinge to it, and one may say in effect, ‘Who needs
the plodding old intellect?’ But more often it seems to go with an independence which is not
attached to being positive or negative. Often here it is associated with creativity. There may
still be a use of techniques (such as the rapport approach of neuro-linguistic programming:
NLP), but usually these techniques are self-invented or put together in an idiosyncratic way
from existing materials. And in any case the person at this level will improvise in any real
situation which may come up. The person can respond with fresh, brand-new insights to
people who present themselves. This is existentialist intuition, and it goes with what we
have called the Centaur level of consciousness. In recent years existentialists have become
more open to discussing the transpersonal, and Emmy van Deurzen in particular has opened
the way to a more hospitable attitude.
The surrendered self: At this level intuition is essentially seen as coming from a source
other than the self. Action has to be taken to open oneself up to this source, which may be
experienced as internal or external; but once this decision to open up has been taken, the rest
is acceptance rather than doing. The source may be conceptualised as inspiration, as the soul,
as the daimon (Hillman), as the Muse, as the antaratman (Cortright), as an archetype, as a
goddess or whatever. At this stage one can tune in to this guidance, which may take the form
of imagery or ritual. There may be an experience of being a channel for this otherness. There
may or may not be an interest in problem-solving. There is often some selection of problems
for solving – some problems are not worth solving, or might do harm if solved. There is a
sense of wanting to be worthy of being used. This is what we find at the Subtle level, the
transpersonal position proper. I have actually investigated this at various conferences, and
have found that different nations, different cultures, have varying access to this level of
intuition. I found very high levels in Mexico, for example, and much lower levels in the
United Kingdom.
The intuitive self: Beyond this there is a further stage, where the person has fully
digested the otherness, and identified with it – entered into a concrete unity with it,
through meditation and/or prayer. At this stage the person may say, perhaps – ‘I am
intuition. Intuition has overcome the me-ness of me. I’m not interested in solving
problems – I can’t even see any problems.’ This could be described as illumination, or
transcendence. This is quite clearly transpersonal, and explicitly mentioned by people
like Mark Epstein and David Brazier. It is an interesting exercise, however, to try
approaching any problem in the spirit of seeing that there is no problem. This may enable
us sometimes to see the whole thing quite differently and act more constructively. This
is intuition at the Causal level.
Of course, having got to one level, one still has access to the earlier levels; but from a lower
level, one does not necessarily have access to the higher levels. Each level is nested within
the one next door, as it were. In the terms used by Ken Wilber (2000) child and magical are
pre-personal stages, role-playing and autonomous are personal stages, and surrendered and
intuitive are transpersonal stages of development.

After recognising these different approaches, it would seem absurd to now ask – ‘Yes, but
what is intuition really?’ It would seem more appropriate to say about intuition, as Hegel says
about God, that – ‘The idea which a person has of [That] will correspond with that person’s
idea of self, and of freedom.’
Like so many things, intuition differs depending on where we are in our psychospiritual
development – this is explained in my book on the transpersonal (Rowan, 2005). At the
earlier levels, intuition, like emotion, tends to be a chancy thing, which comes and goes. It
just comes in a flash, and goes away again – we have no means by which to hold on to it.
At the autonomous level, intuition begins to be more regular and dependable, and it
becomes the main way in which we perceive things. Wilber (2000) talks about ‘vision-logic’
at this stage, and we are using symbols and images much more now, instead of relying on
words so much. We feel that we don’t need to know how or why we intuit things, any more
than we have to know how we see the sunset, or how we lift our arm.
It is at the surrendered level that intuition comes into its own, and becomes our main way of
relating to other people. At this level we can tune into it at will, and either bring it in or switch it
off, just as we can close our eyes or open them, or listen to something or switch off. This has to
do with relaxing our definition of where we begin and end, and with opening up the level of soul.
There seem to be at least three different experiences within intuition: the first of these is a
feeling which might be expressed in the words – ‘I know but I don’t know why’. This is what
we often call a hunch. At the earlier levels this is uncomfortable, as if we had no right to know
things without proper evidence. But with further development we learn to separate those we
can trust from those that are mere fantasies, simply by using this faculty much more often. It
is of course very useful for a therapist to have access to this.
A second type could be expressed in the words – ‘I have a sense it is right’ – this ‘sense’
comes into the superconscious as described by Assagioli, and is to do with rightness and
choice. This again can come at any stage, but it is only at the transpersonal stage that we can
choose to tune into it at will.
The third type can be stated in the words – ‘It came to me in a flash’ – these intuitions may
be very minor and chancy at the earlier stages, as mentioned above, but at the autonomous
stage and beyond they may include major insights, sometimes glimpses of what seems like
an intuitive plan at the highest level.
Goldberg (1983) has a good discussion of many of these matters at greater length. In all
these cases, the message may be more or less ambiguous. Intuition may give only part of the
picture, leaving the rest to be filled in by some other means. At other times there is little doubt
about the completeness of its message, for it enters consciousness with enough light to make
itself felt in an unambiguous way.

I have found here the alchemical process to be of use, in providing a general conspectus
of the general stages to expect. I have described this in detail elsewhere (Rowan, 2005:

Chapter 6), so there is no need to introduce it here. But one of the main findings of this
approach is that there are three phases to the process of therapy, seen from a transpersonal
point of view.
The first phase takes the person from the ordinary everyday level of consciousness to the
higher level, which has been variously named by different researchers self-actualisation, the
authentic level, the existential stage, post-conventional morality, and so forth. This is charac-
terised by dialectical thinking, second-tier thinking, non-linear thinking and generally a logic
which embraces paradox and contradiction. This a huge change in consciousness, and often
regarded as the final stage of therapy, because the Shadow has been fully explored and dealt
with. In alchemy this corresponds to the movement from the Materia Prima and the first
Nigredo, through the Fermentatio, where the client starts to experience the therapy continu-
ing between sessions, Separatio, where the family of origin often needs to be explored, the
Calcinatio, where we begin to see that opposites are necessary rather than a nuisance, and
where the therapist may be questioned, to the Albedo, where some or all of the original symp-
toms have been dealt with. This ‘whitening’ is often regarded as the end of therapy, and
short-term therapies never go beyond this: many do not even go this far, and rest content with
much earlier and simpler stages, patching up the client sufficiently to continue with his or her
life in the former pattern, whatever that was.
The second phase takes the client on to the Conjunctio, which is mostly about consolida-
tion, and making links between the therapy and everyday life. This then can lead to the
Mortificatio, where all seems to be lost. This can be a distressing phase, where the client may
feel that the therapy is doing more harm than good, and may exit in a panic. But if this can
be endured, and of course much here depends upon the relationship between therapist and
client, this can lead to the Solutio, involving deeper explorations and rites of passage. After
some time working through this phase, the client may be ready for the next transition, to the
next higher level, which has been variously called the Subtle, the Bhakti initiation, the
Sambhogakaya, the level of Soul and so forth. This is the realm so powerfully explored by
people like Jung, James Hillman, Thomas Moore, Joseph Campbell, Marie-Louise von Franz,
Molly Young Brown and others. It is the level of consciousness where we start to see our-
selves as spiritual beings, and want to read more about mythology, nature spirits, polytheism,
angels, archetypes, standing stones and the like – the whole realm of concrete representations
of the divine. And it brings the client to the phase of the Coagulatio, a complex stage where
all kinds of doubts may assail the client, as we shall see in the case study. This may take some
time to work through.
But at a certain point something new emerges. This is the Sublimatio, where all that has
been achieved in the last phase has to be surrendered. The joys and excitements of the
Subtle have to be given up. The existing sense of self can then die and be reborn. This is a
huge task, because it involves questioning everything that has been achieved so far. But it
inevitably leads to the Rubedo, the final stage of the process, which is described in so many
different ways in the alchemical literature that one may doubt whether the alchemists really
understood it. Today we can see clearly that it represents what has been called variously
the Causal, the ultimate, the Sunyata, the Void, the Emptiness and so forth. It is a mystical

level of consciousness, where we have to let go of all the definitions we have arrived at up
to now. Here there are no signposts, no handrails, no landmarks – just the deep ocean of
mysticism.
Now the transpersonal psychotherapist is mainly concerned with the second and third
phases just outlined. Humanistic therapists cover the first phase very well, so there is no need
for the transpersonal therapist to pay much attention to it, though often there are some
remaining issues from this stage which need seeing to. It is an interesting fact that when
transpersonal psychotherapy first came upon the scene, most of the emphasis was on Phase
2, the Subtle realm. This is because this is normally the first phase of the transpersonal which
becomes available. It is on the whole easier to approach than the third phase outlined above.
But in recent years it has become obvious that therapy can embrace this third phase without
hesitation, and in fact it has been well treated by people like Michael Eigen, Robert
Rosenbaum, Amy Mindell and others.
Certain cautions are necessary here. The transpersonal is not the extrapersonal. The extrap-
ersonal includes the whole range of the paranormal, and also the whole set of phenomena
often labelled as fakirism. It has been suggested that while the transpersonal refers to the
divine realm, the extrapersonal is non-divine.
Again, the transpersonal is not to be identified with the functions of the right brain. This is
a popular idea, but it cannot be useful. If the left brain is to be linked with the world of ration-
ality and formal thought, then the right brain has to be the repository of everything else, from
the lowest to the highest, so to speak. The transpersonal would then be mixed up with super-
stition and primitive beliefs, which is not the case at all. Wilber calls this the pre/trans fallacy,
lumping the prepersonal (the primitive, the prelogical) with the transpersonal, and cautions
against it.
Another possible confusion is with New Age thinking. A major characteristic of New
Age thinking is that everything has to be positive. The transpersonal is nothing like this.
Actually New Age thinking is a major problem today, because of its prevalence and its
popularity: it even invades some quite respectable books and films and makes for a confus-
ing message about spirituality. The idea that by using visual images one may ensure a
parking space, for example, is a clear example of confusing ego demands with Subtle
insights. There is no such thing as the Law of Attraction, and the idea of Cosmic Ordering
is just laughable.
There are books on the transpersonal which confuse it with religion. This again is a mis-
take: a religion is something organised, with rituals and dogmas, often with books and build-
ings. The transpersonal is more like an individual quest or discovery, undertaken by oneself
for oneself. At certain points – particularly in the Subtle realm – it may involve groups and
rituals, but these are in the service of the personal search, not an end in themselves. Those
who have rejected religion do not have to worry that they are going to be confronted with it
if they embrace the transpersonal.
Also I think it is important to distinguish the transpersonal from the spiritual. The trouble with
spirituality is that it covers the whole psychospiritual range, from the pre-rational to the furthest
or deepest rationality. That means that certain forms of spirituality, such as fundamentalism, are

fully spiritual, but they are not transpersonal. The transpersonal is essentially post-conventional,
post-conformist and so forth.
Within the transpersonal, as we have said, there is an important distinction between the
Subtle and the Causal. The Subtle is the realm where Jung is one of the main contributors,
and other Jungians have made great contributions. It is also the realm where Assagioli has
made further innovations, as have his followers John Firman and Ann Gila. Jean Houston,
with her idea of a sacred psychology, is also a great contributor to the understanding of
this realm. It is the realm of Tantra, of dakinis, of nature spirits, of visions and audible
messages, gods and goddesses, and so forth. It is also the realm where we may get very
interested in symbol systems, such as astrology, the Tarot, the I Ching, the Kabbalah, the
Myss archetypes and so forth. There are in fact some fascinating correspondences between
different symbol systems, such as, for example, the Tarot and the Kabbalah. Here is
important to tread carefully and with discrimination. Mystics such as St Teresa of Avila
have much to offer in understanding this territory, as Wilber has emphasised. Historically,
this is where the main work of the transpersonal in therapy has been done, because it is
the most accessible, the most friendly, aspect of the transpersonal. It is also the area of
greatest compassion: the normal empathy of therapy here becomes the transcendental
empathy described by Tobin Hart.
More recently, however, partly because of the work of Ken Wilber and Alan Combs, partly
because of the work of Thomas Genpo Merzel, David Brazier, A.H. Almaas, Mark Epstein,
Robert Rosenbaum and others, it has been found possible to do therapy at the Causal level.
This is the level of the Dharmakaya, which is the most central and classic mystical realm,
described by all the main mystical traditions as the ultimate aim. (Incidentally, the term
Causal has nothing to do with determinism: it comes from Wilber, who I believe got it from
the Theosophists, who got it from the Vedanta. It is just a label.) The strange thing is that at
this level empathy disappears altogether. At this level there are no problems, so how could
the therapist empathise with the client’s problems? But once we see that there are no prob-
lems, the whole game changes. It is more a case of seeing through the client’s pathetic
attempts to hold on to false assumptions – assumptions which are keeping the problems
unsolved. In fact, this approach – that there are no problems – is a very interesting one, which
can often shed light upon certain issues.
There is, however, a further point of interest here. Many authorities agree that there is a
quite different approach to mysticism, which is called the Nondual, and this is something I
have been exploring for the past twelve years. Instead of seeing the transpersonal quest as a
set of steps to be taken, boundaries to be crossed, levels to be risen to, and so forth – a kind
of spiritual continuum – it sees the ultimate state as always present, never absent. There is no
quest, no seeking, no achievement. Here we are, already. Looking for it would be funny, a
joke, a laugh. This sounds very much like the Causal, but actually it is quite different. In a
recent paper I discovered that the Zen koan cannot be solved at any of the normal levels – it
can only be solved at the Nondual. Wilber suggests that if we regard all the spiritual levels
as a continuum printed on a piece of paper, the Nondual is like the paper. There is now a
group of therapists in California who claim to be working at the Nondual level, but from the

evidence I have seen, this is not actually the case. They seem to be doing therapy at perfectly
normal and ordinary levels, and talking about the Nondual to the client.
4 CASE EXAMPLE
4.1 The client

The client was a man of 52, who had recently emerged from a marriage of 15 years, which had
produced two children, now 11 and 13. He had become more and more aware of a growing
difference between him and his wife, in their interests and concerns. He said that she was more
interested in the children than in him, and was a very practical person, which he had liked in
their earlier days, but which he had now less sympathy with. He had had good experiences in
therapy, particularly in psychodrama and primal integration, and felt he had gone a long way
in self discovery.
He had also had a bad experience with a guru of Indian extraction, who had impressed him
very much originally, to the extent of idealisation, but who had now been accused of sexual
and financial wrongdoing which had put the client off. However, he had been left with an
abiding interest in spiritual matters, and had read a good deal of Buddhist, Sufi and other
literature. He was also politically interested, and had been active in that field. His job was
changing, and he was less sure than before that he wanted to continue with it indefinitely.
He had already been through a good deal of therapy, and had become a whole person, who
could reconcile all these different pressures and opportunities, but now he felt that there was
somewhere further to go. I encouraged him to come into therapy, saying that it seemed as
though transpersonal therapy might be best for him. Using a good deal of guided fantasy and
spontaneous imagery, he moved quickly into the Subtle realm, and joined a Neopagan group,
which he attended for two years. During this time, he had some important mystical experi-
ences, such as being taken over by Pan, and being able to feel his furry haunches and sharp
horns. His dreams became very important to him, and at one point he had a vision of a new
business he could go into. This turned out to be much more fulfilling than his previous
employment: he was now his own boss.
He then felt ready to move on in his therapy from the Subtle to the Causal, and we had a
few sessions in which he was able to experience a shift in his consciousness. He then decided
to change from therapy into meditation, and joined a Buddhist group. We stayed in touch for
a few years, and it seemed as though he had found meditation very fulfilling.
4.2 The therapy

We made good eye contact at the beginning, and I found it easy to follow his movements. He
came across as quite heavy in his movements, only changing position at quite long intervals.

As the work went on, it became clear that we had a good alliance, which deepened as time
went on. We were really engaging in the dance of soul-making (Hillman, 1989). We also went
through some difficult times, which are well dealt with in the alchemical literature under the
heading of the nigredo, something not to be avoided, but to be taken into account as a perhaps
painful part of the process.

We agreed that we were not there to work on problems, but to explore his journey and his
positive concerns. As we went on talking, it became more and more obvious that he was quite
capable of sorting out his divorce and the pressures of his job. It was also clear that his
political awareness had advanced to the point where he could see how powerfully he had
been conditioned by his earlier life, and how he had taken for granted that a good job, good
money and a good marriage were the only real considerations. But now he was seeing that a
spiritual journey was well under way, and that he had achieved some gains along the way,
with more to come. It seemed that I could help him with this.

I asked him to do a life chart, showing his major journeys and discoveries, and this revealed
that he had always been interested in spiritual questions, even at school writing an essay on
Buddhism. It also revealed a liking for adventure: he had once spent a year sailing round the
Caribbean. I also asked him to do a psychosynthesis exercise, involving drawing pictures of:
(1) Where I come from; (2) Who I am; (3) Where I am going; (4) What gets in the way; and
(5) How I overcome it. This led to a very important insight, which proved to be useful again
and again.
Several times in the course of therapy I used chairwork to explore the inner conflicts
between his various I-positions (Rowan, 2010). This I found to be a very useful method,
because the client really entered into these encounters in a very vivid way, making full use
of the opportunities offered. On one occasion there was a real catharsis, which opened up an
important issue and helped to resolve it.
All the way through I was using imagery to help explore his experience. For example,
when he was referring to his wife, I asked him what animal she would look like when he first
knew her. It was a lovely white swan. I then asked him what the animal would be in his latest
experience of her. It was a fat rabbit. It has been said that a picture is worth a thousand words,
and I have found this to be true.
Later techniques involved him in taking up the identity of his Subtle self and starting to
see the world from that perspective – although this was done in quite a minimal way. Many
other techniques were made up on the spot, depending on the opportunities offered at certain
moments.
At a certain point he spoke about an encounter with a friend where he had broken through
into a new kind of relationship, which seemed more authentic than before. At this point I
spoke of the Albedo, and it seemed that this was a breakthrough.


The basic outcome was his emergence into the Subtle self as described by Wilber (2000).
Along with this came a much greater ability to see round a problem instead of meeting it head
on. He described this as a more female way of perceiving problems. He began to take respon-
sibility for his world, as if he had created it himself. After that we started to conduct a deeper
investigation into the Subtle stage of consciousness (Wilber, 2000), and he started to see
himself as a spiritual being. He was inspired, through a vision that he had one afternoon, to
start a new business. However, this was followed by a particularly painful session, where
some deeper material, not dealt with up to now, emerged with some force. This represented
the Coagulatio, a phase mentioned above, where we have to go back and pick up material not
fully dealt with in the previous work. This was dramatic and exciting, and I worried that it
might be too much for him, but he did come through it. In one session we said nothing, but
held each other’s hands and looked deeply into one another’s eyes, and this was one of our
most memorable sessions. After some further work it seemed that he might go on further
without me, into the realm of meditation and the Causal stage of consciousness. We parted
on good terms.
5.1 Developments
5.1.1 Brief therapy
I do not know anyone who has developed a brief form of transpersonal therapy. It seems to
me essentially a long-term task, because of the deep changes required.

Transpersonal therapy is particularly well suited to work in the field of diversity, because of
its open acceptance of the spiritual, which is so important in some cultures. Fukuyama and
Sevig (1999) have written well about this, and Maguire (2001) has written very movingly
about one particular aspect. She draws attention to the importance of metaphor in working
with clients from other cultures. Of course different cultures have different labels for the
levels of consciousness which we have outlined here. In Yoga, for example, what we have
called the Subtle corresponds quite well with what they call the Bhakti approach; while what
we have called the Causal corresponds well with what they call the Jnana approach. But
many other cultures recognise the levels which have been outlined here, and it just needs the
practitioner to use the language understood by the client.
Similarly, many cultures do not accept the individualism which is so characteristic of what we
have called the Centaur level of consciousness. They have a more communal view of self and
society. But this is highly compatible with the higher levels, of Subtle and Causal, which we have
concentrated on here. In fact, these ideas often came in the first case from Eastern cultures, which
are also compatible with Jewish culture as found, for example, in the Kabbalah.


Transpersonal therapy is only suitable for people who have reached a certain turning-
point in their lives, and these are a small minority. However, it does offer a critique of
the ordinary everyday way of thinking and being, which may be a challenge worth wres-
tling with, and may in fact open the eyes of people who desperately need to have their
eyes opened. It would be a bold person who could say with truth – ‘These ideas are
nothing to do with me.’
There is an issue which may arise when the practitioner gets into Subtle level thinking. One
may get very interested in shamanic practices such as soul retrieval or the use of power ani-
mals, or one may get interested in healing and the curandero tradition. But these are not
therapy. The important distinction to remember here is that in any therapy which goes beyond
the instrumental it is the client who does the work; the therapist is just an attendant who can
offer useful assistance, methods, encouragement and so forth. But in healing and similar
practices, it is the practitioner who does the work, and who holds the responsibility for the
success or otherwise of the treatment. One person I met solved this dilemma by having two
entrances to her therapy space, each with its own waiting room. But, however it is solved,
this is a real issue which may have to be faced.

The criticisms of the approach tend to come from people who do not know much about it,
and may indeed misunderstand it completely. The classic example of this is the book by
Ellis and Yeager (1989), which mixes up the transpersonal with fundamentalism and black
magic. One of the problems of our culture is the way in which it perpetually confuses the
spiritual with the religious, and some of the books in this field turn out to be written by those
with no awareness of the problems of homophobia and feminism so characteristic of reli-
gious approaches. These books tend to be very pushy in urging religious answers to spiritual
questions.
On the contrary, the transpersonal approach steers clear of religion, and is not guilty of
prejudices based on patriarchy. In fact the transpersonal approach is particularly good on the
issue of prejudice, because it is so critical of the everyday false assumptions that go with
first-tier thinking.
5.4 Controversies
There is a controversy within the transpersonal field as to whether we should think of mysti-
cal experiences as hierarchical in nature (thus the Subtle is regarded as a lower level than the
Causal) or whether they are equal (thus Bhakti Yoga is on a par with Jnana Yoga, rather than
prior to it). In practice, this makes very little difference to the therapy. So long as we agree
that there is a difference between the florid approach of the Subtle and the purist approach of

the Causal, it does not really matter how we name them. But it does help not to reject the
whole notion of a hierarchy, as many do at the Centaur and even at the Subtle level of
thought.
There is also a difference between the perennial philosophy approach of people like
Schuon, Guenon and Coomaraswamy, which is fixed and eternal, and the perennial philoso-
phy approach of people like Wilber and Cohen, which is evolutionary. I personally prefer the
evolutionary approach, simply because it is more open to evidential checking. Wilber (2000)
himself did an immensely impressive job in tabulating all the existing versions of the peren-
nial philosophy, and showing how closely they corresponded with one another, irrespective
of climate or century. In the practice of psychotherapy, it does not seem to matter very much
which version we take, in spite of the view of Ferrer (2002) that it matters very much. Of
course, Ferrer is not a therapist but more of an academic.
6 RESEARCH
In common with other long-term approaches, there is very little research that deals with
the whole process. The resources required make it quite prohibitive in terms of time and
finances. Of course, long-term research is possible. We may remember the two-year
research of Puschner, Kraft, Kachele and Kordy published in 2007, or the four-year
research of Blomberg, Lazar and Sandell published in 2001, but these are quite rare
examples.
However, there are some points that need to be made in relation to research in the transper-
sonal field. At the Subtle level we run into the problem of third tier thinking (Rowan, 2012).
In the history of research methodology, it has emerged that for doing research with human
beings, qualitative research is very much superior to quantitative research, because it puts the
researcher more on the same level at the other participants, and therefore more likely to be
trusted by them. But even within qualitative research there are two levels, which have been
called little q and Big Q. In little q research we avoid numerical calculation but still leave the
researcher in charge of the research to the exclusion of the other participants. In Big Q
research the researcher involves the other participants in a more or less equal fashion, such
that they get involved in the planning of the research and the eventual publication of the
results. In the transpersonal realm, we tend to prefer the Big Q approach, and researchers like
Braud and Anderson (1998), Bentz and Shapiro (1998) and Heron (1996) have shown exactly
how this works. For example,
Alzak Amlani extended these nonverbal additions further by attending to visual, auditory, and proprio-
ceptive images – and their emotional and intuitive meanings – that arose in him as he listened to each
taped interview while in a meditative state. After incubating those impressions for several weeks, he
recognised key archetypes associated with particular images and sensations. Connecting them with each
participant’s life story, Amlani found certain myths, stories, gods, and goddesses that mirrored the par-
ticipants and their inner processes. In addition to the rational thematic analyses, he developed cross-
cultural, mythic personifications for each participant. After returning these mythic descriptions to the

participants, Amlani reported that the participants found that the augmented descriptions rang true to
them and that they often added accurate information contained in the original transcripts. (Braud and
Anderson, 1998: 50–1)
More recently we have found that in researching the Subtle realm, we cannot ask the
question – ‘Is it true?’ Instead, we have to ask the question – ‘What effect did that have on
you?’ This is just the kind of limitation that irritates the conventional quantitative researcher,
particularly if they are of a scientistic bent. But it seems that we can still do research effec-
tively, even with this limitation. There is now a network of people around the world who are
prepared to listen to people experiencing spiritual emergencies, and the basic question they
always ask is – ‘What effect did that have on you?’ As time goes by, more and more of the
material collected in this way will be published, and this is to be welcomed. Of course we are
here well into the area of transpersonal therapy.
More radically still, we can use dialogical self research (Rowan, 2010) to explore even the
Causal and the Nondual levels of consciousness as and when they arise. This is a fascinating
and relatively recent form of research, which involves the researcher interviewing his or her
other levels of consciousness to find out what they have to offer. So the whole field of
research opens up and becomes fresh and new.
7 FURTHER READING
Cortright, B. (1997) Psychotherapy and Spirit. Albany: SUNY Press.

Matteson, D.R. (2008) Exploring the Spiritual: Paths for Counselors and Psychotherapists. Hove: Routledge.
Rowan, J. (2005) The Transpersonal: Spirituality in Psychotherapy and Counselling (2nd edn). Hove: Routledge.
Sperry, L. (2012) Spirituality in Clinical Practice: Theory and Practice of Spiritually Oriented Psychotherapy (2nd
edn). Hove: Routledge.
Wilber, K. (2000) Integral Psychology. Boston: Shambhala.
8 REFERENCES
Assagioli, R. (1975) Psychosynthesis. Wellingborough: Turnstone Press.

Barrett-Lennard, G.T. (1998) Carl Rogers’ Helping System: Journey and Substance. London: Sage, pp. 77–82.
Bentz, V.M. and Shapiro, J.J. (1998) Mindful Inquiry in Social Research. London: Sage.
Blomberg, J., Lazar, A., Sandell, R. (2001) Long-term outcome of long-term psychoanalytically oriented therapies:
first findings of the Stockholm outcome of psychotherapy and psychoanalysis study. Psychotherapy Research
11(4): 361–82.
Braud, W. and Anderson, R. (1998) Transpersonal Research Methods for the Social Sciences: Honoring Human
Experience. London: Sage.
Chaplin, J. (1999) Feminist Counselling in Action (2nd edn). London: Sage.
Clarkson, P. (1995) The Therapeutic Relationship. London: Whurr.
Ellis, A. and Yeager, R.J. (1989) Why Some Therapies Don’t Work. Buffalo: Prometheus Books.

Ferrer, J. (2002) Revisioning Transpersonal Theory. Albany: SUNY Press.

Fukuyama, M.A. and Sevig, T.D. (1999) Integrating Spirituality into Multicultural Counselling. London: Sage.
Goldberg, P. (1983) The Intuitive Edge Los Angeles: Tarcher.
Gordon-Brown, I. and Somers, B. (2008) The Raincloud of Knowable Things: A Practical Guide to Transpersonal
Psychology. Dorset: Archive Publishing.
Heron, J. (1996) Co-operative Inquiry: Research into the Human Condition. London: Sage.
Hillman, J. (1989) The Essential James Hillman (ed. T. Moore). London: Routledge.
Ingersoll, R.E. and Zeitler, D.M. (2010) Integral Psychotherapy. Albany: SUNY Press.
Ingram, B.L. (2006) Clinical Case Formulations: Matching the Integrative Treatment Plan to the Client. Hoboken:
John Wiley & Sons, Inc.
Jung, C.G. (2010) The Red Book (Liber Novus). London: W.W. Norton.
Maguire, K. (2001) Working with survivors of torture and extreme experiences. In S. King-Spooner and C. Newnes
(eds), Spirituality and Psychotherapy. Ross-on-Wye: PCCS Books.
Matteson, D.R. (2008) Exploring the Spiritual: Paths for Counselors and Psychotherapists. Hove: Routledge.
Meier, A. and Boivin, M. (2000) The achievement of greater selfhood: The application of theme-analysis to a case
study. Psychotherapy Research 10(1): 57–77.
Puschner, B., Kraft, S., Kachele, H., Kordy, H. (2007) Course of improvement over 2 years in psychoanalytic and
psychodynamic outpatient psychotherapy. Psychology and Psychotherapy: Theory, Research & Practice 80:
51–68.
Rowan, J. (1996) Developments in transpersonal psychotherapy. In W. Dryden (ed.) Developments in Psychotherapy:
Historical Perspectives. London: Sage.
Rowan, J. (2002) The three approaches to a therapeutic relationship: instrumental, authentic, transpersonal. BPS
Counselling Psychology Review 17(4): 3–10.
Rowan, J. (2005) The Transpersonal: Spirituality in Psychotherapy and Counselling (2nd edn). Hove: Routledge.
Rowan, J. (2010) Personification: Working with the Dialogical Self in Psychotherapy and Counselling. Hove:
Routledge.
Rowan, J. (2012) Third tier thinking and levels of consciousness. Integral Transpersonal Journal 3(3):10–18.
Stiles, W.B., Meshot, C.M., Anderson, T.M., Sloan, W.W. (1992) Assimilation of problematic experiences: The case
of John Jones. Psychotherapy Research 2: 81–101.
Wilber, K. (2000) Integral Psychology. Boulder: Shambhala.
Winnicott, D.W. (1971) Therapeutic Consultations in Child Psychiatry. London: Hogarth Press.

20
Integrative Therapy
Henry Hollanders
1 INTRODUCTION
By its very nature integration cannot stay still. To be true to itself it must go on integrating – it
cannot be pinned down! Within its sphere there is huge variety and each therapist, with each
client, will develop their own way of constructing therapy. It follows that the subject matter
of this chapter requires a different kind of treatment from those chapters that deal with spe-
cific ‘mainstream’ therapeutic approaches. It is for this reason the editors of this book have
granted liberty to digress from the structure laid down for other chapters. Nevertheless, I will
seek to follow that structure as closely as I can, and, in the process, point out where and why
it poses problems for someone who is an integrationist in the sense I am suggesting. Thus,
my intention in this chapter is to tentatively explore a philosophy of therapy that is quite dif-
ferent from that implied in structures most appropriate for ‘purist’ approaches. It is the need
for such a philosophy that the movement towards integration, at least in some of its forms,
attempts to address. First, however, I must try to define some terms used, often without expla-
nation or clarification, in the literature.
1.1 Definitions and expansions

Purism: Purist practitioners identify with only one particular approach. Thoroughgoing
purists believe all that is necessary and sufficient for therapy can be found within the
single approach they have adopted. That doesn’t mean, however, they will necessarily be

closed to processes of development and change that take place within their approach as
time passes. Nevertheless, any developments must be within the confines prescribed by
those considered to be the founders and current custodians of the approach. Purism is
sometimes (though not necessarily) associated with Schoolism, in which advocates of one
approach defend passionately the ‘truth’ of their own school and attack with equal passion
the ‘errors’ of rival schools.
Pluralism: The philosopher A.J. Ayer (1982: 13) describes pluralism as ‘denying that there
is a single world, which is waiting there to be captured, with a greater or lesser degree of
truth, by our narratives, our scientific theories or even our artistic representations’. From this
perspective ‘there are as many worlds as we are able to construct by the use of different sys-
tems of concepts, different standards of measurement, different forms of expression and
exemplification’. Nicholas Rescher (1993: 40–1) provides a more ‘flowery’ (literally!)
description:
It is clear (or should be) that there is no simple, unique, ideally adequate concept-framework for ‘describ-
ing the world’. The botanist, horticulturist, landscape gardener, farmer, and painter will operate from
diverse cognitive ‘points of view’ to describe one selfsame vegetable garden … Different perspectives are
possible, no one of them more adequate or more correct than any other independently of the aims and
purposes of their users.
Diverse perspectives, however, do not have to result in hostilities. Pluralism seeks to

hold unity and diversity in balance by recognising the possibility of a multitude of
‘world views’ operating within a field of interest, unified at some level, if only because
the occupants somehow find themselves rubbing shoulders with each other in spite of
having arrived there along very different routes! In practice, therapists with a pluralistic
philosophy may work within a preferred single approach, but will not hold it as the
exclusive truth. Rather, they will recognise other approaches as having genuine, even
equal, value, and ideally, will work closely with colleagues from different orientations
to whom they can refer when they consider particular clients will gain more benefit
from approaches other than their own. From a slightly different perspective, Cooper and
McLeod (2011; this volume, Chapter 21) have developed a framework for therapists
seeking to incorporate a range of possibilities into their practice on the basis of a ‘sus-
tained engagement with the client’s view of what will be helpful to them’. This will
inevitably require ‘the therapist to accommodate ideas and practices that are outside
their existing assumptions about therapeutic concepts and methods’. Although naming
this ‘Pluralistic Therapy’, they acknowledge it is really ‘an integrative approach that
seeks to build on the ideas of existing models of therapy integration’ (2011: 6). On this
basis we might think of it more as an integrative approach based on a pluralist philoso-
phy than as a ‘pluralistic therapy’ as such.
Eclecticism: The word ‘eclectic’ comes from a Greek word meaning ‘to select out’/‘to
choose’. Thus, eclectic practitioners select techniques from a number of different approaches
on the basis that it is possible to do so without subscribing to the underlying philosophy from
which they arose.

INTEGRATIVE THERAPY 521
Integration: Whereas eclecticism emphasises ‘selecting out’, integration emphasises ‘put-

ting together’. In today’s literature ‘integration’ is mostly used to refer to the integration of
theories as distinct from techniques. However, there is some evidence among practitioners
at grassroots level that the integrative ‘label’ is used simply to indicate an unwillingness to
be rigidly confined to one approach. In this respect the finer distinctions between ‘eclecti-
cism’ and ‘integration’ seem to carry little practical significance. Generally, therapists who
might have called themselves eclectic a decade ago are now just as likely to refer to them-
selves as integrative. This doesn’t indicate a change of practice, only a preference for what
might be considered a more therapeutically friendly term!
It is important to distinguish between ‘model’ and ‘process’ in relation to the term ‘integra-
tion’. ‘Integration’ sometimes refers to integrative models, and sometimes to the process that
can take place within any approach or model if the needful conditions are present. In recent
years a number of models purporting to be integrative have been constructed. Arguably, this
has contributed to the impression that the dynamic of effective integration can somehow be
achieved by creating new models. This, in turn, has compounded the very situation the inte-
gration movement was originally supposed to address, namely the chaotic proliferation of
therapeutic approaches. In contrast to this, the concept of integration as a dynamic process
that may go on within the ‘flow’ of any form of therapy, regardless of model, may help us to
avoid these pitfalls. I will return to this distinction later in this chapter.
One further use of the term ‘Integration’ should be noted. It may be used to refer to bring-
ing together different modalities or arenas, such as group and individual therapy; psycho-
therapy and psychopharmacology; spirituality and psychotherapy etc.
2 HISTORICAL CONTEXT AND DEVELOPMENT IN BRITAIN
What follows is a brief outline of the development of integration in psychotherapy since the
first half of the last century. I will attempt to identify some of the key figures and texts,
though publications are multiplying now so rapidly that I suspect I am bound to miss some
considered to be essential reading by other integrationists!
Integration in psychotherapy is not new. While the history of psychotherapy is dominated by
competing, even warring, schools, it is possible to trace a different strand of development within
that adversarial climate. As long ago as 1932, T.M. French drew the attention of the American
Psychiatric Association to the commonalities between Freudian psychoanalysis and Pavlovian
conditioning. This received a mixed, though mainly critical, reception and in the years that fol-
lowed eclecticism/integration failed to flourish openly. There is evidence, however, for the
existence of what has been called a ‘therapeutic underground’ consisting of practitioners who
identified publicly with a single orientation but who, in the privacy of their own studies and
consulting rooms, were open to influences from other approaches. Lone voices were raised
intermittently in favour of a more eclectic/integrative stance in the 1930s, ’40s and ’50s, but it
was only in the 1960s that a discernable movement towards eclecticism/integration began to
emerge and gather momentum. Jerome Frank published his important work Persuasion and

Healing in 1961 (Frank and Frank, 1993), in which he sought to distil the prime factors that
produce change in the lives of individuals, and in 1967 Arnold Lazarus first introduced the term
‘technical eclecticism’ to describe the concept of using techniques from a variety of approaches
without being bound by the philosophy that gave rise to them.
By the mid-1970s therapists were openly identifying themselves as eclectic in increasing
numbers. Surveys of American practitioners indicated that 55% of those surveyed were pre-
pared to adopt the ‘eclectic’ label to describe their orientation.
In 1975 Gerard Egan published the first edition of The Skilled Helper (Egan, 2010), setting
out an eclectic framework for a ‘problem management approach’ to the counselling process.
Egan began from an essentially humanistic position but subsequent revisions of his work
shifted progressively towards a more action-oriented form of helping. This has exerted a
major influence on counsellor training programmes in the UK. Another important contribu-
tion to the debate on integration was made by Paul Wachtel in 1977 with the publication of
Psychoanalysis and Behavior Therapy: Toward an Integration. Further reference to Wachtel’s
work will be made later in this chapter.
During the 1980s and 1990s practitioner surveys continued to indicate that the broad trend
towards eclecticism/integration was continuing. However, many of these were conducted in
America amongst clinical psychologists. From the few surveys conducted in the UK there
were some indications that British clinical psychologists were less likely to identify them-
selves as eclectic than their American counterparts (Norcross, Dryden and Brust, 1992).
However, one multi-level survey of British therapists from a range of traditions indicated
that at the level of the use of techniques virtually 95% of respondents revealed a tendency
towards eclecticism/integration (Hollanders and McLeod, 1999).
The formation of the Society for the Exploration of Psychotherapy Integration (SEPI) was a
major event in the development of a professional identity for integrative practitioners. The soci-
ety’s first newsletter appeared in 1983, and by 1991 there was sufficient growth in membership
to warrant publication of the first issue of the Journal of Integrative and Eclectic Psychotherapy
(later becoming the Journal of Psychotherapy Integration). In 1989, SEPI’s membership was
listed as 394, with 348 in the USA and 46 in the rest of the world spread over 17 countries. By
2012 the overall membership had grown to 759, with 18 members in UK.
Publications on eclecticism/integration increased dramatically in the 1990s, and have con-
tinued to appear regularly in the first part of this century.
Training courses in various forms of integrative therapy have also continued to grow in the
UK. Of the 80 accredited courses listed by the British Association for Counselling and
Psychotherapy (BACP) in 2012, 15 (18.75%) are described as psychodynamic, 28 (35%) as
humanistic and 30 (37.5%) as integrative, with 7 (8.75%) as ‘Others’.
‘Integration’ covers a wide range of perspectives, making it impossible to present a unified

set of theoretical assumptions in a way that may be possible for ‘purist’ approaches.

Nevertheless, we can take a step back to another level of abstraction by examining three main
areas: Philosophical Strands underpinning the integration movement; Routes taken towards
Integration, and Levels at which integration may take place.
3.1 Philosophical strands

Two very different philosophical strands can be identified.
3.1.1 Modernist/positivist
On the basis that over the past decades of therapeutic activity no single approach has man-
aged to distinguish itself overall as better than any other, some integrationists consider
integration to have the potential to produce a superior, research based therapeutic system
that could eventually unify the field of psychotherapy. This single system, once achieved,
will clearly define what constitutes psychotherapy, and enable therapists to demonstrate
to allied professions, and to the world at large, what psychotherapy is about. Such a sys-
tem is likely to contain an integrated understanding of what it means to be a person, what
goes wrong, and how it can be rectified. It is, therefore, likely to be able to conform to the
structure suggested for the chapters in a book of this kind (except that one consequence
of the discovery of such an approach would be that only one chapter would be needed!).
Because, from this perspective, integration represents a search for ultimate psychothera-
peutic ‘truth’ – a quest to find a therapeutic ‘whole’ that will have greater correspondence
to ‘reality’ than any single ‘part’ that currently exists – we might think of it as the modern-
ist or positivist philosophical strand.
3.1.2 Post-modern/constructionist philosophical strand

Other integrationists, however, are moving in a very different direction. These also accept
that no single approach has proven itself to be more effective than any other, but they draw
very different conclusions from this. They believe this should lead us, not to search more
intensely for the single approach, but rather to give up the search altogether and accept that
the world in general, and the world of therapy in particular, can be (and should be) con-
structed in many different ways. From this perspective, there is no absolute ‘truth’ about
anything, least of all about what it means to be a fully functioning human being – there are
only perceptions, ways of seeing, constructions.
Moreover, every construction is made under philosophical, social, cultural, economic
and political influences. Even what some might like to think of as ‘objective scientific
truths’ are subject to the same non-scientific influences and, therefore, should also be
considered to be a particular set of constructions. Thus the quest for the single ‘true’ sys-
tem of therapy is considered to be a mistaken, even a nonsensical, endeavour. At certain
moments in the changing movements of cultures, societies and communities, we are faced
with the challenge to revisit, deconstruct and reconstruct our theories. Failure to respond
to this challenge will leave us stranded with approaches that are no longer relevant to the

world in which we live. This process, however, is not to be seen as a linear advancement
towards the goal of a grand theory of everything therapeutic. Rather it is an attempt to
ensure that as the world goes around, our theories and our practices will go around with
it, so that at any given point in time, we are able to speak with a voice that really does
resonate with men and women where they actually are. For those who think in this way,
integration is about welcoming the rich diversity in our field. They want to engage with a
multiplicity of concepts of the self, health, pathology and therapy, and to find imaginative
ways of using as many different constructions as possible, without succumbing to the illu-
sion that any of them constitutes ‘the truth’ for all people, for all time. Particular construc-
tions will depend largely on:
(a) Individual client variables – life experience and personality variables; the nature of the difficulties; the
way the story is presented and where the client positions herself, explicitly or implicitly, philosophically,
culturally, socially, economically and spiritually.
(b) Individual therapist variables – life and therapeutic experience and competencies; preferred
approach, and, crucially from an integrative perspective, an openness to a variety of ways of seeing
the world.
(c) relationship variables – how the client/therapist relationship develops, and how its meaning is con-
structed individually and together.
This philosophical strand might be thought of as the post-modern or constructionist version

of integration (Hollanders, 2003).
4 ROUTES TOWARDS INTEGRATION
As well as the two broad philosophical strands indicated above, we can identify at least four
routes along which attempts at integration are moving.
4.1 Technical or systematic eclecticism

‘Technical eclecticism’ is a major route towards integration today. As we noted earlier, ‘eclec-
tic’ refers to those who ‘select out’ from a range of approaches whatever seems to be useful
for their purpose. ‘Technical’ here refers to techniques, skills and strategies, as distinct from
theories. To be able to use a technique well it is not necessary to subscribe to the theory or
approach in which it was first developed, since, generally, techniques have transferable
potential and can be utilised in a variety of ways depending on the purpose, imagination and
creativity of those using them. For example, the two-chair technique, originating in gestalt to
be used as a way of facilitating an intrapersonal dialogue between polarities within the self,
may also be utilised in behaviour therapy to rehearse an interpersonal dialogue (e.g. between
employer/employee) to be used in vivo.

However, we must make a clear distinction between what has been called ‘haphazard
eclecticism’ on one hand, and ‘systematic eclecticism’ on the other (Dryden, 1984: 351). In
the former, techniques are grabbed at and used willy-nilly without any comprehensible
rationale, whereas, in the latter, practitioners follow a procedure of some kind for making
systematic interventions that enable them to work consistently over time. Some adopt an
eclectic framework, enabling them to make systematic use of a variety of techniques by
matching them with different stages in the therapeutic process (e.g. Egan, 2010), or with dif-
ferent aspects of the unfolding therapeutic relationship (e.g. Clarkson, 2003).
4.2 Theoretical integration

A second major pathway towards integration is what is now generally referred to as ‘Theoretical
Integration’. Those following this route focus attention primarily on theories rather than tech-
niques, since they are not content simply to make use of techniques regardless of their theo-
retical underpinnings. In particular, they are seeking to discover the points at which different
therapeutic theories converge, with the ultimate intention of melding them into a single theo-
retical orientation that will be more meaningfully comprehensive than the various parts that
make it up. They believe that if the theoretical foundations are ‘right’, then consistent and well-
grounded techniques can be safely built on them, thus creating an integrated ‘whole’ system of
therapy. This is no mean task, since, on the surface at least, and, in some cases, far below the
surface, many therapeutic theories seem to be in direct conflict with each other.
If integration is to be achieved at this level it is likely to involve a considerable reframing of
the theories being integrated, together with the development of a therapeutic language not tied
too closely to any of the pre-existing theories. Examples of British approaches that have come
out of this kind of integration are Robert Hobson’s ‘Conversational Therapy’, now renamed
‘Psychodynamic Interpersonal Therapy’, and Anthony Ryle’s ‘Cognitive Analytic Therapy’.
4.3 Common factors

The third main route towards integration is usually referred to as the ‘Common Factors
Approach’. Common factors integrationists draw our attention to those non-specific (or
extratherapeutic) aspects of psychotherapy that seem to be effective across all approaches.
Based on 100 research studies, Lambert and Barley estimated that the factors contributing to
positive change in psychotherapy are:
Extratherapeutic factors 40%

Common factors 30%
Techniques 15%
Expectancy/placebo effect 15%

Since only techniques can be reasonably considered to be identified with specific

approaches, it follows that 85% of positive outcome is attributed to factors common to all
psychotherapeutic endeavours. However, although Lambert and Barley describe their esti-
mate as ‘painstakingly derived’ (2002: 18), they acknowledge that no statistical procedures
were used in their formulation and that the estimate may be considered to be somewhat
‘crude’. Noting this proviso, Wampold produced ‘a more scientifically derived’ (2001:
206) estimate of Lambert and Barley’s allocations, and came to the conclusion that
approach-specific factors account for, at most, only 8% of positive outcome. More recently,
however, Norcross and Lambert (2011) have revised the earlier estimates, introducing fur-
ther refinements into the picture and suggesting that a more balanced view would look
something like:
Patient contribution 30%

Therapy relationship 12%
Treatment method 8%
Individual therapist 7%
Other factors 3%
Unexplained variance 40%
Whatever way we look at it, it is clear that effective therapeutic factors are to be found, not
so much in the distinctive characteristics that mark out the divisions between the orientations,
as in those less obvious ‘non-specific’ things they have in common. Of course, by their very
nature, ‘non-specifics’ occur differently in different therapy encounters and cannot be
prescribed or built concretely into a specific model. Moreover, many non-specific factors
operate entirely outside the therapy session. Deeply significant events (e.g. a loss; a new
relationship etc.) can occur in clients’ lives outside therapy, having profound effects both on
them and on the course the therapy takes. Although such events can be incorporated into the
therapeutic process, it is obviously not within the power of the therapist to reproduce them
as part of a therapeutic approach. There are also ‘unscheduled’ and unexpectedly influential
events that occur from time to time within the therapy session itself. One example of this was
recounted by a prominent psychoanalyst at a seminar I attended some years ago. On entering
the therapy room, a client tripped and fell. The analyst jumped up immediately and gently
helped the woman to her feet, exclaiming, ‘Oh my dear, I’m so sorry!’ On completion of the
analysis, the client reported this moment of spontaneous human contact to be one of the most
significant elements in the therapy, enabling her to see both the therapist and the therapy in
a new light.
Apart from these occasional unplanned personal events occurring both outside and inside
the therapy room, there are other non approach-specific factors common to all the ‘talking
therapies’, and it is these that are of particular interest to Common Factors integrationists. If
these factors can be made explicit, it may be possible to develop them into a new approach,

or, more importantly, to utilise them more effectively within existing approaches. An example
of this is the work of Miller, Duncan and Hubble (1997), who suggest there are four common
curative elements central to all forms of therapy:
1. extra-therapeutic factors – non approach-specific factors coming chiefly from the positive contribution of
the client, which is so often discounted by therapists (see also Cooper and McLeod, 2011, and Chapter 21,
this volume);
2. therapy relationship factors – the therapist and client together;
3. model and technique factors – on the somewhat humbling basis that something has to be done in ther-
apy, mainly for the crucial purpose of…
4. generation of belief, expectancy and hope – referred to as the placebo effect.
They suggest these four elements can form a unifying basis for psychotherapy practice, since,
irrespective of the personal orientation of therapists, they can be put together in different
ways, by different therapists working collaboratively with different clients.
Related to this line of thinking, but taking it some steps further, Wampold (2001), building
on the work of Frank and Frank (1993), considers the main effects of psychotherapy to reside
in ‘the healing context’. This consists of:
1. a believable rationale for the therapy;

2. therapeutic ‘actions’ delivered by the therapist that are consistent with the rationale;
3. emotional arousal, belief and expectation of improvement engendered in the client;
4. a developing therapeutic relationship.
From this perspective, it is primarily belief in the therapy that matters. A convincing
rationale is needed, but unless there is a real belief in both the therapy and the therapist,
therapy that is actually therapeutic will not take place. We might think of techniques,
therefore, as secondary rather than primary players in the therapeutic process. That is,
they do not contain effective ingredients within themselves in the way medication might,
but rather are effective only in as much as positive meaning is attributed to them, and
belief and expectancy are engendered through the whole healing context in which they are
practised.
4.4 A home of your own: assimilative and accommodative integration

A fourth route to integration could be described as having a ‘Home of Your Own’. There
is evidence to suggest that a large proportion of integrative therapists in the UK adopt a
mainstream label (humanistic, psychodynamic, cognitive-behavioural etc.) whilst at the
same time practising integratively or eclectically (Hollanders and McLeod, 1999). The
mainstream orientation is essentially a place to work from, providing a kind of theoreti-
cally secure base, while, at the same time, maintaining the possibility of building into it
whatever seems appropriate for each client. In this way therapists can enjoy the benefits

of identifying with a particular therapeutic community whose language they speak and
understand, whilst retaining the liberty to create different ways of working that fit with
the needs of individual clients.
This process of building integratively into a mainstream base may be ‘assimilative’ or
‘accommodative’ – or both. ‘Assimilative integration’ places the emphasis on adapting the
elements incorporated into the mainstream home base approach, making them fit more read-
ily. ‘Accommodative integration’ leaves open the possibility of making changes in the home
base itself in order to accommodate some intervention in its almost ‘pristine’ form, recognis-
ing that it has something important to add to the existing make-up of the base. It is likely that,
in practice, most integrationists will both assimilate and accommodate as they go on develop-
ing their own approach to therapy.
5 LEVELS OF INTEGRATION
As well as philosophical strands and different routes towards integration we can identify at
least three levels at which integration may take place.
5.1 Formal construction

At this level, integration is thought of as a model to be constructed, tested and validated to
some degree. As a model, it can be published, introduced into training programmes, and be
progressively adapted to meet the needs of individual clients. Understood in this way, inte-
grative models are particular representations of integration and, as such, vie for a place
alongside other models on an ever-growing list of therapies. Interestingly, a recent analysis
(2012, unpublished) of a randomised sample of 264 therapist entries on the BACP website,
yielded the following results:
047 (18%) indicated using a single approach;

061 (23%) indicated using multiple approaches without identifying themselves as integrative;
156 (59%) identified themselves as integrative;
001 (0.3%) indicated the use of a recognisable integrative model.
Clearly the sample is too small to generalise, but we can see that while 82% of these thera-
pists describe themselves as working in an integrative/multi-approach way, only 0.3%
(N=264) indicate the use of a specific model of integration.
Based on available research rather than theoretical conjecture, some integrative models
have been constructed to target particular problems/disorders (e.g. eating disorders, depres-
sion, dependency problems etc.). This may prove to be a more therapeutically productive way
ahead for those integrationists working at this level.

5.2 A working process of collaboration

At this level integration is seen as a creative process that goes on in the flow of therapy
regardless of any particular model adopted by the therapist. Although therapy may begin
with procedures suggested by the approach favoured by the therapist, the integrative
process emerges progressively out of the developing ‘subject-to-subject’ interaction. The
integrative construction of the therapy is to be worked on and fashioned by both therapist
and client together as co-workers. The process here is essentially an associative activity.
As the client’s narrative unfolds, associations are made by each of the co-workers and
allowed to interact in a process of coming together, diverging, conflicting at times, and,
bit by bit, coalescing into a picture, a story or a shared silence of mutually felt meaning,
carrying the therapy forward, sometimes in hard-earned steps, sometimes in surprising
leaps.
For therapists to be able to facilitate and engage with integration as a creative process of
association in this way, it is essential for them to be integrative in their experience of life as
well as in their work (see below). By broadening and deepening their own associative field,
they develop within themselves a rich reservoir of experience from which associations to
their clients’ experience can emerge, be ‘translated’ into the language of the relationship, and
crafted into therapeutic interventions.
Because this process is bound to be different from client to client and therapist to therapist,
it is not possible to solidify it into a transferable model of ‘set’ practice, except in terms so
broad as to make it a virtually meaningless exercise.
5.3 An experiential ‘happening’

We may think of this as the deepest and most profound level of integration. It is a particular
micro-process within the working process of collaboration described above. As the subject-
to-subject interactions deepen, associations from both client and therapist in the form of
thoughts, words, images, concepts etc. may come together simultaneously in an extraordinary
way to create a deeply significant insight, usually with the felt qualities of ‘suddenness’ and
‘givenness’. Such ‘happenings’ cannot be commanded, manufactured or manipulated into
existence.
Much ‘ordinary’ therapeutic work may have to be done before it happens, but if/when it
happens it has the potential to transform the therapy, the client and the therapist alike. Of
course, this kind of ‘happening’ may take place in any form of therapy in which client and
therapist are deeply engaged. It is integrative, however, to the extent to which the therapist is
open to, and ready to make use of, associations and influences as they make themselves avail-
able to her from the range of sources ‘collected’ consciously and unconsciously in the course
of her life and work – regardless of whether or not they fit into a ‘pure-form’ model of
therapy. Indeed, an attitude of rigid adherence to a model is not conducive to the kind of
openness required to be able to recognise and respond to such integrative moments as they
present themselves.

6 PRACTICE
So far we have been mainly considering in broad strokes the philosophy of integration and the
theories built on it, and our discussion has been somewhat academic. We turn now to matters
of practice. Because integration presents us with such diverse possibilities, it is extremely dif-
ficult to create a sense of coherence when seeking to describe within limited space what it
means to practise integratively. Two dangers are to be avoided. The first is that of retreat!
Facing so many possibilities, such a profusion of choices, it may seem advisable to retreat to
the comparative comfort and security of a clearly defined model with a set of ‘authorised’,
even manualised, procedures. To do so may indeed afford the therapist some comfort, but at
the cost of losing the enormous potential integration has to offer to the client.
The second danger is the reverse. Rather than a call to retreat, integration may seem to be
a call to charge ahead, away from the domains of established approaches and into the
unknown, without any discernable rationale or direction. A clear distinction needs to be
drawn between genuine integrative therapists and impetuous practitioners who rush thought-
lessly after the latest therapeutic gimmick. Integration is a serious undertaking and, for genu-
ine integrationists, it is primarily a perspective on life. Indeed, it is only in as much as it is a
pervasive ‘way of being’ that it can flow into the process of integration in therapy. With this
in mind we now come to the some broad aspects of practice.
7 GOALS OF THERAPY
It is impossible to identify an over-all set of integrative therapy goals. That doesn’t mean that
individual integrative therapists are without any sense of direction – only that we cannot
generalise to all integrationists within the confines of this chapter. Nevertheless, there are
certain principles that can be enunciated here, which, though broadly relevant to all therapeu-
tic approaches, have particular application to integration.
1. Neither the goal nor the construction of the therapy should be pre-determined, but should emerge out of
a process of collaboration between each individual client and therapist. The concept of integration is
entirely suited to this, since it will clearly open up more possibilities, and be a richer process, if what both
therapist and client have to bring to the collaboration is allowed, appropriately, to take the therapy
beyond the confines of a single approach.
2. There must be flexibility for reformulating goals and reconstructing the therapy. Goals identified early in
the process are likely to need some reformulation as the therapy progresses and, consequently, some
reconstruction of the therapy may be called for. A therapist with a rigid model mindset may resist ‘hearing’
the need for such shifts of direction, especially if not explicitly articulated by the client. Where this is so,
perhaps the best on offer amounts to little more than a rehash of what has already taken place, rather
than any really meaningful reconstruction.
3. If the goals and the construction of therapy are to emerge out of an on-going collaborative process, the
relationship between client and therapist must be authentic (i.e. not contrived or postured). Imbalances
in the therapeutic relationship are unavoidable, but the more they tilt towards the therapist, the less likely

real collaboration will take place. If a client feels either obliged to go along with the therapist, or com-
pelled reactively to resist the therapist’s ‘authority’, it is unlikely that any goal formulation or therapy
construction will emerge with the kind of emotional resonance needed for the client to be able to identify
with it as truly her own. No doubt therapists from most orientations would recognise this principle.
Nevertheless, it is most applicable to integrative therapists who do not look in the direction of a ‘tight’
model for guidance. For them the client–therapist relationship is considered to be a kind of ‘living, in-
session guide’ to the way the therapy is developing and the direction it needs to take – even if that means
moving beyond the clearly defined parameters of a single approach.
8 SELECTION CRITERIA
Again, we cannot identify a single set of selection criteria used by all integrative practition-
ers. The decision on whether this therapist can usefully work with this client will be deter-
mined by a complex combination of influences. If the therapist is working integratively by
building on the base of a preferred mainstream approach, the criteria applicable to that
approach will be a dominant influence. However, where integration is considered to be
largely process oriented, the broad selection criteria should be related to: this individual
therapist’s sense of competency in relation to this individual client; the perceived potential
and willingness of this client to be open to the therapy offered by this therapist; and the abil-
ity of both this therapist and this client to engage in a therapeutic relationship within any
constraints placed upon them by setting and circumstances.
Having said that, however, we must recognise that, in practice, these things can only be
estimated over a period of time and often only emerge within the process of therapy itself,
which makes the notion of ‘selection’ criteria somewhat problematic. Moreover, in the reality
of today’s world, many therapists work in far from ideal institutional settings in which genuine
assessment and selection are often little more than theoretical possibilities to which lip service
is paid. In such situations there is very considerable pressure on therapists to agree to seek to
be of some help, in whatever way possible, to clients who are allocated to them.
9 QUALITIES OF EFFECTIVE THERAPISTS
In a study of psychotherapists’ development conducted by Orlinsky and Ronnestad, those psycho-

therapists who experienced themselves predominantly as being able to enter into an effective ‘heal-
ing involvement’ with their clients were: ‘personally committed and affirming’ in relating to clients;
able to engage ‘at a high level of basic empathic and communication skills’; were ‘conscious of
Flow-type feelings during sessions’; had ‘a sense of efficacy in general’, and were able to deal
‘constructively with difficulties encountered if problems in treatment arose’ (2005: 162).
Over the past six decades research has repeatedly shown that the conditions set out by Carl
Rogers as long ago as the 1950s, still hold good as enduring qualities of effective therapists
(Norcross and Wampold, 2011). Of course, these apply to integrationists as much as to all others.

My intention here, however, is to focus on what might be considered to be the more distinctive
qualities of effective integrative therapists. In addressing this question I want to reiterate a distinc-
tion I made earlier between integration as a way of being, and integration as a therapeutic activity.
I do not wish to create a false dichotomy between the two, but rather to suggest that ability to ‘do
integration’ effectively in therapy will be closely related to ‘being integrative’ throughout life.
Indeed, I consider that ‘doing’ will flow progressively out of ‘being’. The more naturally
we can be integrative in our whole approach to life, the more those with whom we share a
relationship, therapeutic or otherwise, will experience us as being able to embrace possibili-
ties and make use of opportunities. If we can truly be integrative through and through, the
whole process of our practice will be freer, less anxiously restrictive and more open to new,
and, perhaps, surprising insights.
10 WHAT THEN, DOES IT MEAN TO BE INTEGRATIVE?
10.1 Being integrative goes hand in hand with a philosophy of life and work that is
truly pluralistic in its vision
This means having an approach to life that is very different from that characterised by what
is sometimes referred to as ‘thinking in binary oppositions’. Binary thinking sees the world
in clear cut categories – ‘good’ versus ‘bad’; ‘right’ versus ‘wrong’; ‘truth’ versus ‘error’;
‘for us’ or ‘against us’ etc. It is this kind of thinking that characterised the schoolistic atti-
tudes that so bedevilled psychotherapy in earlier decades, and is still evident in some circles
today. In contrast to this, the integrationist has the kind of vision Zohar and Marshall describe
as characteristic of a ‘Quantum Society’:
It (the Quantum society) must be plural. The old vision of one truth, one expression of reality, one best
way of doing things, the either/or of absolute, unambiguous choice, must give way to a more pluralistic
vision that can accommodate the multiplicities and diversities of our new experience. Learning to live with
many points of view, many different ways of experiencing reality, is perhaps the greatest challenge of the
new, complex society in which we find ourselves. (1993: 9)
This is the kind of ‘worldview’ integrative therapists are likely to have adopted. They may
have done so deliberately by design, or because it has crept up on them somehow, bit by bit,
during long hours of work with a great diversity of clients. Perhaps, for most integrationists,
it has been some of both.
10.2 Being Integrative means being committed to the whole project of

therapy, rather than to a particular approach
James Prochaska suggests the process of maturing psychotherapeutic development runs
through four primary stages: ‘Dualistic’ (‘I’m right you’re wrong!’); ‘Multiplistic’ (‘We all

have some of the truth, but I have more than you!’); ‘Relativistic’ (‘We all hold different
aspects of the truth equally’), and, finally, ‘Committed’ (‘There is no absolute ‘truth’, and
since none of us really know, let’s commit ourselves to working together’). Clearly, in this
view, the committed practitioner is not holding tenaciously to a single approach with an ‘I’m
right and you’re wrong’ attitude, but, rather, accepts with genuine humility the validity of
different systems. Mature commitment here is not to a narrow school but to the whole project
of therapy. In line with this attitude, Prochaska goes on to suggest that the central concerns
of committed practitioners are:
what is the best way to be in therapy; what is the most valuable model we can provide for our clients,
our colleagues, and our students, and how we can help our clients attain a better life. (Prochaska,
1984: 367)
There is a sense in which purist practitioners have settled these issues in advance, since they
are committed to a particular set of theories and to a broadly predetermined way of working.
The integrationist, however, considers these concerns must be addressed anew, again and
again, with each client, in every session, without anticipating the answers and without resort-
ing to stereotypical, theory dominated, responses.
10.3 Being integrative means having an expansive vision of life and work
As a lifelong project the integrationist will seek insights into what it means to be an
authentic human being wherever they may be found. They will consider themselves free
to carry their search into any field of life. The worlds of science and art, of philosophy
and mythology, of literature and linguistics, of anthropology and theology – all the
‘worlds’ in all the world – will be legitimate spheres of interest for integrationists. Of
course, they will not expect to be able to explore them all in a single lifetime, but will take
the liberty of choice to venture where they will, refusing to be prohibited from any area
of potential interest because it does not accord with a particular theoretical stance.
Moreover, and most importantly for the therapeutic process of integration, they will be
prepared to make appropriate use of whatever insight they gain from any field of interest
if it can be of help to others.
10.4 Being integrative means being open to experience in both

breadth and depth
Vision must lead to venture, and fundamental to both vision and venture, if they are to be
truly useful, is a readiness to be open to experience. While this must surely be true of all
therapists for the purpose of their own personal development, integrative therapists allow
themselves to make creative use of their experience in their therapeutic practice in a way that
will not be determined by one particular theoretical approach. In his book Forms of Feeling

(1985) Robert Hobson applies what the poet Rilke had to say about the place of experience
in the creation of a verse of poetry, to the experience of the psychotherapist in ‘creating’ a
genuinely therapeutic intervention:
verses … are experiences. In order to write a single verse, one must see many cities, and men and things;
one must get to know animals and the flight of birds, and the gestures that the little flowers make when
they open out to the morning. One must be able to return in thought to roads in unknown regions, to
unexpected encounters, and to partings that had long been foreseen; to days of childhood that are still
indistinct, and to parents whom one had to hurt when they sought to give some pleasure which one did
not understand…. There must be memories of many nights of love, each one unlike the others, of the
screams of women in labour, and of women in childbed, light and blanched and sleeping, shutting them-
selves in. But one must also have been beside the dying, must have sat beside the dead in a room with
open windows and fitful noises. And still it is not yet enough to have memories. One must be able to
forget them when they are many and one must have the immense patience to wait until they come again.
For the memories themselves are not yet experiences. Only when they have turned to blood within us, to
glance and gesture, nameless and no longer to be distinguished from ourselves – only then can it happen
that in a most rare hour the first word of a poem arises in their midst and goes forth from them. (Rilke,
in Hobson, 1985: 36)
This is itself a piece of poetic writing, but it conveys well the central place of real experience
in the development of the therapist as well as the poet. This kind of experience, to be true to
itself, will find expression in many forms and will not fit easily into the confines of narrowly
defined theories. There is a world of difference between a response that is a type of formulaic
pronouncement determined by a manualised model, and that which comes from the kind of
experience that has ‘turned to blood within us’.
10.5 Being integrative means not avoiding anxiety about

the unknown by remaining defensively within the security of the
supposedly known
This is so of both life and work. From a therapeutic perspective this has been well expressed
by both Yalom and Saffron and Muran:
the capacity to tolerate uncertainty is a prerequisite of the profession. Though the public may believe that
therapists guide patients systematically and sure-handedly through predictable stages of therapy to a
foreknown goal, such is rarely the case: instead … therapists frequently wobble, improvise, and grope for
direction. The powerful temptation to achieve certainty through embracing an ideological school and a
tight therapeutic system is treacherous: such belief may block the uncertain and spontaneous encounter
necessary for effective therapy. (Yalom, 1991: 13)
Therapy is an ongoing flow of moments that are woven together through a process of construction….
It is important to remember that new information and new possibilities are constantly emerging in
every moment of interaction with the patient. The therapist who is able to let go of his or her current
understanding of what is happening in order to see what is emerging in the moment will have more
flexibility and adaptability to the situation than the therapist who cannot do so … it can be very
anxiety-provoking to do psychotherapy without the solid ground provided by the concepts one normally

uses to impose order on what is going on…. As therapists, we must constantly struggle with the
temptation to hold on to fixed conceptions of what is taking place between us and our patients.
(Saffron and Muran, 2000: 37)
Doubtless, being integrative means much more than there is space to explore in this chapter,
but two further aspects call for brief mention: engagement with the process of inner integra-
tion, and some concept of the transcendent dimension of human experience. The former may
come through a multiplicity of channels, including experiencing a variety of different thera-
pies as a client. The latter may lead us into the more controversial realm of the place of
religion and spirituality in counselling and psychotherapy. All that can be said here is that so
much human experience in every age has been expressed in terms related to transcendence
and immanence (a sense of ‘beyond’ and ‘within’ at the same time), that a failure to explore
it in ourselves might truncate our experience of what it means to be human, and limit our
usefulness when working with clients for whom such constructs are an important aspect of
their lives.
11 THERAPEUTIC RELATIONSHIP AND STYLE
The therapeutic relationship has become an important focus for therapists from different
schools. However, its acknowledged place differs from orientation to orientation. For
psychodynamic and humanistic orientations, the relationship has a central place as the
essential ‘vehicle’ of therapy. In contrast to this, the behavioural and cognitive orienta-
tions think of the relationship as significant in as much as it facilitates a more effective
application of the techniques and strategies that really constitute the ‘active ingredient’ in
the therapy.
From an integrative perspective, Clarkson (2003) suggests that some level of integration
can be achieved through the recognition that the process of psychotherapy involves a multi-
plicity of relationships, including the working alliance, the transference/counter-transference
relationship, the developmentally needed relationship, the person-to-person real relationship,
and the transpersonal relationship. As therapy proceeds, at any given point, one or other of
these will take precedence. It is fundamentally important that the therapist should be ‘rela-
tionally tuned’ to the client and be able to discern what is needed, when it is needed, and how
to make what is needed available to the client when moving across these different modes of
relating.
Taking it from a slightly different perspective, Kahn (1997) seeks to bring together insights
from humanistic, psychodynamic (object relations), and self-psychology sources. Whereas
Clarkson sees a multiplicity of relationships, Kahn sees the therapeutic relationship as singu-
lar, all of one piece, though having different facets to it. He invites us to imagine ourselves
as having successfully integrated the work of Freud, Rogers, Gill and Kohut, and seeks to
draw out those elements of the relationship that make for effective therapy. From this we can
see that, for Kahn, the therapeutic relationship is one in which the therapist is truly present

and actively involved with the client. The ‘core conditions’ of genuineness, empathy (with a
Kohutian flavour) and unconditional acceptance are central, together with spontaneity and
non-defensiveness. However, a genuine and empathic relationship does not preclude the
development of transference and counter-transference. These play an important part in the
therapy, casting light on the client’s developmental pathways, to be interpreted as seems
appropriate throughout the therapy.
Although both Clarkson and Kahn are seeking to provide an integrative perspective on
the therapeutic relationship, it is clear that they are primarily interested in combining
humanistic/existential and psychodynamic/psychoanalytic elements, without much refer-
ence to the kind of relationship likely to be fostered in technique oriented cognitive
behavioural approaches. This third element of the therapeutic relationship has been
addressed by Wachtel (2005) who, as a psychoanalytical therapist, started to study behav-
iour therapy in order to demonstrate its therapeutic inadequacies. Contrary to his expecta-
tions, however, he began to discover there was more to it than he had been prepared to
admit, and the eventual outcome was the publication in 1977 of the widely acclaimed
Psychoanalysis and Behaviour Therapy. Wachtel retains an emphasis on unconscious
processes, transference, countertransference, and the place of the therapeutic relationship
in providing a corrective emotional experience. In the earlier stages of therapy what is
likely to be most needed is a therapeutic relationship in which the therapist facilitates the
sometimes powerful and painful expression of previously warded off emotions in a recep-
tive and even welcoming way.
However, it also needs to be recognised that the response of the therapist in the session
is not necessarily going to be reproduced in other relationships in ‘real life’ outside,
especially when the changes taking place in the client are not understood or accepted by
significant people in her life. As therapy progresses the client may need help from the
therapist in making appropriate ‘translations’ of experience with the therapist in the ses-
sion, into the experience of life and relationships outside. The therapist will need to be
able gradually to introduce into the relationship more openness about her own reactions,
be ready to give feedback, and even actively assist in the rehearsal of appropriate verbal
and behavioural responses.
To gain a more research related perspective on the therapeutic relationship, the American
Psychological Association (APA) set up a task force in 1999, to review the research evidence
on ‘empirically supported therapy relationships’. The report, entitled ‘Psychotherapy
Relationships that Work’, was completed and presented in 2002, and subsequently updated
in 2011 (Norcross, 2002). In summary, the report graded a number of ‘relationship elements’
into three categories on the basis of the extensive research reviewed. These are:
Demonstrably effective elements: alliance; empathy; collecting client feedback;

Probably effective elements: goal consensus; collaboration; positive regard;
Promising but insufficient research to judge: congruence/genuineness; repairing alliance rupture; managing
countertransference.

None of this will surprise mature therapists from all orientations, including integrationists,
whose own therapeutic experience has led them to value each of these elements regardless
of the grading allocated to them here. Based on its findings the report goes on to make some
‘practice recommendations’ that will be of particular interest to integrationists:
• ‘Practitioners are encouraged to adapt or tailor psychotherapy to those specific patient characteristics in
ways found to be demonstrably and probably effective’ (as set out above).
• ‘Practitioners are encouraged to routinely monitor patients’ responses to the therapy relationship and
on-going treatment. Such monitoring leads to increased opportunities to re-establish collaboration,
improve the relationship, modify technical strategies, and avoid premature termination.
• ‘Concurrent use of evidence-based therapy relationships and evidence-based treatment adapted to the
patient is likely to generate the best outcomes.’ (Norcross and Wampold, 2011: 424 ff)
Collaboration has been referred to repeatedly throughout this chapter as an aspect of the
therapeutic relationship that has come more to the fore in recent years. To be sure, it has
always been part of the picture, but now it is more evident from research that it has an
important role to play in the development of effective therapeutic relationships (see
Miller, Duncan and Hubble, 2005; Wampold, 2001; Cooper and McLeod, 2011). However,
in considering collaboration, it is important to take into account the ‘out-of-awareness’
processes operating in both client and therapist, which emerge, overtly or covertly, into
the relationship, on the basis of which the conscious work of collaboration proceeds.
Some exploration of these processes is essential if an authentic, in-depth collaborative
relationship is to be achieved. Moreover, for client/therapist collaboration to be genuine,
there must be a serious intent to follow it together along whatever pathway it takes, wher-
ever it leads. The therapist with an integrative perspective on life and work is well situated
to be able to rise to this challenge.
12 THERAPEUTIC STRATEGIES AND TECHNIQUES
I think it would be true to say that there are no strategies or techniques that are intrinsi-
cally closed to the integrationist. However, in common with all therapeutic approaches,
there are certain principles that the practitioner must be guided by in their choice of
interventions.
1. Since it is obvious that you cannot use what you do not know, it is important for the integrative
practitioner to be in touch with what is going on across a wide range of therapies and disciplines. No
doubt research should have a place in all approaches, but since integrationists claim that they are
centrally concerned to use whatever is of use to their clients, research should be of particular interest
to them.
2. Since it is also obvious that knowledge about something is not the same as competency in something, the
integrative therapist must be wary of taking up what they are not competent to use. Of course, working

within competencies is important for all practitioners regardless of therapeutic orientation, but since inte-
grative practitioners do not accept what might be thought to be the more secure confines of a single
approach, the less experienced therapist may be more open to the temptation to use something too quickly,
without due consideration of competence. Supervision and continuing professional development is, there-
fore, of particular importance.
3. Since the therapeutic relationship is recognised by most integrative practitioners to be central to the
process of integration, every intervention used by the practitioner must be sensitively ‘translated’ into the
relationship as it develops. This means that regardless of where a particular intervention may be drawn
from, the therapist will only present it to the client in a way that fits the language, concepts and spirit of
the relationship that exists between them.
4. In common with all other practitioners, the strategies and techniques used by integrative therapists will
be bounded by an ethical framework. However, this is, perhaps, a more complex area for the integration-
ist than it is for those who work within a single orientation. Apart from the clear boundaries that would
be agreed by virtually all approaches, there are areas of difference between approaches. What is consid-
ered to be bad practice in one, may be allowed by another (e.g. the boundary of touch is placed differently
in different approaches). Those who work within a single orientation have guidelines to help them decide
on what is good and what is bad within their approach. For the integrationist, however, apart from broad
ethical frameworks of the kind developed by British Association for Counselling and Psychotherapy, it is
less clear-cut. Thus, it is important to develop an ethical sensitivity in relation to each client, and to be
able to give a clear ethical rationale for what is done or left undone. Clearly, supervision takes on an even
more important perspective in the light of this responsibility.
13 CASE EXAMPLE
It is important to bear in mind that the following case example presents briefly the work of
one integrative therapist, working with one particular client.
It cannot be generalised. Nevertheless, it is hoped that it will provide some indication of
what integration was about in this particular case, and, perhaps, provide some pointers to the
way integration, in a broad sense, can work elsewhere.
13.1 The therapist

I describe my psychotherapeutic base as humanistic/existential, into which I integrate concepts
from psychodynamic and cognitive-behavioural approaches. I am also ready to include concepts
from other approaches/sources if the work with individual clients suggests it would be useful to do
so, providing these can be appropriately introduced into the relational flow of the therapy.
13.2 The client

Andrew was a 34-year-old man who self-referred for therapy having just gone through a
divorce. His experience raised a number of issues about his ability to relate to women, and

he wanted to get some kind of ‘handle’ on these before making any further attempts at form-
ing a relationship. At the first assessment session some time was given to considering
together whether a male or female therapist would be best for him. Andrew was clear that he
had deliberately chosen a male because he feared he would not feel free enough to be open
with a female therapist. It was agreed that sessions would be weekly and last for one hour.
However, Andrew’s work necessitated him going away for periods of time, usually at short
notice, and this would need to be taken into account. The therapy was to be open-ended, but
with an agreed review after six sessions, and intermittent reviews after that, initiated by either
the client or the therapist.
From the first session it was evident that Andrew was highly articulate, outwardly confi-
dent, intelligent and capable of some self-exploration. However, by the end of the session,
his ability to talk and his need to cram in as much detail as possible began to feel like an
attempt to keep me at a safe distance.
13.3 The therapy

Encapsulating a lengthy period of intensive therapy into the space allowed in this chapter is
not possible. I have chosen, therefore, to focus on those aspects of the therapy that I hope will
give some sense of the process of integration in this particular case.

When asked what he hoped would come out of the therapy Andrew’s initial response was: ‘to
get a handle on what goes on when I’m in a relationship – why I get so screwed-up that I
suddenly panic and have to get out!’ The initial goal, therefore, was agreed simply as ‘to gain
some understanding about himself-in-relationship’. This initial ‘insight’ goal was expanded
during the second and third sessions to include some change in cognition, affect and behav-
iour: ‘to get some idea of what goes on in my thinking and in my feelings, so that I can
behave differently in a relationship’. These somewhat general goals of therapy were further
refined as the therapy progressed.

The early sessions were spent listening to the client’s story without seeking at this stage
to make any kind of formulated intervention. It was important for the relationship to
emerge out of the interaction between us without risking any intervention that might inter-
rupt or disturb it. For me, this is always a central part of therapy, but since this client’s
expressed concerns specifically identified problems in forming lasting relationships, it
was particularly important to be alert to the nuances of the relationship as it was emerging
between us. As a therapist I seek to be genuinely present in the sessions. However, this

does not necessarily impede the development of transference, countertransference and

projections of various kinds, the identification and use of which I consider to be an impor-
tant part of the therapeutic process.
13.6 Andrew’s story

Andrew’s story unfolded in the first stages of therapy. His childhood was marked by a close
relationship with his mother, who, on adult reflection, Andrew recognised as being depressed,
though as a child he simply experienced her unhappiness as a norm. Andrew believed his
father had ambitions in life that were unfulfilled and he had settled for a mundane career as
a salesman. He spent a lot of time away from home, presumably travelling with his job.
Andrew experienced his father as largely ‘absent’ even when ‘present’, and, though unaware
of it at the time, he spent much of his childhood seeking to do what he could to ease his
mother’s unhappiness in his father’s place.
In spite of this gloomy picture, Andrew believed he had a happy and contented childhood.
He enjoyed school and was successful academically, eventually going to university and
graduating with first class honours in Law. It was at university that he had his first real rela-
tionship with a woman. This was short-lived, however, being brought to an end because he
thought his mother would not approve, though he never spoke of this with her. Later he
formed another relationship, and though he had some reservations about it, the young woman
pressed hard for a commitment. He felt he had to give her what she wanted and within a short
time they were married. Although this relationship lasted for six years, Andrew ‘never felt
present in it’. He complained that he had never really been able to assert himself by express-
ing his own needs and desires and had consequently gone along with what others wanted.
There were no children, and the relationship ended when his wife informed him that she
was dissatisfied with the relationship and needed a change. Andrew did not protest, though
he showed some signs of distress when recounting this. Some time after the divorce, Andrew
developed another relationship with a woman who he was ‘carried away’ by. The woman was
beautiful, considerate, and undemanding. The relationship was ‘as good as it could be’, until
they discussed the possibility of buying a house together.
Although he had felt a desire to do this, the actual possibility of it taking place raised con-
siderable anxiety in him. It rapidly reached panic proportions and, without warning or expla-
nation, he ended the relationship. It was this relationship and these events that became the
focus of the therapy. As Andrew’s outward story unfolded, so the inner story of the hindered
development of a sense of self also emerged. This enabled insight into, and identification of,
the therapeutic tasks needing to be undertaken, in particular: the development of a sense of
‘his-self’, secure enough not to feel overwhelmed in the ups and downs of a relationship; the
ownership of his own life that could then be shared with another; the development of a felt,
self-empathic acceptance and expression of his own needs; the ability to recognise the needs
of others without perceiving and feeling the expression of these as an attack on his own frag-
ile sense of self.

13.7 Elements of therapy

Although not structured in this way, the therapy can be set out more concisely by pointing to
the humanistic/existential, psychodynamic and cognitive-behavioural elements, together
with some of the extra-therapeutic elements that were part of the therapy.
13.8 Humanistic/existential/psychodynamic
The therapeutic relationship, built on the Rogerian core conditions, provided a context in
which Andrew could progressively experience emotions that he had never allowed himself to
feel, let alone express, for fear of adding to, rather than relieving, his mother’s unhappiness.
Although Andrew’s mother had not been consciously or actively intending to restrict her
son’s emotional development, he had nevertheless been rendered unable to ‘presence’ him-
self, to assert his existence as a person in his own right, in the relationship. His dilemma,
begun in childhood, carried into adulthood, and now beginning to form in awareness, was
‘How can I live my own life and be in a relationship? If I gain my life, I will lose the other;
if I hold on to the other, I will lose my life!’ Insights into this were gradually developed
through a process of very tentative interpretations, offered only occasionally, and only when
the emotional climate seemed to invite them, until increasingly he began to be the interpreter
of his own experience. During this work, my empathy towards Andrew became a very real
experience, moving far beyond a strategy or technique.
One particular ‘happening’, that could be considered ‘extratherapeutic’ in the sense that it
was unplanned and outside the session, occurred when Andrew went with a friend to see a
film that unexpectedly had some scenes relating to loss in early life. These were not promi-
nent in the film itself, but they captured Andrew’s attention in a way that evoked a number
of flashbacks to his own childhood. On recounting this in our next session he became angry
with both me and the therapy, because his belief in his happy childhood was being destroyed.
Following on from this, however, ‘grief-work’ became the central feature of many of the
subsequent sessions.
A later event is also worth mentioning here. Andrew had to spend some weeks away from
home because of his work, at a time when he felt particularly in need of continuity in the
therapy. He asked if it would be possible to maintain contact by telephone or through the use
of Skype. This was not part of my usual practice – in fact, I had never used Skype for therapy
before. However, we agreed that I would make myself available at our usual appointment
time, and that he would initiate the contact. We had two consecutive sessions in this way. It
was difficult for us to assess just how useful the actual content of the sessions were therapeu-
tically but they did serve the purpose of maintaining some sense of ‘holding’ at that time.
What was particularly useful, however, was the subsequent processing of the sessions in our
next real face-to-face meeting. Andrew reported a certain sense of security in having some
control over the sessions, with Skype providing him with a way of making a quick exit from
the session should it be needed! This gave rise to some useful, and, at times, light-hearted

analysis of our process, resulting in a recognition of how a version of the conflict between
‘the need to be in’ and ‘the impulse to get out’ could be played out at times in his relationship
with me.
13.9 Cognitive-behavioural elements

Cognitive-behavioural elements really came into their own when, well over halfway through
the therapy, a friend introduced Andrew to a woman who he became deeply attracted to, and
after subsequent encouraging meetings he ‘risked’ entering into a relationship with her. He
reported being ‘really taken’ with her and considered her to be an ideal person for him. This
real-life relationship presented good opportunities to capture automatic negative thoughts, to
uncover and ‘own’ projections, to test the validity and reliability of the insights gained so far
and to develop new ways of relating in the light of them.
In particular, it was important for Andrew to recognise the difference between the way he
assumed his partner would respond on the basis of his oft replayed internal drama with ‘old
players’, and the way she actually responded as an independent person in current life situa-
tions. To be able to make this distinction between the assumed and the actual, he had to take
the risk of recognising and expressing his own feelings and desires in relational events as they
occurred. Preparations were made for this in the therapy session, but the actual work had to
be done by Andrew on his own outside. The woman knew of Andrew’s therapy and was
prepared to work with him by being up-front about her own feelings and responses. The real
test of how much Andrew had developed therapeutically came when he decided to move in
with his partner. In considering this in the therapy sessions, some old anxieties relating to the
earlier relationship that broke down at this point, were re-evoked, and provided a useful
opportunity to show that though they may re-appear from time to time these anxieties can be
coped with and need not dominate life. The move went ahead surprisingly smoothly, and
actual life, positively lived, began to take over from the therapy. Some months later the
therapy came to an agreed end.
13.10 Conclusion
In re-reading this account of the therapy I am conscious of how thin it seems and how
little it reflects the actual session-by-session experience of the therapeutic work done.
Perhaps it cannot be otherwise when trying to convey such complexities in so small a
space! Centrally, the relationship held all the elements together and became the integra-
tive touchstone of when and how to make use of the different therapeutic concepts and
their related strategies. Feedback was a regular feature, and at such times care was always
taken to come to an agreement on how best to proceed in the light of it. There were trans-
ference elements in the relationship, but these did not become a major focus of the therapy
as such. As with all therapies, it had its highs and lows, but overall its process could be

described as a gradual progression from bewilderment to insight, to a sense of inner

growth and to action and involvement in life, with all the elements described above hav-
ing a part to play. Two post-therapy follow-up contacts indicated the relationship had
continued to progress.
14 REFLECTIONS ON THE LIMITATIONS OF INTEGRATION – PRACTICE, TRAINING

AND RESEARCH
The development in psychotherapy integration owes much to the efforts of many commit-
ted therapists and researchers on both sides of the Atlantic – notably John Norcross in
America and Windy Dryden in the UK. Steady progress has been made over the past three
decades in changing attitudes from narrow ‘schoolism’ towards greater openness to, and
appreciation of, the rich diversity in our field. Nevertheless, there is much still to do, and
the following represents brief concluding reflections on some of the current limitations to
be addressed.
14.1 Practice
Although integration is much more established than it once was, it is still open to the criticism
that integrative practitioners do not have sufficient depth in any approach to be of significant
use to those who seek their help. While this kind of criticism doesn’t take into account the
fact that many of those who are now prominent integrationists were first grounded in a par-
ticular approach, it is, nevertheless, a valid area for concern. It is possible that, for some,
integration is little more than a convenient label with which to cover a failure to be well
focused and cohesive in their therapeutic work.
14.2 Training
It is peculiarly difficult to provide good training in integration within the confines of the
kind of training structures common in the UK. There are now many courses that claim to
be integrative, but Hinshelwood’s criticism still applies to the way integration is often
presented:
Many trainings advertise themselves as eclectic, offering a non-partisan approach.… But what it means
… is that students are taught by staff selected from different orientations, leaving the students to try to
integrate the systems of thinking that on the whole the teachers have found themselves incapable of
doing. (1985: 13)
Addressing the issue of how substantial training can be provided within the limits of time
and structure available to us in the UK remains one of the most important tasks facing

experienced integrationist trainers. This is a creative project, and, of all people, integration-
ists should be creative!
14.3 Research
Clearly, research is important to integrationists who seek to apply to their work whatever is
shown to be useful to clients. However, researching integration itself, in a way that places it
in the ranks of empirically validated therapies in the eyes of the medical/scientific commu-
nity, presents us with an extraordinarily complex challenge. The variables generated by the
individual nature of integrative psychotherapy make it impossible to manualise and test it in
ways usually required for formal validation. It is vital that innovative and rigorous research
methods should be developed that both fit the nature of the therapeutic process and can hold
their own in our increasingly scientific research dominated society. Some progress has been
made, but much more is needed.
15 FURTHER READING
Bott, D. and Howard, P. (2012) The Therapeutic Encounter: A Cross-modality Approach. London: Sage.
Norcross, J.C. (ed.) (2011) Psychotherapy Relationships That Work: Evidence Based Responsiveness (2nd edn).
Oxford: Oxford University Press.
Norcross, J.C. and Goldfried, M.R. (eds) (2005) Handbook of Psychotherapy Integration (2nd edn). Oxford: Oxford
University Press.
O’Brien, M. and Houston, G. (2000) Integrative Therapy: A Practitioner’s Guide. London: Sage.
Wachtel, P.L. (1993) Therapeutic Communication: Principles and Effective Practice. New York and London: The
Guildford Press.
16 REFERENCES
Ayer, A.J. (1982) Philosophy in the Twentieth Century. London: Unwin.

Clarkson, P. (2003) The Therapeutic Relationship. London: Whurr.
Dryden, W. (1984) Issues in the eclectic practice of individual therapy. In W. Dryden (ed.), Individual Therapy in
Britain. London: Harper Row.
Egan, G. (2010) The Skilled Helper (International Edition). Belmont: Brooks/Cole.
Frank, J.D. and Frank, J.B. (1993) Persuasion and Healing (3rd edn). Baltimore: John Hopkins University Press.
Hinshelwood, R.D. (1985) Questions of training. Free Associations 2: 7–18.
Hobson, R.F. (1985) Forms of Feeling: The Heart of Psychotherapy. London: Tavistock Publications.
Hollanders, H. (2003) The eclectic and integrative approach. In R. Woolfe, W. Dryden, S. Strawbridge (eds),
Handbook of Counselling Psychology. London: Sage.
Hollanders, H. and McLeod, J. (1999) Theoretical orientation and reported practice: a survey of eclecticism among
counsellors in Britain. British Journal of Guidance and Counselling 27(3): 405–14.

Kahn, M. (1997) Between Therapist and Client: The New Relationship. New York: W.H. Freeman and Company.
Lambert, M. and Barley, D. (2002) Research summary on the therapeutic relationship and psychotherapy outcome.
In J.C. Norcross (ed.), Psychotherapy Relationships That Work: Therapist Contributions and Responsiveness to
Patients. Oxford: Oxford University Press.
Lazarus, A.A (1967) In support of technical eclecticism. Psychological Reports 21: 415–16.
Miller, S.D., Duncan, B.L., Hubble, M.A. (1997) Escape From Babel: Toward a Unifying Language for Psychotherapy
Practice. New York & London: W.W. Norton & Co.
Miller, S., Duncan, B., Hubble, M. (2005) Outcome informed clinical work. In J.C. Norcross and M.R. Goldfried
(eds), Handbook of Psychotherapy Integration. Oxford: Oxford University Press.
Norcross, J.C. (ed.) (2002) Psychotherapy Relationships That Work: Therapist Contributions and Responsiveness to
Patients. Oxford: Oxford University Press.
Norcross, J.C. and Lambert, M. (2011) Evidence based therapy relationships. In J.C. Norcross (ed.), Psychotherapy
Relationships That Work: Evidence Based Responsiveness (2nd edn). Oxford: Oxford University Press.
Norcross, J.C. and Wampold B.E. (2011) Evidence-based therapy relationships: research conclusions and clinical
practices. In J.C. Norcross (ed.), Psychotherapy Relationships That Work: Evidence Based Responsiveness (2nd
edn). Oxford: Oxford University Press.
Norcross, J.C., Dryden, W., Brust, A.M. (1992) British clinical psychologists: a national survey of the BPS Clinical
Division. Clinical Psychology Forum 40: 19–24.
Orlinsky, D.E. and Rønnestad, M.H. (2005) How Psychotherapists Develop: A Study of Therapeutic Work and
Professional Growth. Washington D.C.: American Psychological Association
Prochaska, J.O. (1984) Systems of Psychotherapy: a Transtheoretical Analysis (2nd edn). Homewood. IL: Dorsey
Press.
Rescher, N. (1993) Pluralism: Against the Demand for Consensus. Oxford: Oxford University Press.
Saffron, J.D. and Muran, J.C. (2000) Negotiating the Therapeutic Alliance. New York and London: The Guildford
Press.
Wachtel, P.L. (1977) Psychoanalysis and Behaviour Therapy: Toward an Integration. New York: Basic Books.
Wachtel, P.L. (2005) Anxiety, consciousness, and self-acceptance: placing the idea of making the unconscious
conscious in an integrative framework. Journal of Psychotherapy Integration 15(3): 243–53.
Wampold, B.E. (2001) The Great Psychotherapy Debate: Models, Methods and Findings. Mahwah, N.J.: Erlbaum.
Yalom, I.D. (1991) Love’s Executioner. London: Penguin Books.
Zohar, D. and Marshall, I. (1993) The Quantum Society. London: Bloomsbury.

21
Pluralistic Therapy
John McLeod, Julia McLeod, Mick Cooper
and Windy Dryden
Pluralistic counselling and psychotherapy, as a specific form of therapeutic practice, represents

a relatively recent development within the domain of individual therapy. Over the history of
psychotherapy innumerable attempts have been made to find ways to combine concepts and
methods from different approaches, in order to construct a form of therapy that allows clients
to benefit from the wealth of ideas that exist within the field of counselling and psychotherapy
theory and practice as a whole. None of these attempts to combine therapy methods has been
entirely successful. In general, ‘eclectic’ approaches to therapy have lacked a set of principles
to specify when and how certain interventions might be favoured over others. ‘Integrative’
approaches to therapy have been based on building new models around selective and partial
selections of concepts, thereby dismissing the potential value of other ideas that might be
equally efficacious. The nature of different strategies for combining therapy concepts and
methods is discussed more fully in McLeod (2013). In response to the perceived limitations
of existing eclectic and integrative models, and in an attempt to harness the possibilities that
are available within the therapy literature, Cooper and McLeod (2007, 2011) formulated a
‘pluralistic’ approach to conceptualising and practising counselling and psychotherapy that
encompassed elements from previous eclectic and integrationist traditions.
This new approach can be regarded as an attempt to explore the implications of the concept
of pluralism for counselling and psychotherapy. One of the key attributes of this way of

thinking about therapy is that ‘pluralism’ is not, in itself, a psychological concept, but instead
is an idea that has its roots in philosophy, ethics and the social sciences. As a consequence,
‘pluralistic’ therapy does not favour any particular type of psychological change process, or
theory of therapy. Instead, the concept of pluralism introduces a ‘meta-therapeutic’ perspec-
tive from which the contribution of all psychological and psychotherapeutic concepts and
methods can be evaluated.
At a philosophical level, the concept of pluralism refers to the view that there exist multi-
ple plausible responses or ‘truths’ in respect of any significant question. The opposite of
pluralism is ‘monism’: the doctrine that there exists a single truth or right answer in relation
to any issue. Although a tension between monism and pluralism has always existed within
Western philosophy, this issue only began to receive an increasing amount of tension at the
beginning of the twentieth century, for example through the publication in 1909 by William
James of A Plural Universe, in which he argued that intellectual and scientific progress was
only possible on the basis of dialogue between opposing sets of ideas, informed by empirical
evidence.
One of the most significant implications of this approach, for the practice of individual
therapy, lies in the distinction between pluralism and relativism. The concept of relativism
implies that anything can be true or valid, depending on the circumstances. For example, for
a relativist, psychoanalysis is neither wrong nor right, but is merely a set of ideas and prac-
tices that made sense to a particular group of people at a particular historical time and place.
Relativism can reflect an underlying scepticism, which is the position that nothing can be
believed. Both relativism and scepticism can be regarded as expressions of a position of
indifferentism, understood as an unwillingness to take a stance on an issue. Indifferentism
can be considered problematic when related to counselling and psychotherapy for two rea-
sons. First, indifferentism does not reflect the way that people live their lives – through
experience we acquire definite points of view on at least some matters, and people tend to
expect each other to be open about their preferences and values, rather than ‘sitting on the
fence’. Second, indifferentism does not seem to represent a sensible or realistic basis for
progress in human affairs – scientific advances, and social innovation, are characterised by
the willingness of some people to follow through on a specific vision that they hold, often
in the face of strong opposition from others.
These reflections imply that pluralism, understood as a distinct position, comprises a
willingness to acknowledge and espouse personal beliefs about what is ‘true’, while at the
same time acknowledging that other people may espouse quite different beliefs, and
accepting the challenge of building bridges across this divide. In such a situation, a mon-
ist stance involves arguing that ‘I am right and you are wrong’. By contrast, pluralist
stance involves adopting the uncomfortable stance that ‘I am right and you are also right’.
Where this leads, in relation to the search for knowledge and understanding, is to a rec-
ognition of the importance of dialogue and conversation. From a pluralistic perspective,
the best answer arises from conversations between people in which contrasting positions
can be explored in a spirit of open dialogue. A pluralistic perspective is therefore also
associated with an ethical stance that emphasises the importance in human affairs of

PLURALISTIC THERAPY 549
acceptance of the ‘otherness’ of other persons, as opposed to any attempt to impose one’s
own categories on others.
These philosophical considerations provide a conceptual and moral framework that allows any
therapist to adopt a pluralistic way of working. Being pluralistic requires being explicit about
one’s own stance, because dialogue can only take place when each participant in a relationship
is willing to disclose their stance, in a spirit of being willing to learn and change through their
contact with the other. Some therapists espouse a therapeutic stance that reflects one or other of
the established ‘brand-name’ therapy approaches. Other therapists articulate their stance in terms
of ideas from a range of therapeutic traditions. Most therapists operate somewhere on a contin-
uum between these possibilities. From a pluralistic perspective, each therapist has his or her own
‘starting point’. However, working in a pluralistic manner is not defined by the starting point, but
by the willingness to engage collaboratively with the starting point of the client.
An important assumption within pluralistic therapy, permeating all aspects of practice, is that
we live in a social and cultural world that is characterised by a multiplicity of ideas concern-
ing problems in living, the good life, and pathways towards healing. From a pluralistic stand-
point, attempts to restrict the understanding of these topics to a single discourse or narrative
(for example, the medical model, or religious fundamentalism) are regarded as oppressive
and undemocratic, and need to be met with active resistance based on respect for the holders
of these ideas and efforts to engage in dialogue.

The image of the person within pluralistic therapy is intentionally fluid and open-ended. From
a pluralistic perspective, any statement about the nature of persons invites serious consideration
of alternative and opposite formulations. This approach to understanding the person can be
illustrated through consideration of some important ‘working principles’ as follows.
2.1.1 People actively construct and co-construct the world that they inhabit
A central working principle of a pluralistic approach to therapy is that a person is not a static
entity, but exists in a process of becoming and transforming, characterised by a sense of a
preferred future.
2.1.2 Personal identity comprises an internal multiplicity

(‘voices’, ‘parts of the self’)
A pluralistic perspective can be applied to the issue of how people understand them-
selves, or possess a sense of identity. From a pluralistic stance, an individual person

cannot be reduced to a single ‘truth’. The phenomenon of internal multiplicity is mani-

fest in a wide variety of ways: people critique themselves, they use phrases such as ‘one
the one hand … and on the other hand’, they contradict themselves, they may even talk
about different ‘parts’ of themselves. However, the opposite of self-multiplicity may also
be an important part of the lived reality of some people. There are those who base their
identity on singular truths (‘without my faith, I would be nothing’) or attributes (‘I am a
depressive’).
2.1.3 Being a person involves existing within a web of relationships

People live out their lives within networks of relationships: family, friendships, work col-
leagues, neighbours, etc. Whatever problem a person brings to therapy will have some
relationship aspect to it, however small. Alongside the importance of relationships is the
significance of the human capacity to be out of relationship, in such areas as the experience
of being alone, and the ability to create imaginary worlds.
2.1.4 Embodiment is an essential aspect of the experience of being a person

The fact of living within a body is an enormously important aspect of being human. There is
always a ‘given’ dimension to embodiment, for instance through being born with a genetic
predisposition to develop an autistic disorder, or being male/female, or being tall/short. There
are aspects of embodiment that are personally chosen, such as eating too much and being fat,
or going to the gym every day and being fit. There are also aspects that are visited upon
people, such as developing multiple sclerosis at the age of 50, or being a car accident. The
experience of embodiment also encompasses the experience and expression of feelings and
emotions.
2.1.5 The person exists within a social and cultural world

The meaning and expression of these dimensions of human existence – self-construction,
self-multiplicity, relational being, and embodiment – are shaped by the social and cultural
world within which a person exists. Cultural aspects of personhood reflect the historical
forces and events that shape identity. These elements of a pluralistic image of the person can
be viewed as providing a meta-perspective which makes it possible to be sensitised to the
concrete and specific image of the person that may be espoused by each client.

Pluralistic therapy is open to many different ways of making sense of the difficulties that may
have resulted in a person making a decision to seek help from a counsellor or psychothera-
pist. In talking about client problems, it can be valuable to adopt the term ‘problems in liv-
ing’, originally used by the radical psychoanalyst Thomas Szasz (1961). The concept of
‘problems in living’ draws on the idea that each person possesses some kind of culturally

derived notion of what constitutes a ‘good life’, and becomes troubled when the intended
unfolding of this implicit life plan goes wrong in some way.

Practising pluralistic therapy involves being knowledgeable about different frameworks
for categorising and assessing client problems, in order to be in a position to engage in
conversations with clients around which framework makes most sense to them, or that
represents a mutually acceptable meeting point between client and therapist, if each par-
ticipant in therapy possesses different assumptions. Medical-model diagnostic categories
such as depression, anxiety, PTSD and borderline personality disorder make a lot of sense
to some clients, while being viewed by other clients as instances of oppressive labelling.
Another approach to understanding disturbance that is widely acceptable is to conceptu-
alise problems in developmental terms, for example as crises associated with the transi-
tion from one life stage of the life course to the next. Several potentially useful systems
for making sense of psychological disturbance exist within the psychotherapy and psy-
chology literature (Bayne, 2012). For some clients, it may make more sense to formulate
their problem in social terms, drawing on concepts of social class and gender, or to refer
to indigenous cultural concepts. It is also possible to approach psychological disturbance
from a phenomenological or descriptive perspective that does not seek to go beyond the
concrete experience of the client.
A pluralistic stance is consistent with the use of a wide range of assessment tools, including
questionnaires and rating scales, diaries, projective techniques and physiological measures.
These techniques represent potentially valuable tools for understanding, as long as they are
applied and interpreted in a collaborative manner. Examples of how collaborative assessment
can work in practice can be found in Finn, Fischer and Handler (2012). In pluralistic work,
the process of assessment comprises a potentially powerful therapeutic method in its own
right, for clients whose primary goal at that point in their lives may be to put their difficulties
in perspective.
From a pluralistic perspective, it is important to be open to the possibility that ‘psycho-
logical’ disturbance is not the only way to make sense of the ‘troubles’ that are reported by
clients who attend therapy. There may be instances in which a moral perspective on distur-
bance is more salient than a psychological approach. A client who is engaged in doing harm
to others, for example through violence, abuse or deception, is exhibiting a serious level of
disturbance of universally accepted moral rules. A client who is engaged in self-harm may
also be considered as morally disordered, although in this situation it could be argued that
people have a moral right to decide their own actions as long as these actions do not harm
others. There are some issues that are associated with strong culturally determined moral
beliefs. For example, in some cultures suicide or homosexual activity would be regarded as
morally wrong. The point here is that a pluralistic stance requires the therapist to be willing
to consider ‘disturbance’ not merely as a question of psychological functioning, but also as a
topic with a moral and ethical dimension.


We live in a culture, and at a point in history, within which there exist many competing ideas
about ‘psychological health’ or what it means to live a ‘good life’. Notions of health and
well-being differ according to gender, social class, culture and religious faith. For example,
for some people, the key indicator of being psychologically healthy is the capacity to achieve
material success. For other people, being psychologically healthy may involve loving and
being loved, or accomplishing spiritual transcendence, or remaining in control of one’s emo-
tions. The conduct of pluralistic therapy is informed by notions of psychological health in
two ways. First, the therapist seeks to help the client to articulate his or her own understand-
ing of psychological health, as a means of developing a marker for therapeutic success.
Second, the therapist is explicit about his or her assumptions about psychological health, in
a manner that does not attempt to impose these values on the client.

Taken together, psychotherapeutic theory and research, and common-sense folk wisdom,
provide a rich resource of ideas about how problems in living can be acquired. Among the
many possible triggers for psychological disturbance are: luck; loss; trauma; making the
wrong choices; exposure to ‘conditional positive regard’ imposed by significant others;
developing coping strategies that were effective at an earlier stage of life but are no longer
functional; being subjected to oppression, cruelty and deception; absence of environmental
support, resources and learning opportunities; physical illness or disability; the illness or dis-
ability of others; and so on. These triggers can occur alone, in tandem or in sequence, and
may operate in different ways at different developmental stages.
Pluralistic therapists are interested in the nature and functioning of all possible ways of
making sense of the acquisition of psychological disturbance. The aim in pluralistic therapy
is to work collaboratively with the client to construct a shared understanding of the origins
of their problem that fits the circumstances of their life and which makes sense of them, in
terms of their general world-view. Hansen (2006) suggests that theories of therapy (which
include ideas about the acquisition of disorders) can be regarded as narrative ‘templates’ that
are available within the culture as means of making sense of problems. He proposes that one
of the goals of therapist training should be to enable practitioners to become fluent in intro-
ducing these templates into conversations with clients.

If the client’s problem is viewed not as a set of symptoms, but instead as a story that can be
told about a difficult period in their life (Hansen, 2006), then the narrative account of the
disturbance needs to be extended to incorporate not only the triggering factors or events
(‘once upon a time…’) but also the subsequent ways in which the problem was perpetuated.
It is clear that in any individual case, the ‘problem story’ may be complex and multi-faceted.

However, such stories will usually include some reference to intrapersonal, interpersonal and
external/environmental processes that were involved.

The therapy literature provides many examples of intrapersonal mechanisms or processes
that may be recognisable or meaningful for a client. For example, if a client attends student
counselling to deal with a fear of making a presentation in a seminar group, he may have a
clear idea about how the problem was first acquired: ‘I can remember in primary school,
running out of the assembly hall when it was my turn to speak in from of everyone, and being
humiliated by the head teacher for doing this.’ The perpetuation of this problem may involve
cognitive mechanisms (‘I have this image in my head of what happened all these years ago’;
‘I tell myself that I can’t do it’) and also emotional processes (‘I just feel sick’; ‘I start to have
a panic attack’). The CBT literature provides a particularly helpful set of ideas about intrap-
ersonal mechanisms that may contribute to the perpetuation of problems (see, for example,
Westbrook, Kennerley and Kirk, 2011).

The therapy literature also provides plentiful examples of interpersonal processes that may
be relevant in the construction of a credible ‘problem narrative’. In the case of a client
struggling to overcome a fear of making a seminar presentation in his university class, it is
possible to envisage several possible interpersonal processes that may have contributed to
the maintenance of the problem. For example: ‘the inconsistent parenting you received in
infancy left you unwilling to trust that anyone would be willing to help you’; ‘your mother
worked long hours and was too tired to listen to your problems’; ‘you were the middle
child in a large family and were often ignored’; ‘you tried to ask your tutor for help but he
was not interested’. The literature on psychodynamic therapy and family therapy represent
sources of ideas about different kinds of interpersonal problem narrative.

Within pluralistic therapy, the concept of ‘cultural resources’ is used to describe the possi-
bilities that exist within the person’s life space that can be utilised for the purposes of build-
ing a sense of identity, giving meaning to life, and solving problems (Cooper and McLeod,
2011). The concept of cultural resource can also be used in constructing an account of the
maintenance of a problem. In the case of the anxious student, it could be that ‘you developed
an interest in science subjects where you would not be expected to make presentations’, ‘your
sister was always confident at making presentations, and offered to help you, but you did not
follow up on her invitation’ or ‘you found a self-help book in the library but have not read it
yet’. These elements of the client’s problem story point toward environmental factors that
could form part of the solution to the problem (e.g. talking to your sister, working through
the self-help book, applying the academic skills that you acquired in your science classes to
organise a coherent presentation).

2.5 Change
The conceptualisation of the change process in pluralistic therapy draws on two key perspec-
tives. The theory of common therapeutic factors (Duncan et al., 2010) suggests that all
therapeutic change arises from the implementation of a set of generic healing experiences.
Lampropolous (2001) offers a summary of these basic change processes:
• a relationship of trust with someone who is viewed as a credible source of assistance;

• expression of painful emotions and relief from distress;
• instillation of hope and raising of expectations;
• provision of a theoretical explanation or rationale for the origins and maintenance of the problem, and
the ways in which change might be accomplished.
From a common factors perspective, the person who seeks therapy is ‘demoralised’ – he
or she has temporarily exhausted their repertoire of coping skills or has run out of people
to whom they can turn for help. Therapy provides a context for ‘re-moralisation’. Through
the development of trust in the therapist, exposure to the hopefulness of the therapist and
being offered a framework for making sense of the problem, the person becomes able to
begin to re-activate his or her capacity for learning in relation to the problem that is both-
ering them.
A further theoretical perspective that is central to a pluralistic understanding of the change
process is the concept of learning style. There is strong evidence that people who seek ther-
apy have preferences in relation to the kinds of change processes and activities that they
believe will be most helpful for them, and that better outcomes are reported when the therapy
that is received matches these preferences (McLeod, 2012). An appreciation of a pluralistic
perspective on therapeutic change can be illustrated by considering the example of depres-
sion, which is one of the most widely reported problems among client who attend therapy.
There is evidence for the efficacy of many different change mechanisms in relation to recov-
ery from depression. Some of the things that seem to help include: gaining insight into the
origins of the problem; changing negative thought processes; expressing emotion; being
more active; engaging in spiritual practices; taking medication; becoming more connected to
other people; changing diet; exposure to sunlight.
3 PRACTICE
It is important to recognise that, in practice, pluralistic therapy can take many different
forms. An appreciation of the range of possibilities associated with a pluralistic way of
working requires recognition of the distinction between principles and contexts. A plural-
istic perspective is associated with a set of general principles of practice, for instance
around the significance of flexibility, active client involvement, dialogue, and use of feed-
back. However, the application of these principles will always depend on the specific

context within which therapy is being carried out. There are four primary dimension of
context that needs to be considered: the client, therapist, the organisational setting within
which therapy takes place, and the broader cultural environment. The practice of pluralistic
therapy draws on contextualised knowledge, in the form of what makes sense to specific
people in specific places, as well as on knowledge that is derived from more abstract or
generalisable theory and research.
The process of pluralistic therapy does not begin with the first meeting between therapist
and client, but requires attention to the whole of the context within which therapy occurs.
For example, the encouragement of active client participation in therapy can be facilitated
through attention to the wording of advertising and publicity materials, the messages given
by first-contact reception staff, and the provision of pre-therapy information in the form of
reading materials or a website video clip. There are likely to be many latent resources
within the broader cultural environment that may be helpful for a client. The more that a
therapist has some familiarity with these resources, the more sensitive they will be to the
potential value and accessibility of these activities for specific clients. The waiting room
in a therapy agency or clinic need not only display copies of popular magazines, but might
also display information about education opportunities, outdoor pursuits, complementary
therapies, political campaigns, support groups, and other cultural resources. Attention also
needs to be paid to the structure of the therapy that is on offer. Probably most clients find
it convenient to attend therapy for one hour on the same day each week. However, there
are other clients who might benefit from longer or shorter sessions, or different lengths of
time between sessions.

It seems reasonable to assume that clients have some reason or purpose in seeking therapy, and
also have some sense of how they will know when or whether therapy should come to an end.
At the same time, it is clear that at least some clients find it hard to articulate what they want
from therapy. From a pluralistic perspective, agreement around client goals is a central aspect
of therapy, because meaningful dialogue that takes place around the best way to work together
cannot take place in the absence of a shared understanding of what the work is for. A plural-
istic approach to therapy accepts that are many different goals that clients might wish to attain
through their participation in therapy. Some clients may want to use therapy to pursue specific
behavioural goals: ‘I need to stop drinking and get more exercise because I have been diag-
nosed with heart disease.’ Other clients may express vague goals, such as ‘finding more mean-
ing in my life’. Preparation for working in a pluralistic way involves becoming sensitised to
the wide variety of goals that may be identified by clients, and being clear about any goals that
the practitioner does not feel able to tackle. In practice, conducting therapy that is appropri-
ately and sensitively goal-informed is based on three main strategies:
Explicit goal identification: It is possible for clients and therapists to believe that they have
reached a mutual understanding of the purpose of therapy on the basis of the client talking

about what is bothering them, and sharing their story. However, in the absence of an explicit
goal statement, each participant may be operating on somewhat different premises. As a
result, it is helpful for therapists to explicitly articulate their understanding of the client’s
goals, and ask if the client agrees.
Regular goal reviews: It is unusual for the goal that a client identifies at the start of
therapy to remain fixed through the course of therapy. If therapy is going well, it is prob-
able that the client’s goals will become more specific, differentiated and concrete, and
more future-oriented. For example, ‘I need to stop drinking and get more exercise
because I have been diagnosed with heart disease’ might become redefined in terms of
specific challenges around time-management of an exercise regime, and developing
skills in saying no to people who exert pressure to drink alcohol in particular social situ-
ations. Sometimes the meaning of a goal can shift to another existential level: ‘I need to
stop smoking and get more exercise because I have been diagnosed with heart disease’
could become ‘I want to learn how to live my own life rather than blindly following the
way of life laid down by my father and grandfather.’ These are just some example of
ways in which goals can shift over the course of therapy. It is only through regular invi-
tations to re-state goals that a therapist and client can be sure that they are working
toward the same ends.
Sensitivity to implicit, unstated or unconscious goals: As a therapist listens closely to a
client, and observes his or her way of being in the therapy room, it can become apparent
that what is being said does not fully reflect the entirety of what is being experienced by
the client, the therapist, or both parties. New meanings emerge from the flow of conversa-
tion. Good therapists are sensitive to this kind of process, and are willing to try to find
words to capture the sense of this implicit or unstated dimension of the interaction.
Psychodynamic theory and practice is grounded in this kind of sensitivity to the emotional
and relational dynamics that lie behind consciously-stated goals. Pluralistic practice in
enriched by a willingness to make use of a psychodynamic sensibility to be open to ways
in which ‘goal conversations’ can be deepened and ‘thickened’. It can also be valuable to
explore such topics as: how a person might know that a goal has been accomplished; the
existence and salience of competing goals; the distinction between ‘life’ goals and ‘ther-
apy’ goals; who would be pleased to know about your progress towards this goals (or
would be displeased)?
The word ‘goal’ is neither adequate nor appropriate for use in some therapeutic conversa-
tions. For example, for some people, the term ‘goal’ is spoiled by its association with
managerialism. It is always important, therefore to talk about this area of experience in a
way that is meaningful and productive for both client and therapist. Some clients and thera-
pists find value in the metaphor of the ‘journey’, or in holding conversations about ‘pre-
ferred’ situations. At a basic level, these conversations are always about inviting the client
to acknowledge that the future is part of the present, and to consider the notion that their
future is something that they have the power to shape through their own efforts.
Conversations about goals can therefore be viewed as part of a broad intention on the part
of the therapist to instil hope.


There are no selection criteria that are specifically associated with the practice of pluralistic
therapy. Pluralistic principles can be applied in work with any client group, or in any thera-
peutic modality (e.g. couple, groups, email counselling, etc.). From a pluralistic perspective,
client suitability is determined by contextual factors, such as the resources and organisational
aims of a therapy clinic or agency or the competence and preferences of therapists. For exam-
ple, a community counselling agency that was struggling to deal with an extensive waiting
list might decide that it was not in a position to offer a satisfactory service to people who
needed long-term support. A centre that specialised in women’s issues would not be open to
male clients. A therapist who had little experience in working with extreme trauma might
choose to advise such a client to work with a colleague with training and experience in
EMDR.
Alongside the criteria that may be used by a therapy organisation, or an individual practi-
tioner, to select clients or patients, are criteria used by clients themselves. From a pluralistic
perspective, effective therapy depends on a capacity to make use of the resources of both the
client and the therapist. Each client has some sense of what is most likely to be helpful for
them, based on their prior experience of coping with problems in living, their observation of
how others cope, and their reading or general exposure to cultural images of therapy. This
sense of what might help is the basis of client preferences for different therapeutic activities
and ideas. Pluralistic practice requires engagement with client preferences, both at the outset
of therapy (e.g. intake and assessment procedures) and through the course of therapy
(McLeod, 2012).

It is not possible to identify any general suitability criteria associated with recruitment of
clients into pluralistic therapy. As discussed in the previous section, there will always be local
criteria that are specific to each particular therapist, therapy agency, and client. Pluralistic
practice involves engaging in as open a dialogue as possible about what these criteria are, and
how they apply in each case. This conversation needs to be informed by the general duty of
care that is accepted by anyone offering a therapy service.

Whether a client is best served by individual therapy, or would receive more effective assis-
tance from couples work, group therapy, medication, self-help or some other form of inter-
vention, is a question that needs to be explored at an early stage in therapy. There are two
main reasons why this is important. First, the ethical principle of informed consent calls for
such a discussion to take place. Second, opening up exploration of the relevance of various
possible ways of addressing a problem in living represents an invitation to the client to begin
to consider multiple options, and conveys to the client that the therapist takes the client’s
views and preferences seriously.


The question of what makes an effective therapist is an issue of central importance to plural-
istic practice. Pluralistic therapy rejects the ‘monist’ position that there will be one valid
therapy approach or protocol for each condition and that the role of the therapist is to function
as a technician who ensures that these procedures are applied in each case. Instead, a pluralis-
tic perspective implies that there are many interventions that may be of potential value for any
particular client. The role of the therapist is therefore expanded to include facilitation and
monitoring of choice of theory and method. The practice of pluralistic therapy is also informed
by the findings of an expanding body of research that has documented significant differences
in the levels of effectiveness of individual therapists (see, for example, Kraus et al., 2011).
This research suggests the eventual outcome of therapy is determined to only a limited extent
by the model of therapy that is used, and depends instead on the qualities of the therapist, and
the capacity of therapist and client to establish a collaborative relationship.

There are three main sources of information about the personal characteristics of effective
therapists. One body of research has been based on interviews with practitioners who are sen-
ior members of the profession, or are nominated by their peers as ‘master therapists’ (Jennings
and Skovholt, 1999). These studies have consistently identified a cluster of therapist charac-
teristics associated with professional success. Highly regarded therapists are people who are
open to learning by means of feedback from clients, personal therapy, reading, and on-going
professional development. This lifelong curiosity is underpinned by a belief in the complexity
of human beings and relationships. No matter which therapy model they might formally
espouse, master therapists are eager to learn about other perspectives. These therapists regard
their own life experience as a valuable source of therapeutic learning, and work hard at main-
taining a work-life balance. A further body of research has examined the differences between
therapists who record the best client outcomes, as assessed by changes on standard pre- and
post-therapy measures, and those whose clients do less well. There are two key characteristics
that have emerged from this type of investigation. Therapists who are more effective have
higher levels of interpersonal skill, which they are able to maintain even when under pressure
(e.g. if a client gets angry with them) (Anderson et al., 2009). In addition, more effective
therapists are self-effacing, and express less confidence in their ability (Nissen-Lie et al.,
2010). A further dimension of therapist effectiveness refers to the goodness of fit between the
therapist and the therapy context within which he or she works. For example, the personal
style of some practitioners may be conducive to brief therapy, whereas colleagues with similar
skills and training may be more effective working with long-term clients. Similarly, therapists
vary in their effectiveness across client groups (Kraus et al., 2011).
The evidence from these studies provides some useful pointers in relation to therapist selec-
tion and training, and the practice of therapy. Good therapists have a pluralistic attitude to their
work, in terms of an appreciation of the limits of their knowledge and appreciation of the
potential value of a range of perspectives. Good therapists are willing to explore difficult and

sensitive issues with clients, because they feel secure enough, in relation to their own lives, to
handle whatever comes back at them.

There exists a wide range of generic counselling skills that form the bedrock of any form of
therapeutic practice. Beyond these core skills, there are three areas in which pluralistic
therapy requires the development of specific skills. In order to respond in a flexible way to
the preferences of different clients, pluralistic therapists need to be competent in facilitating
a number of different types of change process. These domains include: meaning-making and
building a sense of self and identity (humanistic and person-centred skills); becoming aware
of and working through the implications of early life experience (psychodynamic skills);
structured facilitation of cognitive and behavioural change (CBT skills); and addressing
issues arising from the functioning of family systems (systemic skills).
Surveys of experienced therapists, where they are asked to indicate the frequency with
which they use certain interventions, suggest that the majority of practitioners routinely
operate across all four of these domains (Thoma and Cecero, 2009). The expectation that
pluralistic therapists should be at least minimally competent in each of these areas does not
therefore represent an unrealistic burden. The other area of therapeutic skill that is specifi-
cally highlighted in pluralistic therapy consists of the capacity to engage in collaborative
action and decision-making. There are several facets of collaboration as a therapeutic skill.
Collaboration draws on an array of ways of using language, for example, metacommunica-
tion and attention to implicit meanings within client language (for example, meaning that is
conveyed by metaphor or silence). The skill of collaboration may encompass the use of tools
and instruments, such as questionnaires that are completed by the client and then discussed.
Collaboration may also involve a willingness to wait until the client is read to articulate his
or her wishes. The third area of skill that is particularly important within pluralistic therapy
can be characterised as active cultural curiosity. From a pluralistic perspective, consulting
a counsellor or psychotherapist is likely to be only one among many initiatives undertaken
by a person who is struggling to deal with a troublesome problem in living. The therapist
therefore needs to be able to learn about these parallel initiatives, and the cultural context
that supports them, in order to be able to begin to explore with the client the ways in which
therapy can be aligned alongside the use of other life resources. In this context does not refer
merely to situations in which client and therapist come from obviously different cultural
backgrounds, but also to the more subtle but at the same time significant ways in which
people from the same community may espouse different beliefs and lifestyles.

From a pluralistic perspective, there are many different types of therapeutic relationship that
may be helpful for clients. Moreover, an individual client may exhibit different relationship

needs at different points in therapy. These principles represent a major challenge for anyone
seeking to conduct therapy in a pluralistic manner, because it is probable that the therapist
has his or her own preferred and familiar style of relating to others, and will find it hard to
shift into other modes of relationship. People who seek to become therapists are drawn to spe-
cific schools of therapy because their preferred approach embodies a way of relating to others
with which they are comfortable. By contrast, being a pluralistic therapist requires a willing-
ness to extend one’s personal relationship repertoire.
Relating to clients in a pluralistic manner requires being willing to be open to the many
different forms of therapeutic or healing relationship that are possible. This involves
being willing to be critical of existing theories of the therapeutic relationship. For exam-
ple, the concept of the ‘therapeutic alliance’ represents a way of thinking about healing
relationships that has been highly influential and facilitative over several decades. But
some clients, at some points in therapy, may want their therapist to be an adversary rather
than an ally, or to be a mother, or to experience a sense of belonging. There are some
clients who gain most from a minimal therapeutic relationship, for example by learning
coping skills by using a self-help book or on-line package. Working pluralistically means
knowing about well-established frameworks for understanding relationship processes in
therapy, such as attachment theory, the concept of transference, and the person-centred
core conditions model. It also calls on a capacity to regard these processes as part of a
complex relational field that is multiply structured in respect of gender, age, cultural iden-
tity and other factors.

The discussion of the concept of pluralism that was offered at the beginning of this chapter
placed a strong emphasis on the idea that genuine pluralism is based on a willingness to own
one’s own personal ‘truth’ while at the same time being open to the ‘truth’ espoused by oth-
ers. It is therefore necessary for pluralistic therapists to identify and accept their own personal
style of relating to others, and to use this style as their starting point in work with clients. By
contrast, attempting to mimic a way of relating that has been modelled by a leading figure in
a school of therapy, or specified in a treatment manual, runs the risk of being seen as false by
the client, and does not represent an authentic starting point for any subsequent efforts to
meet the client halfway. It is extremely unlikely that the relationship repertoire that has been
developed by a trainee therapist over the course of several decades of their life will readily
map on to the relational style associated with any particular brand of therapy. From a plural-
istic perspective, this is an advantage, because it acts as a reminder to therapists that there are
ways that they are capable of being in relationships that transcend any specific model.

Assessment and case formulation are central to a pluralistic way of working. Only when
the therapist is willing to make an open and explicit statement of his or her understanding

of the client’s issues is the client is in a position to decide whether or not what is on offer
is relevant and useful to them. In order to engage the client in a meaningful process of col-
laborative decision-making, the therapist needs to be able to convey his or her understand-
ing in a respectful manner, using plain non-technical language, and in a style that allows
space to the client to adapt, modify or decline the therapist’s formulation. It is also neces-
sary to keep the shared understanding under review, to allow emergent ideas and insights
to be incorporated into the therapeutic process. The scheduling of the assessment and for-
mulation process will depend on contextual factors such as the existence of time limits for
therapy. A pluralistic perspective invites practitioners to consider the potential contribution
of the many different traditions of formulation and assessment that are described within the
therapy literature (see, for example, Eells, 2007), and to incorporate elements of these
strategies into their own personal style.
3.5.1 Assessment
A pluralistic stance allows therapists and clients to consider as wide a range of sources of
information as possible when constructing a formulation: brief outcome and process scales;
ratings of therapy goals; open-ended questionnaires; interview schedules; projective tech-
niques; client diaries, letters and emails; autobiographical writing; artwork and photographs
made by or selected by clients; official documents (e.g. medical or school reports); and the
views of significant others. The intention is not that the therapist arrives at a single authorita-
tive appraisal of these data. Instead, the aim is to arrive at a shared understanding, guided as
far as possible by the client’s frame of reference.

As a means of emphasising the collaborative nature of therapy, it can be useful to externalise
the formulation, or a version of it, as a diagram on a flipchart page, a written report, or a let-
ter. The activity of co-creating an external object allows the client and therapist to work side-
by-side on a shared task, rather than being engaged in a face-to-face discussion that may be
all too readily dominated by the therapist’s greater experience and authority. It is useful for
the therapist to try to incorporate perspectives from a range of everyday discourses about the
causes, maintenance and resolution of personal problems. For example, it makes sense to
most people to think about an issue such as low mood or depression as reflecting any or all
of the following factors: (a) a pattern of thinking and feeling that has its origins in difficult
experiences in childhood; (b) faulty or irrational thought processes; (c) problems in relation-
ships with others; (d) suppressed emotions; (e) an unhealthy lifestyle; (f) an absence of a
sense of meaning and purpose in life; or (g) a response to social injustice. Each of these nar-
ratives can be linked to various healing processes and therapy methods. From a pluralistic
perspective, the point in therapy where a collaborative formulation is accomplished can be
regarded as a process of creating a space for consideration of the possibilities afforded by
these cultural discourses.


The primary therapeutic strategy within a pluralistic approach is to find and make use of
specific learning experiences that will allow a specific client to make progress in the direction
of his or her goals at a specific point in time. There is no assumption that what works for one
client will necessarily be helpful for other people, or even for the same person at a different
stage in his or her life. Furthermore, there is no assumption that the learning experience will
occur within a therapy session, or that it will be recognisable as an identifiable therapeutic
intervention. The intention in pluralistic therapy is to create an environment in which the cli-
ent’s problem can be viewed from different perspectives. On the whole, people seek therapy
because they feel stuck. The metaphor of life as a journey has meaning for most people. In
general, people who come into therapy have a sense of where they want to get to in their
lives, and what they need to do to get there. However, for whatever reason their progress has
come to a halt, or has been reversed. Therapy provides a space apart from everyday life,
where the person can look at what has gone wrong, and discover a new route, mode of trans-
port or destination that will allow the journey to resume.

Much of the time, a client will have access to resources within their own life space and life
history that will form the basis for creating a new way of moving forward in life. For a
client, their therapist will almost certainly represent the person they have met who has the
most knowledge of how people get stuck and how they can become unstuck. It can be a
puzzle and source of disappointment for clients when their therapist is not willing to share
this knowledge with them. The aim of pluralistic therapy is to arrive at a place in which
both client and therapist knowledge, along with external cultural resources, are harnessed
together in the service of the client. Taking these sources of knowledge as a whole, there
are always multiple possibilities that can be brought to bear on the client’s problem. The
implicit message, communicated by a pluralistic therapist through such actions as empha-
sising the importance of active client involvement in therapy, using feedback tools, using
meta-communication, and co-constructing a formulation and shared understanding, is a
reinforcement of a ‘both/and’ philosophy of life: there are many small things that can make
a difference rather than one big thing.
The ‘meta-strategy’ of identifying the specific remedies that make a difference for each
client leads to episodes in therapy where client and therapist work together on applying these
remedies. While it is important to be open to whatever change methods and strategies are
suggested by the client, or emerge from collaborative exploration of what might seem useful,
it is also necessary for pluralistic therapists to be able to draw on techniques and interventions
that are well established within the world of counselling and psychotherapy. To be able to
respond flexibly to the issues presented by clients, a therapist needs to be able to engage
constructively with the following therapeutic tasks:

• making meaning: talking through an issue in order to understand things better;

• making sense of, and coming to terms with, specific problematic events and experiences;
• problem-solving, planning and decision-making;
• changing behaviour;
• negotiating a life transition or developmental crisis;
• dealing with difficult feelings and emotions;
• finding, analysing and acting on information;
• undoing self-criticism and enhancing self-care;
• dealing with difficult or painful relationships.
The capacity to facilitate completion of these tasks is based primarily in the life experience
and interpersonal skills of the therapist. Entry into training as a counsellor or psychothera-
pist requires evidence of a baseline of competence in these areas (for example, demon-
strated through relevant work experience). Therapy training provides opportunities to
reflect on, and refine these competencies. Specific therapy interventions, such as two-chair
work for unfinished business, or CBT protocols for working with OCD, comprise
sequences of basic counselling and interpersonal skills. The field of counselling and psy-
chotherapy embraces multiple, alternative approaches to conducting productive therapeutic
work in each of these task areas. There is no way that pluralistic therapists can be familiar
and competent in all of these approaches. Instead, each therapist needs to start somewhere,
in terms of being able to facilitate behaviour change, help the client come to terms with
traumatic events, and other tasks.

A pluralistic standpoint holds that there can be multiple change processes in therapy; but it
can generally be understood as a cyclical process that moves back and forward between
phases of involvement in specific activities that are intended to produce change, and standing
back from these activities to reflect on whether they have made a difference. The kind of
change that occurs within the phase of using specific methods to accomplish therapeutic tasks
is no different from the kind of change that might occur in any form of therapy. For example,
if a client is working on how to be less anxious and more confident and assertive in social
situations, then the outcomes would be expected to be similar to what might be expected from
the use of CBT or EFT for social anxiety, and a similar change process might be observed.
By contrast, the change that is enabled through taking part in collaborative conversations
about the direction and progress of therapy opens up possibilities around processes that are
concerned with enabling the person to learn meta-strategies that they can carry with them for
the rest of their lives. This higher level change can be characterised as a form of ‘learning
how to learn’, and comprises such elements as:
• becoming more aware of one’s personal learning style, strengths and resources, and how these attributes
can be used to prevent, mitigate and deal with issues that arise in the future;

• acquiring, or developing an appreciation of, a ‘pluralistic worldview’ that invites consideration of a prob-
lem from multiple perspectives, and willingness to seek creative ‘both/and’ solutions;
• practical knowledge of what is involved in working collaboratively with another person, and being
engaged in open dialogue.
A pluralistic perspective is not based in an assumption that the formation of a therapeutic

alliance needs to occur in advance of productive work on therapeutic tasks. Instead, each
successful turn of the action-reflection cycle serves to build a relationship. In other
words, a strong client–therapist relationship, observable in later stages of therapy as
episodes of relational depth and open dialogue, is built on and arises out of practical
achievements.
An important change event within pluralistic therapy is the discovery or creation of a
therapy method that fits the client in respect of the particular problem with which he or she
is struggling. Arriving at the point of being able to see that ‘this works for us’ is typically
energising for both client and therapist, and leads to a phase of intense and productive
activity. There are many ways that pluralistic therapists can facilitate the search for ‘what
will work’: asking the client; exploring what worked in the past; inviting client suggestions
and paying attention to what they say; being alert for problem-solving processes that are
enacted in the client’s everyday life or in the therapy room; encouraging the client to try
something they have never done before, to see whether it would be helpful; reviewing
activities and interventions that have been used, and modifying and adapting them; explor-
ing the possibilities inherent in culturally available resources; improvising idiosyncratic
rituals and procedures.
4 CASE EXAMPLE
The therapist in this case was Julia McLeod, a counsellor in a university student counselling
service that allowed clients to continue in therapy for as long as they needed, subjected to
regular review.
4.1 The client

When she entered counselling, Ellie was 24, single, and a university student in the second
semester of the first year of a social science degree. Ellie had felt increasingly anxious
and worried during the first semester of her studies, and unable to sleep. She had visited
her GP, who suggested that Ellie should try the university counselling service as a first
resort, but that he would be willing to prescribe sleeping tablets and anti-depressants if
the counselling did not work. At our initial meeting, I (Julia) invited Ellie to tell me about
her problem, the people and activities that were important in her life, and her goals for
counselling. I also asked her about any previous counselling she had received, or other

strategies that she had used to cope with her worries. Toward the end of that session I also
talked about what counselling involves, and how it might help, and asked Ellie to com-
plete the CORE outcome measure (www.core.ims), a therapeutic goals rating form, and
the assessment version of the Therapy Personalisation Form (Bowen and Cooper, 2012).
At the end of the first session we agreed to meet again. At the start of the second session
I began by asking Ellie whether there were any questions that she had about what we had
discussed at the previous meeting, or further thoughts about her problem that had arisen
during the ensuing week. I then asked her whether it would be all right for her if we just
continued to talk about what was happening in her life for, so that we could get a better
understanding of the issues that were bothering her. We also had a brief discussion of her
responses to the scales she had completed, and I told her that, if acceptable to her, I
intended to use some of the time in our third session to share my understanding of her
difficulties, and look at some possible ways of dealing with them.
During these first two sessions, Ellie described herself as a ‘complete failure’. She was
the oldest of four children, and always felt under pressure to do well at school. Ellie was
close to her grandmother, who died when she was 16. She told me that she had never felt
that she received enough support or encouragement from her parents. Her mother was an
alcoholic, who would disappear from the home for days at a time, leaving Ellie to take
care of her brothers and sisters. Her father was a remote figure, who did not seem to be
interested in his children, other than to criticise them for not doing well enough at
school. He had a job that involved a great deal of travelling. Ellie had failed to get good
grades in her university entrance exams, and worked in a shop for a year before doing an
‘Access to University’ course at a community college. She described herself as ‘living a
lonely existence’, with no friends or boyfriend. She found it difficult to talk to her flat-
mates. She had ‘no idea’ what she was going to do after graduating. Ellie regarded her-
self as being seriously overweight, as a result of eating too much chocolate. She avoided
writing essays, and spent a lot of time reading detective novels rather than doing aca-
demic work. When asked about activities other than her studies, Ellie mentioned that she
had enjoyed singing in a choir in school, but was ‘too fat’ to join the university choir. In
respect of what she thought might be helpful in counselling, she replied that she has
never had any therapy before, but she needed advice on how to handle situations in her
life, and was worried about the risk of being overwhelmed by bad feelings and past
memories. When asked about how she made sense of her difficulties, Ellie replied that
she did not have enough ‘will-power’ to make herself do what was needed to be a success
in life.
During the course of these early meetings I was aware that Ellie came across to me as
rather emotionally distanced, detached and harshly self-critical. Ellie seemed to use meta-
phors and images associated with fighting, such as ‘It was a battle to get to University’, and
‘I retreat into my bed with a carton of ice cream.’ I was aware of a vague sense of sadness,
and wondered whether Ellie would come back for further sessions. I had a sense that I had
let Ellie down, and had not done enough for her.

4.2 The therapy

Therapy with Ellie continued for almost three years, punctuated by pauses and vacations. We
met weekly for the remainder of her first year of study, then through the second year of her
course. This was followed by occasional consolidation and ‘crisis prevention’ sessions in the
final year of her degree and over the summer following graduation.

There were two main strands of my relationship with Ellie. At one level, we worked together
in a practical and purposeful manner to explore possible ways that the problems that Ellie
was experiencing might be addressed. At another level, I was aware of Ellie’s wish to receive
the kind of love that had not been available to her when she had been a little girl. I was also
aware that her neediness elicited the mothering side of me, along with occasional feelings of
frustration and resentment around being asked to ‘take care’ of her. Ellie was around the same
age as my own daughters, and there were times when I needed to use supervision to make
sure that I was not importing patterns from my own real-life parental role into my relation-
ship with Ellie. A turning point in our relationship, described below, occurred about halfway
through therapy. After this episode, we seemed to move onto a new phase of relating, where
Ellie became more active in defining how she wanted to use our time together, and both of
us became more able to say what we thought and felt.

My assessment incorporated an appraisal of the strengths and resources available to Ellie, as
well as the problems in her life and her goals for counselling. I also sought to identify her pre-
ferred learning and relationship style, although it took many sessions before I began to gain a
clear understanding of these factors. At the start of our third meeting, I asked Ellie if it would
be a good time for me to share some of my thoughts about what she had told me up to that point,
and outline some possibilities for ways that we might work together to help her to move on in
her life. With her agreement, I used a sheet of flipchart paper and some coloured pens to draw
a time-line of key episodes in her life, and how they might be connected to her current prob-
lems. I told her that what I was depicting was only a preliminary understanding of what was
happening in her life, and that it would be useful if she could clarify any misunderstandings I
might have, or add further relevant information. Figure 21.1 provides a simplified version of
the diagram that we created together. The ‘starburst’ concepts at the top of the diagram represent
strengths and resources. What I was trying to do, through this technique, was to introduce mul-
tiple ways of understanding her problems, in a way that would allow her the possibility of
selecting which perspective might be most relevant for her at this point in time. I was also hop-
ing to create a scaffold for collaborative work, in the sense of offering a framework that could
be modified and adjusted in line with her own ideas and experience. The ‘formulation timeline’
reflected what I could offer Ellie, in terms of my own skills and knowledge as a therapist –
another therapist working with the same client would have different things to offer.

21_Dryden & Reeves_Ch-21.indd 567
Memories
of
ic grandmother
Mus
ation
Determin
STRENGTHS and
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rti resilien
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Su GP
FIND
SOMEONE
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rien ME
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ho
at sc lege
col WANT TO
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t Not able
– absen to take
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m Wo ding to peop
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Eating is “all FOR ALL
Mother
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– unpre ve LOSE
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of brothers
Not good enough
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CHILDHOOD NOW FUTURE
Figure 21.1 Simplified example of the use of a time-line collaborative formulation
08-Oct-13 10:33:37 AM

Ellie agreed that all of the potential counselling tasks identified in the timeline diagram made
sense to her, and were important. Her immediate priorities were to ‘fight my fears by getting
a handle on how much I am stressed out by my academic work’ and to find ways to ‘get more
support’ from other people in the university. She saw these two issues as closely linked, and
that it would only be possible for her to tackle the other tasks outlined in the timeline once
she ‘felt a bit more secure’. The next six sessions followed a pattern of work that was
informed by ideas from cognitive and behavioural therapy and social skills training, and my
own experience as a university tutor. We identified the specific situations in which Ellie felt
anxious and engaged in unproductive rumination, analysed the triggers for these events, the
negative thoughts associated with them, and the interpersonal skills that were used by Ellie
to avoid difficult situations and (occasionally) face up to them. We worked together to devise
ideas for how to handle these situations in a more constructive way, which Ellie tried out and
reported back on.
In her feedback to me, Ellie used the Therapy Personalisation Form to convey that she
wanted me to offer her more structure, guidance and challenge. This information was
extremely valuable in helping me to re-align my therapeutic style in accordance with Ellie’s
needs at that time. Gradually, in the remaining weeks of that semester, Ellie began to believe
that she might have a viable future as a student. In the final session before the summer vaca-
tion, we reviewed progress so far, and agreed to keep in touch by email and meet at the start
of the next academic year.
Ellie then went off to spend the summer in her family home. It was clear from the few
emails that Ellie sent me over the vacation that all was not well at home. When we met in
September, she talked at length about the lack of interest that her parents had shown in her,
other than to be critical of the grades she received in exams. Our sessions over the next three
months consisted largely of a review of what it had been like for Ellie to grow up with a
mother who had caught up in a cycle of alcohol misuse and depression. I was aware that Ellie
had become highly sensitive around my acceptance and support. I talked to her about my
experience of being her, and invited her to consider whether and how this perspective might
be relevant to the work we were doing.
This intense connection came to a climax one week when I was five minutes late for the
start of a session, and arrived at the counselling room to find Ellie beside herself, caught
up in tears and rage because I had forgotten about her. I carefully explained that I had been
held up by a phone call that had come in immediately after a previous appointment, that I
had never let her down before, and that if I ever needed to miss a session I would make
sure that she was informed in advance. We talked about her response to my absence, and
she realised that her response that morning had been a replay of what she had felt on many
occasions when her mother had not been in the house when she came home from school.
Working through the meaning of that episode had the effect of allowing Ellie to become
more confident in her relationship with me. She became more proactive in setting the
agenda for counselling, and more able to say what she felt. This shift began to be apparent
in relationships with other people.

The final year of intermittent contact was characterised by a sense of two people being in
open dialogue with each other, as Ellie moved to a stage of using me as a sounding board to
talk through specific issues that arose, such as joining the university choir, looking at her
options following graduation, and dealing with her fears around committing emotionally
herself in a relationship with a new boyfriend. During this period, Ellie also attended an
‘Understanding your Eating’ (Buckroyd, 2011) course that was running within the university
community.
My work with Ellie involved using ideas, methods and relational styles drawn from CBT,
transactional analysis, person-centred and psychodynamic approaches, at various points in
the process of therapy.

Ellie accomplished the goals that she had identified at the start of counselling – to handle
the demands of university life, and to be less alone and isolated. The CORE-OM scales that
she had completed on a regular basis over the course of therapy indicated a reduction from
a moderate/severe level of distress to a score that hovered around the threshold of the ‘nor-
mal’ range. By the end of therapy, Ellie had gained a degree, left home once and for all, was
in a stable and loving relationship, and had a job that was satisfying to her. She had stopped
talking about ‘fighting’ and instead was busily ‘building’ a new life. She still felt unhappy
and unsure of herself at times, and had a tendency to resort to secretive binge eating when
under stress.
A pluralistic stance in relation to therapy practice invites consideration of the potential

contribution of all available therapy theories and methods, as well as a wide range of
cultural resources. As a result, there are many ways in which pluralistic principles can be
articulated in therapy practice. At the present time, only a few of these possibilities have
been explored.
5.1 Developments
5.1.1 Brief therapy
A pluralistic framework provides both therapist and client with a range of strategies for working
effectively within time limits. The process of identifying specific therapeutic tasks, and prior-
itising which tasks are most urgent, allows client and therapist to make choices around what can
be done in the time that is available. The pluralistic model of practice incorporates several
therapeutic procedures that are found in empirically validated brief therapy protocols, such as
the adoption of a strengths paradigm, attention to the potential value of extra-therapeutic
resources, and flexible scheduling of sessions.


The pluralistic framework for practice described in the present chapter represents a therapy
approach that places cultural factors, and sensitivity to human diversity, at the heart of ther-
apy. The flexibility of pluralistic therapy, and the specific procedures that are used to engage
with client preferences and cultural resources, mean that the cultural identity of every client
is regarded as playing a central role in the process of therapy. Pluralistic therapy is open to
the incorporation in therapy of a many different modes of delivery, such as group work, the
use of email and letters, outdoor therapy and bibliotherapy. Further developments in plural-
istic therapy include the use of client–therapist collaborative decision-making around the
length and scheduling of sessions, and services that enable joint working between psycho-
therapists and practitioners of complementary therapy, education, social work, healthcare,
outdoor pursuits, fitness training, yoga, and many other activities that promote personal
growth, healing and learning. A pluralistic framework provides a robust framework for car-
rying out therapy in setting that impose time limits, because it includes a structured approach
to arriving at an agreed focus for therapy and agreeing on what can be achieved within the
time that is available. A pluralistic framework also calls on the therapist to explore extra-
therapeutic resources that a client might utilise.

An important limitation of all forms of individual therapy concerns the capacity to respond
adequately to the needs of people who have been severely damaged in their lives, or who lack
social support. In such instances, responsible practice involves the exploration of other
sources of help that might be pursued alongside, or instead of, individual therapy. Clients
who present with highly specific problems, such as severe and long-term depression, eating
disorders, obsessive-compulsive disorders or other psychiatric categories may benefit from
working with therapists who can draw on advanced training and lengthy experience in a
particular area. An example of a pluralistic approach to working with clients with a specific
disorder (in this instance, depression) can be found in Levine (2007). Pluralistic therapy is
also likely to be of limited value for clients who seek a specific type of therapy experience.
For example, a client may have read about, or attended a workshop on, gestalt therapy, psy-
choanalysis, narrative therapy or any other ‘brand name’ approach, and decide that they
would like to commit themselves in that way of working.

There have been three different types of critical response that have been made in relation to
the development of pluralistic therapy. First, it has been suggested by some commentators that
it is unhelpful or even confusing to use the concept of pluralism to characterise a particular
approach to therapy, rather to retain it as a term that describes a more general attitude or value
position. Second, there have been strong objections to pluralistic therapy by individuals who

uphold the central or fundamental significance of a single change process or conceptual

model. For example, anyone who believes that good therapy requires analysis of the transfer-
ence, or access to primary emotions, or uncovering negative automatic thoughts, is likely to
believe that a pluralistically-oriented attention to client preferences and multiple change pro-
cesses merely represents a distraction from what the client ‘really’ needs. A third area of criti-
cism of pluralistic therapy concerns aspects of how it is implemented in practice. Examples of
this area of critical response include questions around the nature of training in pluralistic
therapy, the possibility that explicit client-therapist collaborative conversation may exclude
the emergence of unconscious material, or the risk that the client’s preferred way of working
may represent an avoidance strategy. Each of these critical perspectives represents a valuable
contribution to the development of a pluralistic framework for practice, within the spirit of a
pluralistic ‘both/and’ dialogue.
5.4 Controversies
At the present time there have been no specific controversial issues associated with the use
of a pluralistic framework for practice.
6 RESEARCH
As a recent development within the field of therapy, the pluralistic approach has yet to gen-
erate a substantial evidence base. However, the development of pluralistic therapy has been
strongly influenced by research in a number of areas, such as the importance of client-
therapist goal consensus, the nature of client preferences for therapy, and the power dynam-
ics of the therapeutic relationship (see Cooper and McLeod, 2011; McLeod, 2012). From a
pluralistic standpoint, research evidence is not considered a ‘royal road’ to understanding
what works in therapy, but is considered one important means – alongside clinical experi-
ence, theory and life experiences – of attuning more closely to what clients may find helpful.
Current research projects include studies of the experience of training in pluralistic therapy,
the use of feedback tools, and the effectiveness of a pluralistic approach in therapy with peo-
ple suffering from depression. Research, using qualitative interview methods, has also
focused on the aspects of therapy that particular groups of clients find helpful, such as HIV-
positive clients, and clients with cancer (Omylinska-Thurston and Cooper, 2013). Because a
pluralistic perspective calls for the adaptation of therapy methods within the specific context
of each client, systematic case study methods represent an appropriate means of documenting
and analysing the process and outcomes of pluralistic therapy (McLeod and Cooper, 2011;
McLeod, 2013; Miller and Willig, 2012) There is also an interest in developing tools that can
facilitate client-therapist collaboration and the tailoring of the therapeutic relationship, such
as the Therapy Personalisation Form (Bowen and Cooper, 2012), and goal outcome measures
(see www.pluralistictherapy.com).

7 FURTHER READING
Cooper, M. and McLeod, J. (2007) A pluralistic framework for counselling and psychotherapy: Implications for
research. Counselling and Psychotherapy Research 7: 135–43.
Dryden, W. (2012) Pluralism in counselling and psychotherapy: Personal reflections on an important development.
European Journal of Psychotherapy and Counselling 14: 103–11.
Hanley, T., Humphrey, N., Lennie, C. (eds) (2012) Adolescent Counselling Psychology: Theory, Research and
Practice. London: Routledge.
Levine, B. (2007) Surviving America’s Depression Epidemic: How to Find Morale, Energy, and Community in a
World Gone Crazy. White River Junction, VT: Chelsea Green Publishers.
8 REFERENCES
Anderson, T., Ogles, B.M., Patterson, C.L., Lambert, M.J., Vermeersch, D.A. (2009) Therapist effects: facilitative
interpersonal skills as a predictor of therapist success. Journal of Clinical Psychology 65: 755–68.
Bayne, R. (2012) The Counsellor’s Guide to Personality. Understanding Preferences, Motives and Life Stories.
London: Palgrave Macmillan
Bowen, M. and Cooper, M. (2012) Development of a client feedback tool: a qualitative study of therapists’ expe-
riences of using the Therapy Personalisation Forms. European Journal of Psychotherapy and Counselling 14:
47–62.
Buckroyd, J. (2011) Understanding Your Eating. How to Eat and Not Worry About It. Maidenhead: Open University
Press.
Cooper, M. and McLeod, J. (2007) A pluralistic framework for counselling and psychotherapy: implications for
research. Counselling and Psychotherapy Research 7: 135–43.
Duncan, B.L., Miller, S.D., Wampold, B.E., Hubble, M.A. (eds) (2010) The Heart and Soul of Change. Delivering
What Works in Therapy (2nd edn). Washington, DC: American Psychological Association.
Eells, T. (ed.) (2007) Handbook of Psychotherapy Case Formulation (2nd edn). New York: Guilford Press.
Finn, S.E., Fischer, C.T., Handler, L. (eds) (2012) Collaborative/Therapeutic Assessment: A Casebook and Guide.
New York: John Wiley & Sons, Inc.
Hansen, J.T. (2006) Counseling theories within a postmodernist epistemology: new roles for theories in counseling
practice. Journal of Counseling and Development 84: 291–7.
Jennings, L. and Skovholt, T.M. (1999) The cognitive, emotional and relational characteristics of master therapists.
Journal of Counseling Psychology 46: 3–11.
Kraus, D.R., Castonguay, L., Boswell, J.F., Nordberg, S.S., Hayes, J.A. (2011) Therapist effectiveness: implications
for accountability and patient care. Psychotherapy Research 21: 267–76.
Lampropolous, G.K. (2001) Common processes of change in psychotherapy and seven other social interactions,
British Journal of Guidance and Counselling 29: 21–33.
Levine, B. (2007) Surviving America’s Depression Epidemic: How to Find Morale, Energy, and Community in a
World Gone Crazy. White River Junction, VT: Chelsea Green Publishers.
McLeod, J. (2012) What do clients want from therapy? A practice-friendly review of research into client prefer-
ences. European Journal of Psychotherapy, Counselling and Health 14: 19–32.

McLeod, J. (2013) An Introduction to Counselling (5th edn). Maidenhead: Open University Press.
McLeod, J. (2013) Process and outcome in pluralistic transactional analysis counselling for long-term health condi-
tions: a case series. Counselling and Psychotherapy Research 13(1).
McLeod, J. and Cooper, M. (2011) A protocol for systematic case study research in pluralistic counselling and
psychotherapy. Counselling Psychology Review, 26(4): 47–58.
Miller, E. and Willig, C. (2012) Pluralistic counselling and HIV-positive clients: the importance of shared under-
standing. European Journal of Psychotherapy and Counselling 14(1): 33–46.
Nissen-Lie, H.A., Monsen, J.T., Ronnestad, M.H. (2010) Therapist predictors of early patient-rated working alliance:
a multilevel approach. Psychotherapy Research 20: 627–46.
Omylinska-Thurston, J. and Cooper, M. (2013) Helpful processes in psychological therapy for patients with
primary cancers: a qualitative interview study. Counselling and Psychotherapy Research. doi:
10.1080/14733145.2013.813952
Szasz, T.S. (1961) The Myth of Mental Illness. New York: Hoeber-Harper.
Thoma, N.C. and Cecero, J.J. (2009) Is integrative use of techniques in psychotherapy the exception or the rule?
Results of a national survey of doctoral-level practitioners. Psychotherapy 46: 405–17.
Westbrook, D., Kennerley, H., Kirk, J. (2011) An Introduction to Cognitive Behaviour Therapy: Skills and
Applications (2nd edn). London: Sage.

PART VI
Professional Issues
22_Dryden & Reeves_Ch-22_Part-6.indd 575 08-Oct-13 1:57:19 PM

22
Research in Individual
Therapy
Andrew Reeves
1 INTRODUCTION
1.1 The nature of research

The previous chapters in this Handbook have all reported on the historical development
and contemporary application of a number of key approaches in individual therapy in
Britain. They represent a rich tradition of work undertaken by theorists, academics,
practitioners and researchers over many decades, each of which making an important
contribution to the evolution of philosophical ideas and principles in the pursuit of the
delivery of therapy. Timulak argues two primary reasons for undertaking research into
individual therapy: to inform therapeutic practice and to serve as the ‘justifier of the
therapeutic endeavour’. The first reason brings an ‘otherwise inaccessible outsider per-
spective’ (2008: 3) to the nature of the therapeutic relationship and supports the thera-
pist in their own reflective position. The second refers to the wider societal investment
in the provision of therapy and the need for its efficacy and value to be clearly and
objectively outlined.
Behind this evolution of course, sits much debate and contention as to the relative effi-
cacy and value of each approach that, in turn, shapes a research agenda and push for an
evidence-base. For many decades the field of individual therapy has been shaped by two

578 PART VI: PROFESSIONAL ISSUES
broad discourses. The first relates to whether change has occurred because of therapy and
secondly, what factors take place during therapy (of any approach) that contributes to
improvement or deterioration in the client’s presenting problems?
1.2 Discordant discourses

The focus on the outcome and process of therapy has fascinated practitioners and
researchers alike, and research into individual therapy can be very broadly categorised
accordingly. However, despite these two discourses being as embedded in the processes
of practice, as they are research, a research-practice divide still exists (Norcross and
Lambert, 2011). Perhaps there are a number of reasons for this: while research has tended
to be viewed as only constituted by large scale trials drawing on extensive data sets, the
practice of individual therapy is a much smaller process, focusing on the nuances and
interchanges between two human beings; research is often viewed as a ‘scientific’ positiv-
ist endeavour, the outcomes of which simply do not translate to a relational paradigm;
research is assumed to take place in academic settings that are not located in the ‘real
world’ of therapy practice; and researchers, and therefore academics, are again far
removed from the experience of delivering therapy.
It is possible to debunk all these assumptions as misguided and inaccurate. While quantita-
tive research may draw on large-scale studies, such as randomised controlled trials (RCTs),
many other research methods, such as those within a qualitative paradigm, instead utilise
much smaller sets of data often drawn from narratives and stories or, in case study research,
from an in-depth analysis of one particular therapeutic relationship. Likewise, while some
methods are rooted within a positivist understanding of truth, many other methods instead are
informed by post-modern ideas and principles of the insights to be achieved from the experi-
ence of a few. While a great deal of research is undertaken in academic settings, it often
draws on direct client experience and is thus bridged back to the ‘real-world’ of practice.
Finally, and linked to the previous point, many researchers are academics but also work as
practitioners and many practitioners are also researchers. When the actuality of the researcher-
practice gap is explored it tends not to be the capacious schism it is often perceived to be.
Instead, the gap might instead be constituted of fear and anxiety of therapists who see the
world of research as sitting beyond their competency and understanding. These issues will be
further explored later in the chapter.
1.3 Quality vs quantity

In the same way that not all individual therapies are helpful, nor all individual therapists
effective, not all research is of quality or is relevant. It is often difficult to differentiate good
quality research in the swaths of papers that appear in journals and online sources. If the point
of research is to ask questions and explore assumptions in a systematic and rigorous way, the
means by which this is undertaken is important. That is, the method employed by researchers

RESEARCH IN INDIVIDUAL THERAPY 579
will help shape the value and meaning of research outcome. It is this context that informs a
wider consideration of research into individual therapy.
This chapter will begin by exploring some of the issues that sit behind research into indi-
vidual therapy before moving on to a discussion of some of the key findings. We will begin
with a brief historical overview of the development of a research culture before then consid-
ering contemporary contextual issues, including: research competency and training; what is
meant by evidence-based practice and practice-based evidence; questions of methodology,
including the use and value of randomised controlled trials (RCTs) and their relevance to
therapy; as well as some of the developing aspects in individual therapy research, such as
practice-research networks and competency frameworks. Finally, we will identify some of
emerging areas in research, criticisms and explore some questions about the dissemination of
research findings and their accessibility to a practitioner audience.
2 AN EMERGING RESEARCH CULTURE IN INDIVIDUAL THERAPY
Russell and Orlinsky (1996) outlined four main phases in the historical development of
research into individual therapy: (1) establishing scientific research (1927–54); searching for
scientific rigour (1955–69); expansion and organisation (1970–83); and consolidation and
reformulation (1984–present). McLeod, in his opening paper for the then new Counselling
and Psychotherapy Research (CPR) journal, of which I later had the privilege to become
Editor, talked of the historical context of research in setting an argument for the value of
research into individual therapy. McLeod notes three periods in the history of counselling and
psychotherapy research significant to the development of the relationship between research
and practice: 1890s to the 1930s; the 1950s; and the 1960s to the 1970s. According to
McLeod, the first period represented the birth of psychoanalysis and the extensive use of case
studies as a research method to document and communicate the emerging and evolving the-
ory. The 1950s saw the work of Carl Rogers, with the new client-centred therapy depending
on ‘extensive collaboration between clinicians, researchers and theoreticians, who identified,
measured defined and tested the elements of client-centred theory’ (2001: 4). Finally, in the
1960s and 1970s the use of single-subject case studies (n = 1) by cognitive behavioural
therapies (CBT) in evaluating the effectiveness of CBT techniques. Later developments,
particularly in the UK, have seen an increasing take-up of qualitative and other research
paradigms and the growing profile of the practitioner-researcher.
McLeod (2001: 3) draws some helpful lessons from the historical development of research
into individual therapy:
• Research method needs to be consistent with the approach of therapy being investigated.
• Research and practice need to be viewed as integrated activities rather than discretely.
• Research is a collective process where teams should work collaboratively.
• Research with the greatest impact (during the phases outlined) has been ‘bottom-up’ rather than ‘top-
down’. That is to say, the most powerful research takes place in the hands of practitioners.

Despite these lessons McLeod notes that the last thirty years has seen more divergence than
convergence in individual therapy research and practice, with few practitioners in surveys
both in the US and UK demonstrating an interest or engagement in research.
3 RESEARCH AWARE OR RESEARCH ACTIVE
For many years a great deal of counselling and psychotherapy training in the UK took
place in non-academic settings and did not require students to possess academic qualifica-
tions prior to training, or recruited from other, allied professions (such as social work,
nursing etc.). This non-graduate demographic has, for several years (and many still hold
this view today), been recognised as one of the strengths of individual therapy. That is,
the profile of individual therapy has been more informed by wider skills, qualities and
experience rather than simply academic background. However, one consequence has been
that many of the psychology-orientated papers published in the US and influential of aca-
demic development in the UK have fallen outside the experience of many UK practition-
ers. McLeod (2001: 5) notes that, ‘many of these people find “psychological” research
papers unreadable, but also unreasonable in their denial of wider social realities, and
objectification of personal experience and feeling’. In short, UK practitioners did not
welcome the type of research not borne out of their cultural imperative of privileging
relational and experiential information.
With this background it is ambitious therefore, to imagine UK therapists will all be (or
should be) active researchers. The move to incorporate research-awareness into individual
therapy training is an important step in providing an opportunity for practitioners to begin
their engagement with research outcomes so that practice is informed by research and, in
turn, practice informs research. Competency in research awareness contributes to cultural
change in individual therapy. Likewise, as more UK therapists enter training at an under-
graduate or graduate level, with an expectation of them undertaking a research study of their
own, or qualified therapists returning to study at Masters or doctoral levels, more practition-
ers are becoming research active.
4 EVIDENCE-BASED PRACTICE AND PRACTICE-BASED EVIDENCE
Linked to the slow but steady increase in research-interest in the UK is the discourse of an
evidence-base for individual therapy. This is now a familiar term to many therapists who
understand that, either through choice or requirement, the commissioning imperative is a
need to demonstrate the efficacy of what they do through establishing a sound evidence-
base. Funding follows ‘facts’ it seems, although the nature of the ‘facts’ being generated is
cause for much disharmony. Thus, in the current culture this helps to ensure funding and
continuation of services as well and an increase in client choice. The term ‘evidence-base’

simply means that individual therapy is based on empirical evidence of what works. It is a
‘top-down’ concept in that the assumption made is that therapeutic approaches are changed
and developed through the interpretation of evidence drawn from empirical studies, such
as RCTs.
As has been outlined already, there is often a resistance to this top-down approach, with
many individual therapists questioning the validity of broadly generated research findings to
the development and application of therapy. Additionally, evidence-based practice tends to be
based on evidence interpreted from quantitative studies with very specific methodological
definition, often excluding evidence from other types of research, such as those studies using
qualitative method, for example. The fact that many UK individual therapists are drawn to
qualitative method, generating data from narrative and discourse (as this tends to most
closely reflect the discourse-orientated nature of therapy itself) creates further divide and a
perceived incompatibility in epistemology and ontology.
Recently Cooper argued for the validity of RCT evidence (amongst other evidence) in the
development of individual therapy, which was not met with universal approval. Cooper
(2011: 10–16) outlined what might be considered as alternatives to accepting the value of
RCT evidence in the development of counselling and psychotherapy but concluded that all
but the final point fell short of what was required:
• trust that policy makers will come to see the value of non-RCT research;
• focus on non-NHS sectors;
• hope that someone (else) will develop the RCT evidence for counselling and other non-CBT therapies;
• challenge the value of RCT evidence;
• appeal directly to service users and providers;
• develop and promote rigorous non-RCT evidence;
• or, as Cooper (2011: 14) finally suggests, ‘Compromise … and develop skills and knowledge in conduct-
ing RCTs’.
While Cooper’s paper offered a compelling argument for the development of skills and
knowledge in conducting RCTs, it noted, and suffered from, an ideological divide around
research that, some might argue, continues to hinder the development of individual therapy
in the UK. Perhaps in the face of this resistance an increasingly popular approach amongst a
practitioner base is practice-based evidence, where evidence is generated from within therapy
as opposed to outside of it. Popular because therapists can more easily see the place of prac-
tice in the development of evidence and thus have a greater sense of their contribution and
thus, an ownership of outcomes.
The sense of ownership of evidence here is key in that ownership as a concept is one
important thread running through the research-practice debate. Through therapy training,
which focuses in great depth and detail on theoretical concepts, individual therapists
develop an allegiance rooted in theory to what they do and how they do it. This may, in turn,
be shaped by the setting in which therapy takes place, but essentially individual therapists
are likely to be drawn to an approach most consistent with their world-view. Additionally,

an allegiance to an approach will also be informed by other, more pragmatic factors, such
as the time and financial costs of training and other investments made in obtaining a quali-
fication. As a consequence individual therapists might more generally be described as
approach-centric, developing and finessing their therapeutic competency through accumu-
lated experience of direct client work, in supervision and peer contact. If research outcome
appears disconnected from, or contraindicatory to, the philosophies and ideas of an acquired
and embedded approach to individual therapy then it is more likely to be seen to sit outside
of a practitioner’s core knowledge. However, if research outcome can be seen to emerge
from within therapy, generated by the therapeutic collaboration between therapist and client,
its relevance and applicability to practice is more evident. In the development of evidence,
however, practice-based evidence and evidence-based practice form part of a bigger picture
in that neither, on its own, provide for sufficient understanding or rigorous evidence-based
for practice.
5 THE DEVELOPMENT OF COMPETENCY AND ADHERENCE
As is discussed in Chapter 23 of this Handbook, there has been a great deal of variance in the
quality and standard of training in individual therapy over many years. Courses have varied
on entry requirements, level of qualification, extent of skills and theory delivery, require-
ments for personal therapy and supervision, numbers of hours required as part of a practice
placement etc. Some UK professional bodies, such as the British Association for Counselling
and Psychotherapy (BACP), the United Kingdom Council for Psychotherapy (UKCP) and
the British Association for Behavioural and Cognitive Psychotherapies (BABCP) for exam-
ple, have taken steps to try and benchmark minimum standards for training through their
registered or accredited training course programmes. While this is clearly relevant for wider
standards in the delivery of psychological therapies, it also has relevance for research in
individual therapy too. For example, it is difficult to measure the efficacy of person-centred
therapy, for example, without being clear what is actually being delivered in the name of
person-centred therapy.
A means of responding to this challenge is through the development of competency frame-
works for particular therapies (what therapists should be able to do competently), which can
be used to inform the concept of manualised treatments (how therapists should deliver a
therapeutic approach) and then adherence measures (a measure to determine adherence to the
manualised therapy). While CBT approaches draw more heavily on manualised treatments as
integral to the delivery of therapy, humanistic and psychodynamic approaches, which tend to
evolve through the emerging dynamics of a relationship, might be more variable in their
delivery. The development of the humanistic competencies (Roth, Hill and Pilling, 2009) is
a good case in point, where competency in the delivery of effective humanistic therapy has
been mapped out. This makes an important contribution to clearly defining what, specifically,
is effective humanistic therapy based on research evidence.

The emergence of competency frameworks contributes to the development of manualised

treatments, which outline how a particular individual therapy should be delivered. The work
by BACP on counselling for depression (Hill, 2010), which developed a core curriculum and
manualised treatment programme based on person-centred and experiential therapies as part
of the UK Improving Access to Psychological Therapies (IAPT) initiative, was informed by
the competency framework described above. The establishment of this manual then allowed
for the development of adherence scales (to measure the degree to which therapists deliver
particular therapy in line with the manualised guidelines), such as the one developed by
Freire and colleagues (Freire, Elliott and Westwell, 2010) on adherence to person-centred and
experiential psychotherapies (PCEPS Scale). All these pieces of work were instrumental in
developing a proposal for an RCT into the effectiveness of counselling for depression that,
in time, will make a contribution to the evidence-base for counselling for depression. This
evidence will be important in informing future incarnations of the National Institute for
Clinical Excellence’s (NICE) treatment guidelines.
6 PRACTICE-RESEARCH NETWORKS
With the increasing interest in practice-based evidence and the move towards further devel-
oping the concept of practitioner-researcher, the challenge has been to find ways of harness-
ing the power of larger number of practitioner-researchers to develop substantial evidence.
The reality is, of course, that practitioners work in very diverse and disparate settings and
finding mechanisms through which they can work collaboratively in gathering data within
the context of a defined research question with a clear methodological base is challenging at
best. Practice-research networks (PRNs) can provide a structure and help address some of the
pragmatic and practical difficulties. Borkovec (2002: 99) defines PRNs as ‘large numbers of
practising clinicians and clinical scientists brought together in collaborative research on
clinically meaningful questions in the naturalistic setting for the sake of external validity and
employing rigorous scientific methodology for the sake of internal validity’. PRNs have been
established for some years and have made important contributions to the evidence-base in
psychology and psychotherapy. In the USA, early PRNs were developed in medicine, such
as one developed by the American Psychiatric Association, and also psychology, by the
The picture is similar in the UK with PRNs established initially in field of medicine and
health, such as the National Cancer Research Network. PRNs are now increasingly used in
the field of psychology and psychotherapy, such as the Art Therapy PRN. BACP have since
launched two PRNs, one looking at developing collaboration in research into supervision
(Supervision Practice Research Network: SuPReNet) and the other looking at counselling
with children and young people in school settings (Schools-Based Counselling Practice
Research Network: SCoPReNet). The routine use of outcome measures can be one means
through which PRNs can develop large data-sets for future analysis. The Clinical Outcomes

in Routine Evaluation outcome measure (CORE-OM: www.coreims.co.uk) has provided

for an excellent opportunity in data collection across a wide range of services, either at
pre- and post- intervention or on a session-by-session basis. For example, a study by Stiles
et al. (2008), replicating a previous study with a larger sample, looked at pre- and post-
CORE data for person-centred, CBT and psychodynamic therapy as practised in UK health
care settings. The study found similar reductions in CORE scores post therapy across all
approaches.
7 RESEARCH INTO INDIVIDUAL THERAPY
Having set a context within which research findings might be usefully considered, the
purpose of this section is to provide an overview of some of the key aspects emerging
from research into individual therapy. These will be focused around several key areas:
research into outcomes; the relationship; differences in approaches; and factors relating to
therapists and clients specifically. Word limitations mean that what will be offered will be
an overview of such findings. I have made a number of suggestions in ‘Further reading’
of books that provide an in-depth analysis of findings. More specifically, Cooper’s (2008)
excellent text, which provides an accessible summary of key findings and how they relate
to practice, as well as Lambert’s 6th edition (2013) of the classic Bergin and Garfield’s
Handbook for Psychotherapy and Behavior Change, which is essential reading for any
individual therapist interested in either becoming a critical consumer of research or a
practitioner-researcher.
7.1 Research into outcomes in individual therapy

There has been extensive research over the years into whether individual therapy is helpful.
That is, do clients who attend for individual therapy improve because of their therapy? There
are two areas to consider here: at the most general level, is therapy helpful? Secondly, do
clients feel better? The research evidence over the years has consistently demonstrated that
therapy is helpful and that clients do improve because of it. Norcross and Lambert (2011)
note there are many factors that contribute to therapy outcome, including: the treatment
method; the client; the context, the therapist; the relationship and alliance. Outcome measures
can be one mechanism through which outcome is measured (set against pre-therapy scores),
and the paper by Stiles et al. (2008) provides an excellent example of how such measures are
helpful in exploring changes in the level of client distress before and after therapy. However,
they do not necessarily demonstrate that it was the therapy that facilitated the change. It is
not uncommon for people to improve naturally over time, or because of other reasons. It is
therefore hard to conclude that the individual therapy was responsible for improvement sim-
ply because an outcome score is improved. To really judge the efficacy of therapy outcomes
the right method of research is required.

It is in this context that the power of RCTs becomes apparent. RCTs employ a control
group (a group of people comparable to those receiving therapy, but who don’t receive the
therapy) and gained prominence in medicine in being able to test the efficacy of pharmaceu-
tical interventions by comparing changes between those receiving the treatment, and those
who did not. In psychology and therapy RCTs, clients are accepted into a trial in virtue of
presenting problems, e.g. depression (usually diagnosed and measured against proven meas-
ures). They are then randomly allocated to a ‘treatment’ or ‘non treatment’ group (who would
receive ‘treatment as usual’, e.g. monitoring by their GP). If the group receiving therapy
improves while the non-treatment group do not, that would be seen as a stronger case for the
efficacy of the treatment being investigated, just as would be the case in drug trials.
While an RCT in isolation can be good evidence, several evaluated together, through the
process of a meta-analysis, can provide more compelling evidence. Thus, the drawing
together of outcomes of many RCTs through a meta-analysis can develop a stronger evi-
dence-base for a particular intervention; Wampold (2001) noted that by 1993 there were over
40 meta-analyses of individual therapy outcomes. The first meta-analysis to make a signifi-
cant contribution to our understanding of the efficacy of individual therapy was conducted
by Smith and Glass (1977), who evaluated 475 studies; they then replicated this at a later date
with additional research. Both these meta-analyses provided strong evidence for the efficacy
of individual therapy. Later meta-analyses, which followed the work of Smith and Glass,
have each in turn replicated these findings, further supporting the value of individual therapy.
An analysis of these studies indicates that a client entering into therapy is 80 per cent better
off than a person not receiving treatment with similar presenting problems.
Lambert and Bergin (1994) considered a number of presenting problems in looking at the
effectiveness of individual therapy. In addition to the work on depression they also noted
positive outcomes for the treatment of agoraphobia, anxiety, panic disorder and substance
misuse, while Roth and Fonagy (2005) note efficacious counselling and psychotherapy treat-
ments for a full range of mental health problems, including post traumatic stress disorder
(PTSD), eating disorders, psychosis, substance abuse, personality disorders and sexual prob-
lems, for example. Additionally, a number of researchers have concluded from the evidence
that therapy appears to be equally effective with adults, young people and their families
(Lambert and Bergin, 1994; Lebow and Gurman, 1995; Weisz, Huey and Weersing, 1998),
with outcomes at least as good as, or equivalent to, medication (Lebow, 2006). It is worth
noting that when individual therapy was offered in conjunction with medication for bi-polar
affective disorder the combination of the two seem particularly effective.
Lambert and Bergin (1994) offer a cautionary message, however, and state that 20–40 per
cent of clients do not improve in therapy, to the point of achieving the level of functioning as
those without the difficulty, and that around 5–10 per cent may deteriorate (Lilienfeld, 2007).
A summary of these points can be found in Table 22.1. Overall, however, drawing all the
evidence over the last few decades of extensive research into the efficacy of individual
therapy, there is now general consensus as to it leading to positive outcome for many across
a range of presenting problems and client demographic; as Wampold writes, ‘Simply stated,
psychotherapy is remarkably efficacious’ (2001: 71 – original italics).

Table 22.1 Summary of findings
• Outcome research has been a prominent focus of enquiry for several decades of research
• Meta-analysis of RCT evidence has provided the most robust insight into the efficacy of therapy outcome
• Evidence suggests that a person entering into individual therapy is generally 80% better off than someone with similar
problems not receiving treatment
• Individual therapy seems to be equally effective with adults, young people and children
• The outcomes of individual therapy can be at least as good as, and sometimes better than, the use of medication (and can
be additionally efficacious if used in combination with medication for certain problems)
• Not everyone improves following individual therapy, with 20–40% of people not improving to an equivalent level of
functioning as someone without the difficulty
• 5–10% of clients may deteriorate because of therapy
• Overall, however, individual therapy has been shown to be very effective across a range of problems
7.2 Research into the relationship in individual therapy

While research has evidenced the value of individual therapy as a efficacious intervention
across a wide range of presenting problems, the particular research into therapy per se does
not say much as to why and how therapy is helpful. Another major focus of research therefore,
is on the therapeutic relationship. This raises an important area of definition that requires
clarity, as while it is assumed by many that it is the humanistic and psychodynamic approaches
that focus more on the relationship as an important factor in therapeutic outcome – and there-
fore cognitive, behavioural and cognitive-behavioural processes do not – as has been demon-
strated through the chapters of this book the relationship is an important aspect for most
approaches in individual therapy. The predominant focus of much research, however, has
been on the therapeutic alliance, as opposed to the relationship in of itself.
The alliance is clearly an important aspect of the relationship and develops from the earli-
est stages. The beginning point of most individual therapies will be the early first meetings
between therapist and client, where the process will begin through the development of a
therapeutic contract. It is during this stage where problems are outlined and shared goals
agreed. The process of goal setting is an important function in the early development of a
therapeutic alliance. Hovarth and Bedi (2002: 41) define the therapeutic alliance as the,
‘quality and the strength of the collaborative relationship between client and therapist’.
Specifically, they note that collaboration and consensus are the most important features of the
alliance that, in turn, inform the relationship. The work of Bordin (1979) is important here in
exploring further what might be meant by collaboration. He noted three main components:
the agreed goals of therapy; the consensus on the task of therapy; and the bond between
therapist and client (the level of trust and confidence). In this regard the therapeutic alliance
can be seen to be pivotal to most individual therapy, regardless of approach, given its col-
laborative nature and is thus not approach-specific.
Beyond the alliance other aspects informing the therapeutic relationship will include char-
acteristics of the therapist, client, as well as the level of trust and faith each has in the thera-
peutic process. Hovarth and Bedi (2002: 41) state that the therapeutic relationship, in addition
to the alliance, includes ‘elements that represent still active components of past relationships

that both client and the therapist bring to the encounter’, however they are termed from
within the language of a specific approach (e.g. transferential, introjects, dysfunctional rela-
tionship schemas etc.). They further note, however, that even when these aspects are taken
into account, research still indicates the powerful impact of the alliance (Gaston, Thompson,
Gallager, Cournoyer and Gagnon, 1998). The practice difference between approaches in
individual therapy might therefore be more about the extent to which the therapist works with
these other aspects of the relationship with the client; the alliance sits at the core of success-
ful outcome. These differentiations are important in contextualising research findings into the
alliance and relationship factors.
The emphasis on the alliance in therapy research is affirmed by Hovarth et al. (2011), who
noted over 7000 items following a search on the alliance in 2009, while Hovarth and Bedi
(2002) note, at the time of their review, there were over 24 different research scales in use to
measure aspects of the alliance. Hovarth and Bedi provide an excellent overview of a range
of studies exploring the relationship between the alliance and therapeutic outcome, and their
work is recommended. Following their evaluation of the available research they state that
‘There is empirical evidence linking the quality of the alliance to therapy outcome’ (2002:
42). Glass and Arnkoff (2000) add, from a qualitative perspective, that clients value a col-
laborative approach in individual therapy, rather than a relationship built on power imbal-
ances. It is additionally worth highlighting that research suggests a strong alliance between
therapist and client can mitigate against client drop-out from therapy (Piper et al., 1999). In
summary, the evidence is clear as to the power of the alliance in positive therapy outcomes.
Hovarth et al. outline a number of important evidence-based practice recommendations that
underpin the importance of the alliance to therapeutic outcome. They state (2011: 15):
• The alliance should not be seen as a distinct aspect of individual therapy, but rather a dynamic embedded
within everything that happens in the relationship.
• Developing a ‘good enough’ (2011: 15) alliance is essential for positive therapy outcome.
• A good alliance helps prevent client drop-out from therapy.
• Responding to client need early in therapy by paying attention to Bordin’s tasks helps build the alliance
and affirms a collaborative position.
• The alliance needs to take into account the resources the client brings to the therapy in determining the
nature of collaboration in response to the client’s problems.
• It is important for therapists to actively monitor the client’s perception of the alliance throughout therapy
and to be aware of simply assuming a client’s positive. perception of the alliance, early on, where this might
not be the case – this can lead to a rupture in therapy and hinder the chance of positive outcome.
• The strength of the alliance will fluctuate in response to a number of factors, including: therapist
challenge; transference; and misunderstandings, for example. If these are managed proactively and
successfully this indicates the potential for good outcome.
• The importance of the therapist responding non-defensively and openly to client challenge is evidenced
in the research as important in sustaining the alliance.
• ‘Recent studies suggest that therapists’ contributions to the quality of the alliance are critical’ (2011: 15).
Where therapists are good at building an alliance with clients, they generally seem to be able to do this
with most clients, and vice versa.

Beyond the alliance and moving onto other relationship factors, research has indicated that
these are important in considering outcome for those approaches that privilege the relation-
ship (such as the humanistic and dynamic approaches), as well as those not typically associ-
ated as relational models, e.g. CBT (Keijsers et al., 2000). An interesting early observation
by Ryan and Gizynski (1971: 8) supports later findings, when they wrote, ‘The patients felt,
and the authors would agree, that the most universally helpful elements of their experiences
(of behaviour therapies) were the therapist’s calm, sympathetic listening, support and
approval, advice and “faith”.’
The relational qualities, as highlighted by Ryan and Gizynski, are not too dissimilar to those
inherent within a person-centred approach, such as empathy, acceptance and congruence. These
have been investigated as part of the research into relational factors and outcome. Bohart et al.
(2002) state that empathy is a more important factor in outcome than specific technique. These
findings have been supported by subsequent studies, and interestingly replicated in helping rela-
tionships beyond individual therapy, such as in the physician-patient relationship (Derksen,
Bensing and Lagro-Janssen, 2013). An important point to note here is one made by Bohart et al.
when they state, ‘While conceptually it may be possible to separate empathy from Rogers’s other
therapeutic conditions of (1) warmth or positive regard and (2) congruence or genuineness, in
practice it is not’ (2002: 102). Despite this, Cooper (2008) states that research into acceptance,
or positive-regard, is not as conclusive as that into empathy, as is the case for congruence too.
This position is affirmed by Norcross and Wampold (2011: 98) who state that ‘congruence/
genuineness, repairing alliance ruptures and managing countertransference were deemed prom-
ising but had insufficient evidence to conclude they were effective’.
Beyond the humanistic models, relational components of other therapy approaches have
been the focus of research, such as in the psychodynamic therapies, including the potential
causes and management of countertransference (Norcross and Wampold, 2011). Gelso and
Hayes (2002) offer a more detailed account of research into this area but to summarise,
research seems to suggest that client factors do not necessarily affect countertransference but
that the more a therapist is able to manage their countertransferential responses, the likeli-
hood is of a better outcome.
Research into the use of transference interpretations has been undertaken, looking at the
frequency of interpretations and their quality. Cooper (2008) notes that research over several
generations seems to indicate that a higher frequency of transference interpretations is
linked with poorer outcome, and that Piper et al. (1999) found that an increased drop-out
from therapy might be associated with a greater focus on transference during therapy.
Self-disclosure, where the therapist reveals something about themselves to the client
during therapy, is more associated with the humanistic and cognitive and behavioural
therapies than the dynamic therapies. Research by Barrett and Berman into self-disclosure
seemed to suggest that increased self-disclosure led to clients reporting lower levels of
distress. However, in a cautionary note they state that, ‘Although therapy was found to be
more effective when therapists increased rather than limited their disclosures, it is impos-
sible to determine from this design whether the difference occurred because increasing
therapist disclosure benefits treatment, restricting therapist disclosure impairs treatment, or

both’ (2001: 602). They conclude that ‘our evidence emphasizes that occurrences of mod-
est levels of therapist self-disclosure is not harmful to treatment’ (2001: 602).
Norcross and Wampold (2011: 101) note a number of important relational considerations
that, from research evidence, could lead to poor negative outcome or indeed be harmful. They
note the importance of the following:
• The therapist avoiding a confrontational style with clients as this has almost always been demonstrated
to lead to negative outcome.
• The therapist avoiding what might be perceived as a critical or judging position in response to client
difficulties or dysfunctional thoughts.
• Therapists not making assumptions about the client’s perception of the relationship (similar to the points
noted by Hovarth et al. (2011) above) as assumptions of client satisfaction and the success of therapy
are often wrong. Frequent enquiries of their clients about their experience of therapy help to promote a
strong and collaborative alliance.
• Making priority the client’s experience of the therapy relationship above that of the therapist’s predicts
best outcome and is central to good practice.
• Empathy, an important aspect in the relationship linked with good outcome, can be undermined if the
therapist takes an overly rigid position with respect to technique and delivery of therapy.
• Flexibility in approach to different client need is essential for good outcome. Applying the ‘same approach
to all’ is not helpful and, according to Norcross and Wampold, can sometimes be unethical.
Cooper (2008: 125–6) offers a useful summary of key findings from research into relational
aspects of individual therapy, including that the quality of the relationship is related to ther-
apy outcome, and that the alliance is consistently linked in research with positive outcome.
Empathy is also linked to outcome, whereas with acceptance and congruence the evidence is
less conclusive. See Table 22.2 for an overall summary of this chapter.
7.3 Research into therapeutic approaches in individual therapy

As outlined earlier, one of the characteristics of the discourse around individual therapy
for several decades has been the comparative efficacy of different individual approaches.
Table 22.2 Summary notes
• The therapeutic alliance as an aspect of the relationship has received the greatest focus for research
• There is strong evidence linking the quality of the alliance to therapeutic outcome
• A strong alliance can help mitigate against client drop-out from therapy
• The therapist’s presence in therapy is important in positive outcome (e.g. calm, supportive and approving)
• Empathy is an important aspect of the relational encounter, more so that therapeutic technique
• The importance of empathy also demonstrate in other professional relationships (e.g. physician-patient)
• How a therapist manages their countertransference response influences outcome
• A higher frequency of transferential interpretations seems to lead to poorer outcome
• Modest levels of self-disclosure can be facilitative of therapy and may lead to improved outcome

Many have asserted the particular values and benefits of their therapeutic approach per
se, but also above other approaches specifically. These debates are generally less fuelled
by differences over technique or skill, but more from a position of philosophy and ideol-
ogy: how the approach views human development, functioning and distress. As Cooper
states, however (2008: 36), with regard to reading the research evidence about the rela-
tive efficacy of different approaches in individual therapy, ‘how one “cuts the cake” – i.e.
how one asks the questions and reads the evidence – makes all the difference to the
answer one gets’.
It is important to be clear about what is being measured. For example, to compare
approaches with each other each therapist delivering the therapy must be doing so suffi-
ciently consistently for comparison to be made. Otherwise, variables, such as particular
characteristics of individual therapists delivering the treatment (the therapeutic approach),
might shape the nature of the outcome. In addressing these concerns around the capacity
to compare like with like, Chambless and Hollon (1998: 7) state that efficacy ‘must be
demonstrated in controlled research in which it is reasonable to conclude that benefits
observed are due to the effects of the treatment and not due to chance or confounding fac-
tors such as passage of time, the effects of psychological assessment, or the presence of
different types of clients in the various treatment conditions’. That is to say, the treatment
was demonstrated as effective without other possible explanatory factors and set against
a comparison of no treatment. They go on to state that replication of findings is an essen-
tial aspect of confirming efficacy, in that the findings must be evident in at least two stud-
ies undertaken by independent research teams for that treatment be labelled as efficacious.
Anything less than that level would label findings as ‘possibly efficacious’ (1998: 8),
pending replication.
Roth and Fonagy (2005) provide an extensive account of individual therapy (and group
therapies also) with an evidence-base for a range of particular presenting problems. They
argue a strong evidence for the benefits of CBT for a range of presenting problems, including:
mood disorders; anxiety disorders; substance dependence; eating disorders; personality dis-
orders; schizophrenia and psychosis; sexual dysfunctions; complicated grief; and health-
related difficulties, amongst others. This evidence assumes, of course, that client presenting
problems can be discretely measured and are sufficiently distinct. While in some approaches
this would be accepted, in other approaches this would be philosophically incongruent with
a view held that the entire concept of diagnostic structure lacks any meaningful experiential
or scientific value at all.
In evaluating the research evidence looking at the efficacy of different approaches the
concept of the ‘dodo bird verdict’ is important here (initially used by Saul Rosenzweig
in 1936 to articulate his hypothesis that there is likely to be little variation in outcome
across a range of approaches; the Dodo bird reference taken from Carroll’s Alice in
Wonderland ‘everybody has won, so all shall have prizes’). Luborsky et al. revisited this
concept and analysed 17 meta-analyses of comparative treatments. Again, and in sup-
port of a number of important and influential studies over the years, they found little

discernible difference in outcome based on therapeutic approach. They stated that, ‘Our
general conclusion, therefore, is that Rosenzweig’s clinically based hypothesis of 1936
has held up. The outcomes of quantitative comparisons of different active treatments
with each other, because of their similar major components, are likely to show mostly
small and non-significant differences from each other’ (2002: 7). Although, some have
criticised the methodology of meta-analysis as not always comparing like with like. As
stated, this might be, in part, due to the fact that when practising an approach different
therapists might do different things in sessions. For example, person-centred therapist
A may deliver person-centred therapy differently from therapist B, even though they
both purport to offer person-centred therapy. This can be mitigated against to some
degree through the use of manualised approaches (discussed earlier), although the is
much debate in the research literature as to the value of manualised treatments also.
It is finally worth noting here that the predominance of evidence for one particular
approach does not demonstrate lack of efficacy for other approaches. Simply, it demon-
strates a lack of evidence generated within the particular research paradigms typically
associated with empirically-supported treatments (e.g. RCTs) for other approaches. As
Cooper (2008: 47) notes, ‘it could be argued that the principal reason that there is so
much more evidence for CBT is because, as a brief structured therapy, it lends itself
much more easily to testing; and because many of its developers are based in academic
institutions where research in encouraged and supported’. In summary then (see Table
22.3), research seems to be pretty conclusive that there are few or no discernable differ-
ences in effectiveness or outcome based on the approach being offered.
7.4 Research into factors relating to the therapist and client

7.4.1 The therapist
Lambert and Bergin (1994) asserted four primary factors in therapeutic change: expec-
tancy and placebo effects (15%); technique and model factors (15%); the therapeutic
relationship (30%); and extra-therapeutic events (such as social context etc.) and client
variables (40%). Cooper (2008) additionally suggests that as the client is as at least as
• Research into the efficacy of the approach needs to address variables, such as how individual therapists practise the
particular approach
• There is extensive research that indicates the efficacy of particular approaches for specific presenting problems. An
approach is deemed efficacious if its benefits are demonstrated by at least two independent research studies
• The Dodo bird verdict (‘everybody has won, so all shall have prizes’), which talks of the equivalence of therapeutic
approaches with respect to outcome continues to be asserted in the research, although some have criticised the meta-
analysis method in reaching these conclusions (not comparing like with like)
• Research over the decades has found little discernable difference in the efficacy of a range of therapeutic approaches

important in the therapeutic relationship as the therapist, together with the client’s expec-
tation of therapy, client factors in terms of influence on outcome could account for nearly
75%. This is known as the ‘common factors model’ of individual therapy: regardless of
approach and technique there are common factors that therapists and particularly clients
bring to therapy that have an important influence on outcome. These might include the
relationship and alliance, client’s perception of the therapist and relationship; therapist
characteristics (warmth, empathy, being non-judgemental); context and techniques, for
example.
Cooper (2008: 80) raises an important question when considering the research into indi-
vidual therapists when he asks, ‘are different therapists (aside from orientation factors) of
differential effectiveness; or is it the case that, as with therapeutic orientations, different
therapists are about equivalent in their outcomes?’ That is to say, are all therapists equal in
their efficacy or are some more equal than others? Luborsky et al. considered the work of
nine therapists practising three approaches in a drugs counselling centre (CBT; supportive-
expressive therapy; and drugs counselling) and, following analysis, found ‘profound differ-
ences’ (1985: 602) in the success of therapists working from the same orientation. While
there were some differences noted between the three different approaches, the biggest varia-
tion occurred at a therapist level.
These findings have been replicated in similar studies on many occasions, and a paper by
Del Re et al. supports this further, with the authors stating:
Specifically, some therapists seem to be consistently better at forming alliances with their patients than
others and these therapists’ patients have better treatment outcomes. Based on these recent findings, it
appears that the quality of the alliance between therapist and patient is more a result of therapist actions
or characteristics and therefore the therapists’ role is the most important for achieving beneficial
outcomes. (2012: 646)
Some of the suggestions about the influence of the therapist on outcome have been chal-
lenged and it is beyond the scope of this chapter to unpick some of the methodological detail
on which this challenge rests. However, Cooper (2008: 82) offers a tentative conclusion
that, ‘it seems that improvement and deterioration rates of different therapists can vary quite
considerably, even when they are attempting to follow the same set of highly manualised
procedures’.
With respect to particular differentiating characteristics of therapists a more detailed
account can again be found in Cooper (2008), but some key points include that little differ-
ence has been found in relation to age or gender of therapist and that there are no discernible
differences in outcome where there is a gender match, (e.g. male therapist and male client
etc.). Sexual orientation, in general terms, does not appear to be an indicator for variance in
outcome although some studies have indicated that lesbian, gay, bi-sexual and transgendered
(LGBT) clients do appear to prefer to work with similar orientation therapists, and that some
of these clients report greater benefit when this orientation match is achieved (King et al.,
2007). For a summary see Table 22.4.

• Research suggests that therapist factors are important in therapy outcome, including forming an alliance, communicating
empathy and technique
• Improvement and deterioration rates in clients can vary according to therapist variables (even when working with
manualised treatments)
• Little difference in outcome is noted with respect to gender or age
• Match of gender between therapist and client does not appear to influence outcome
• There are some differences noted for LGBT clients, who appear to do better with LGBT therapists and those of the same
sexual orientation
7.4.2 The client

The client will bring a number of characteristics and expectations to therapy, all of which
will play some part in determining the process, progress and outcome of that therapy. As
therapists we may reflect on our work with our clients and anecdotally note a comparison
in work with clients who are reluctant, ambivalent or unclear about therapy and their
preferred outcomes, as opposed to those clients with a clear goal, focus and determina-
tion for change. With respect to a client’s level of motivation or involvement in therapy,
Orlinksy et al. (1994: 361) state, ‘The quality of the patient’s participation in therapy
stands out as the most important determinant of outcome. The therapeutic bond, espe-
cially as perceived by the patient, is importantly involved in mediating the process-outcome
link.’ Motivation has been found to be a key factor across a number of studies and with
respect to different presenting problems. Conversely, where a client is reluctant to enter
therapy, or lacks belief in the potential for therapeutic change, this is likely to negatively
effect outcome. Additionally, clients willing to actively engage in therapy, such as under-
taking tasks between sessions, reflecting on the work and ensuring regular attendance
seem to lead to better outcomes. Additional characteristics associated with levels of
engagement, such as not being defensive, being interested, willing and open to change,
for example, all link with positive outcome. Cooper notes that ‘clients who have a lot of
faith in the therapeutic process tend to do better than those who are sceptical about it’
(2008: 64).
It seems it is important for clients to have realistic expectations of what might happen as a
consequence of individual therapy as unrealistic expectations are shown to hinder the benefit
of therapy. With this in mind, and related to the earlier research on alliance and collaboration,
it is important for therapists to actively engage early on with client’s expectations so they can
be carefully match against their goals.
How the client conceptualises their difficulties will influence the nature and progress of
therapy. For example, a client who believes their problems stem from a medicalised under-
standing of their distress, (e.g. my depression is biochemical) but is treated from a psycho-
logical position is less likely to do well. Therefore, those clients who have a psychologically
orientated understanding of their difficulties and a belief in the potential of psychological
therapy are more likely to improve because of therapy.

• Orlinksy et al. (1994: 361) note, ‘The quality of the patient’s participation in therapy stands out as the most important
determinant of outcome.’
• The alliance between therapist is again demonstrated to be important, with a client having a clear sense of goals and focus
for therapy
• The client’s willingness to engage in therapy, attend regularly and work between sessions indicate better outcome
• The level of motivation for change is an important factor
• How client’s understand and conceptualise their problems is influential, (i.e. the greater degree of psychological
mindedness and defining their problems within a psychological ‘frame’)
• Faith and openness in the possibilities inherent in therapy can lead to better outcomes
• It is important for therapists to work with clients so that expectations are realistic and linked to the agreed goals and tasks
of therapy
• A number of other client characteristics can inform therapy outcome, including attachment style, social support network
and previous relational experiences can all be significant
Beyond the immediacy of the therapeutic relationship lie other factors with the poten-
tial to influence outcome, including: the client’s attachment style; nature of a diagnosis
personality disorder (with the number of personality disorder diagnoses a client has being
related to outcome); more general psychological and social functioning; and relational
styles and relationship experiences (the client’s experiences of relationships and their
capacity and willingness to develop trust, or have faith, in a therapeutic relationship).
Additionally, the client’s level of: perfectionism; social support network; psychological
mindedness; demographic features (such as gender, age, ethnicity and cultural back-
ground); and socioeconomic status also relate to psychotherapy outcome. A more detail
analysis of the research related to these areas can be found in Cooper (2008: 62–79) and
a summary of this section in Table 22.5.
8 CHALLENGES FOR RESEARCH INTO INDIVIDUAL THERAPY GOING FORWARD
Throughout this chapter I have outlined what I see as the current context of research into
individual therapy in the UK, as well as providing an insight into some of the key find-
ings from research over several decades that have contributed to our understanding of
what works, and doesn’t, in therapy. Given this, how do these factors prepare us for the
next challenges in research in the field? The status quo raises, in my view, a number of
challenges to address:
• the philosophical divide between research and practice;

• methodological purism or pluralism;
• common research discourses;
• research awareness and competency.

8.1 The philosophical divide between research and practice

As we have previously outlined, collectively the largest proportion of research into counsel-
ling and psychotherapy comes from outside of the UK and is located typically within psy-
chology departments of large universities. That is not to say this does not make good
research, for a proportion of it has made an important contribution both to our understanding
of some of the dynamics of individual therapy, but also towards its development as a viable
option for many clients who, before such research, were left with in-patient and pharmaco-
logical treatments as a front line choice.
However, while on one hand such research evidence is of enormous importance to our
profession, there are cultural and ideological considerations to address. When considering the
position in the UK things are not so clear. While there are many psychology, social work,
nursing, teaching, mental health and medical departments in universities undertaking excel-
lent research with very real implications for the practice of counselling and psychotherapy,
the state of research located within the field of individual therapy itself is more fragile. It may
be argued that research in individual therapy has a lot to learn from research in other, related
areas and that standards in counselling and psychotherapy research have been raised because
of the influence of other disciplines. It is certainly important that counselling and psycho-
therapy remain open to other areas of academic enquiry to help further a rigorous and rele-
vant evidence-base for practice.
However, there are relatively very few centres of excellence in academic settings with a
primary identification being counselling or psychotherapy. There are only a handful of pro-
fessors who, by virtue of their profile and expertise, have the potential to attract sufficient
sums of money to conduct larger scale research studies. While the UK practitioner base
seems to be moving towards a greater research competency, this more often tends to be small
scale, self-funded studies. While these have real potential value and contribution to make to
our understanding, they are hard to locate and thus integrate into a more powerful whole.
They therefore can remain disparate and, too often, unseen by a wider audience at all given
that few practitioner-researchers in the field are encouraged to publish. There is arguably lit-
tle value in research findings if they are never viewed and critiqued by a wider audience.
The ongoing challenge, which has been present for many years already, is to continue to
find ways of bridging the research-practice gap. While this can be achieved through training
and increased awareness, arguably such change will be rooted in ideological and philosophi-
cal shift, so that research awareness becomes as second nature to practitioners as the impor-
tance of supervision and personal therapy currently. Clearly the profession needs to retain its
diversity, not only in demography, but also in perspective and activity and not all practition-
ers will wish to engage in any active way in a research process. However, the development
of structure and support is important in helping those who wish to make a shift towards a
research paradigm.
With this in mind therefore, support from within the field, and then within higher education
institutions themselves, for the centres of academic excellence that currently exist will help them

flourish and, in their wake, new ones be established. This is clearly a process that will happen over
time rather than quickly, but the danger of it not happening at all is that the research agenda and
thus subsequently the nature of individual therapy itself will become more externally defined.
8.2 Methodological purism or pluralism

As we have outlined, the published field of research into individual therapy is shaped heavily
by quantitative, mostly positivist method, drawing on medicine and psychology. The RCT is
still viewed as the ‘gold standard’ for research and is, by such definition, privileged above
many other types of approaches to enquiry. A look at any of the NICE treatments guidelines
for the psychological therapies will quickly confirm the predominance of positivist study. Yet
an increasing body of research into individual therapy in the UK is from within a qualitative
paradigm, drawing instead on phenomenological principles and ideas to reach coherent and,
sometimes, powerful outcomes. Wampold (2001) discusses helpfully the challenges and
implications of a move away from a medical model of research.
McLeod considers the state of methodological purism (the focusing on one particular form
of research method), as opposed to methodological pluralism (the integration from different
perspectives of both method and philosophy in the exploration and acquisition of knowledge)
and states:
Useful research knowledge is not manufactured through the mechanical application of method. Rather
method is used to assist the basic human impulse to know and learn. Perhaps the real significant in the
‘shift in attitude’… lies in the rejection of what has been called ‘methodolatry’ in psychotherapy research
and the beginnings of a movement in the direction of a greater readiness to ‘confront the tensions’
inherent in the research process. (2003: 183)
The tensions McLeod refers to are those inherent in bringing together quite different positions in
epistemology and ontology. This dichotomous positioning is a familiar one for counselling and
psychotherapy that has, for too long, focused on an either/or position with respect to therapeutic
approach, as opposed to the power of a pluralistic positioning. McLeod (2003: 182), drawing on a
range of ideas, points out ways of combining quantitative and qualitative research methods, includ-
ing: the value of triangulation (findings from different studies being used to check findings from
others); the importance of qualitative research facilitating quantitative research (and vice versa);
and how perspective informs the research approach used. The challenge is not to water down the
rigour of method, but instead to continue to enhance the value and status of all relevant method-
ologies for researching counselling and psychotherapy while, at the same time, find imaginative
and compelling ways in which different perspectives in research can inform each other.
8.3 Research awareness and competency

As we have already identified, for many years training in individual therapy in the UK
did not contain any meaningful consideration of research: either to equip trainees to

retrieve and critically consume research evidence, or become practitioner-researchers.

The consequence of this has been a perceived incongruence between the practice of indi-
vidual therapy, and research into individual therapy. Too many practitioners remain
derisive of research and consider that it has no relevance to what they do in their work
with clients.
The same practitioners, however, might also identify themselves as reflective therapists,
considering the nature of their work through supervision or peer consultation, with the
view that such enquiry lies at the heart of ethical and accountable practice. Yet the simi-
larities between what they do in practice and the role of research in informing work are not
acknowledged.
My own experience in editing a practitioner-orientated research journal has been of a
slow but steady shift over recent years. While this is clearly anecdotal evidence, indi-
vidual therapy practitioners generally seem less adversarial in response to research and
more willing to find ways of engaging with it. Books by McLeod (2003) and later
Cooper (2008) for example, have certainly played an important role in that change. As
have initiatives undertaken by professional organisations in offering research confer-
ences for new practitioners to present their findings, as well and embedding into a train-
ing curriculum research awareness while, at the same time, providing tools for therapy
trainers to learn how to deliver research-orientated content effectively. The change may
be slow, but it is in the right direction and the imperative is for the field of individual
therapy, through its practitioners, theorists and academics, to grasp the initiative in set-
ting a research agenda.
8.4 A research dialogue

At a recent meeting I attended I heard two eminent therapy researchers describe research
as a discourse – a dialogue. This was an interesting and liberating description because just
one word stripped away much of the unnecessary (and inaccurate) mystique about
research that has, for too long, been a barrier between research and practice. Individual
therapy has always been, and will continue to be, rooted in dialogue: between therapist
and client. As therapists we are familiar with dialogue and generally are very willing to
find ways of engaging in dialogues that are meaningful and equal. Each chapter in this
Handbook has contained a significant section on a Case example and it is in this section
that the described theory and approach becomes alive, building on the theoretical context
that has been outlined.
Constructing research as a dialogue between: ideas; philosophies; theories; clients;
therapists; outcomes; and processes, for example, has the potential to transform a process
that is too often perceived to be boring and irrelevant and located in ivory towers instead
into the real-world setting of practice. Each approach outlined in this text, without doubt,
will continue to develop and transform through the process of enquiry. Once the therapist
has engaged in the research dialogue they have the potential to make a contribution to that
change.

8.5 Where to from here?

Cooper states: ‘There is much, then, we can be relatively certain of, but reviewing the research
on counselling and psychotherapy seems to throw up as many questions as it answers’ (2008:
157). He then outlines a number of those questions and challenges, including:
• whether particular orientations or techniques are more effective for particular problems;
• whether the Dodo Bird verdict still has relevance;
• the need for greater independence in research to combat concerns about the allegiance effect;
• RCTs looking an non-CBT approaches;
• further research into therapist effects on outcome;
• further research into client effects on outcome;
• continuing to develop ways of further engaging clients in therapy and how such therapist or client factors
influences outcome. (2008: 158)
Wampold goes one step further and makes a number of recommendations based on his read-
ing of research into individual therapy (2001: 209–30). These include of number of points
that are likely to speak to many UK individual therapists. He suggests limiting the number of
RCTs, given their relationship to medicine and that there is probably little more that is new
to be learnt from them. He recommends a shift of emphasis away from treatment manuals, in
that ‘manuals focus attention toward a wasteland and away from the fertile ground’ (2001:
212). He suggests that future research should focus on effectiveness rather than efficacy and
that there should be a move away from the concept of empirically support treatments (EST)
because ‘the EST criteria and the list of therapists so designated [by the American
Psychological Association] are saturated with the medical model conceptualisation of psy-
chotherapy. The bias is instinctively toward behavioral and cognitive-behavioral treatments,
reducing the likelihood of acceptance of humanistic, experimental, or psychodynamic thera-
pies’ (2001: 225). Many would argue this position is fundamentally inconsistent with the
development of an evidence-base; certainly in the UK, empirically-supported treatments,
rooted within the evidence of science, continue to be a predominant discourse.
Further, Wampold states that research evidence suggests the importance of clients choosing
the best therapist and should choose a therapy that fits with their world-view (2001: 226). Finally,
Wampold argues that individual therapists should be trained to understand, appreciate and be
skilled in the common core aspects of therapy (2001: 230). He finally asserts:
Detrimental is the practice of training therapists by having them learn a series of ESTs, totally ignoring the
acquisition of the core therapeutic skills that form the basis of therapy and therapeutic effect. Many
psychotherapy trainees prefer to learn a series of ESTs because they wish to avoid the frightening prospect
of being present with a client and examining themselves and their interpersonal qualities. (2001: 230)
There is something in Wampold’s assertion that speaks of the careful balance between the
science of enquiry and the soul of therapy. Some might argue there is soul in enquiry and
science in therapy too: it is the bringing together of the two that will arguably continue to
create the evidence base from which individual therapy can truly prosper.

9 FURTHER READING
Sage.
Lambert, M.A. (2013) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (6th edn).
Norcross, J.C. (ed.) (2002) Psychotherapy Relationships that Work: Therapist Contributions and Responsiveness to
Patients. New York: Oxford University Press.
Roth, A. and Fonagy, P. (2005) What Works for Whom? A Critical Review of Psychotherapy Research (2nd edn).
London: Guilford Press.
Timulak, L. (2008) Research in Psychotherapy and Counselling. London: Sage.
10 REFERENCES
Barrett, M.S. and J.S. Berman (2001) Is psychotherapy more effective when therapists disclose information about
themselves? Journal of Consulting and Clinical Psychology 69(4): 597–603.
Bohart, A.C., Elliott, R., Greenberg, L.S., Watson, J.C. (2002) Empathy. In J.C. Norcross (ed.), Psychotherapy
Relationships that Work: Therapist Contributions and Responsiveness to Patients. New York: Oxford University
Press, pp. 89–108.
Bordin, E.S. (1979) The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy:
Theory, Research, Practice, Training 16(3): 252–60.
Borkovec, T.D. (2002) Training clinic research and the possibility of a national training clinics practice research
network. The Behavior Therapist 25(5/6): 98–103.
Chambless, D.L. and Hollon, S.D. (1998) Defining empirically supported therapies. Journal of Consulting and
Clinical Psychology 66(1): 7–18.
Sage.
Cooper, M. (2011) Meeting the demand for evidence-based practice. Therapy Today 22(4): 10–16.
Del Re, A.C., Flcker, C., Hovarth, A.O., Symonds, D., Wampold, B. (2012) Therapist effects in the therapeutic
alliance-outcome relationship: A restricted maximum likelihood meta-analysis. Clinical Psychology Review 32(7):
642–9.
Derksen, F, Bensing, J., Lagro-Janssen, A. (2013) Effectiveness of empathy in general practice: a systematic review.
British Journal of General Practice 63(606): 76–84.
Freire, E., Elliott, R., Westwell, G. (2010) Development and Validation of an Adherence/Competence Measure for
Person-centred and Experiential Psychotherapies. 8th World Conference for Person-Centered and Experiential
Psychotherapy and Counseling. Rome, Italy.
Gaston, L., Thompson, L., Gallager, D., Cournoyer, L.G., Gagnon, R. (1998) Alliance, technique, and their interac-
tions in predicting outcome of behavioral, cognitive and brief dynamic therapy. Psychotherapy Research 8:
190–209.
Gelso, C.J. and Hayes, J.A. (2002) The management of countertransference. In J.C. Norcross (ed.), Psychotherapy
Relationships that Work: Therapist Contributions and Responsiveness to Patients. New York: Oxford University
Press, pp. 89–108.
Glass, C.R. and Arnkoff, D.B. (2000) Consumers’ perspectives on helpful and hindering factors in mental health
treatment. Journal of Clinical Psychology 56(11): 1467–80.

Hill, A. (2010) Curriculum for Counselling for Depression: Continuing Professional Development for Qualified
Therapists Delivering High Intensity Interventions. London: National IAPT Programme Team.
Hovarth, A.O. and Bedi, R.P. (2002) The alliance. In J.C. Norcross (ed.), Psychotherapy Relationships that Work:
Therapist Contributions and Responsiveness to Patients, New York: Oxford University Press, pp. 37–69.
Hovarth, A.O., Del Re, A.O., Flückiger, C., and Symonds, D. (2011) Alliance in individual psychotherapy.
Psychotherapy 48(1): 9–16.
Keijsers, G.P.J., Schaap, C.P.D.R., Hoogduin, C.A.L. (2000) The impact of interpersonal patient and therapist
behaviour on outcome in cognitive-behavioural therapy. Behaviour Modification 24(2): 264–97.
King, M., Semylen, H., Nazareth, I., Osborn, D. (2007) A Systematic Review of Research on Counselling and
Psychotherapy for Lesbian, Gay, Bisexual and Transgender People. Lutterworth: BACP.
Lambert, M.J. (1992) Implications of outcome research for psychotherapy integration. In J.C. Norcross and
M.R. Goldstein (eds), Handbook of Psychotherapy Integration. New York: Basic Books, pp. 94–129.
Lambert, M.A. (2013) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (6th edn).
Lambert, M.J. and Bergin, A.E. (1994) The effectiveness of psychotherapy. In A.E. Bergin and S.L. Garfield (eds),
Handbook of Psychotherapy and Behavior Change. Chichester: John Wiley & Sons Ltd, pp. 143–89.
Lambert, M.J. and Barley, D.E. (2002) Research summary on the therapeutic relationship and psychotherapy out-
come. In J.C. Norcross (ed.), Psychotherapy Relationships that Work: Therapist Contributions and Responsiveness
to Patients. New York: Open University Press.
Lebow, J.L. (2006) Research for the Psychotherapist: From Science to Practice. London: Routledge.
Lebow, J L and Gurman, A S (1995) Research assessing couple of family therapy. Annual Review of Psychology 46:
27–57.
Lilienfeld, S.O. (2007) Psychological treatments that cause harm. Perspectives on Psychological Science 2(1):
53–70.
Luborsky, L., McLellen, A.T., Woody, G.E., O’Brien, C.P., Auerbach, A. (1985) Therapist success and its determi-
nants. Archives of General Psychiatry 42(6): 602–11.
Luborksy, L., Rosenthal, R., Digeur, L., Andruyna, T.P., Berman, J.S., Levitt, J.T., Seligman, D.A., Krause, E.D. (2002)
The dodo bird verdict is alive and well – mostly. Clinical Psychology: Science and Practice 9(1): 2–12.
McLeod, J (2001) Developing a research tradition consistent with the values and practices of counselling and
psychotherapy: why counselling and psychotherapy research is necessary. Counselling and Psychotherapy
Research 1(1): 3–11.
McLeod, J. (2003) Doing Counselling Research (2nd edn). London: Sage.
Norcross, J.C. and Lambert, M.J. (2011) Psychotherapy relationships that work II. Psychotherapy 48(1): 4–8.
Norcross, J.C. and Wampold, B.E. (2011) Evidenced-based therapy relationships: Research conclusions and clinical
practices. Psychotherapy 48(1): 98–102.
Orlinsky, D.E., Grawe, K., Parks, B.K. (1994) Process and outcome in psychotherapy – noch einmal. In A.E. Bergin
and S.L. Garfield (eds), Handbook of Psychotherapy and Behavior Change (4th edn). Chichester: John Wiley &
Sons Ltd, pp. 270–376.
Piper, W.E., Ogrodniczuk, J.S., Joyce, A.S., McCallum, M., Rosie, J.S., O’Kelly, J.G., Steinberg, P.I. (1999) Prediction
of dropping-out in time-limited, interpretive individual psychotherapy. Psychotherapy: Theory, Research,
Practice, Training 36(2): 114–22.
Rosenzweig, S. (1936) Some implicit common factors in diverse methods of psychotherapy. American Journal of
Orthopsychiatry 6(3): 412–15.
Roth, A. and Fonagy, P. (2005) What Works for Whom? A Critical Review of Psychotherapy Research (2nd edn).
London: The Guilford Press

Roth, A.D., Hill, A., Pilling, S. (2009) The Competences Required to Deliver Effective Humanistic Psychological
Therapies. Centre for Outcomes Research and Effectiveness, University College London. Available online at:
www.ucl.ac.uk/clinical-psychology/CORE/humanistic_framework.htm
Russell, R.L. and Orlinsky, D. (1996) Psychotherapy research in historical perspective: Implications for mental health
care policy. Archives of General Psychiatry 53(8): 708–15.
Ryan, V.L. and Gizynski, M.N. (1971) Behavior therapy in retrospect – patients’ feelings about their behavior
therapies. Journal of Consulting and Clinical Psychology 37(1): 1–9.
Smith, M.L. and Glass, G.V. (1977) Meta-analysis of psychotherapy outcome studies. American Psychologist 32:
752–60.
Stiles, W.M., Barkham, M., Mellor-Clark, J., Connell, J. (2008) Effectiveness of cognitive-behavioural, person cen-
tred and psychodynamic therapies in UK primary care routine practice: replication in a larger sample.
Psychological Medicine 38 (5): 677–88.
Timulak, L. (2008) Research in Psychotherapy and Counselling. London: Sage.
Wampold, B. (2001) The Great Psychotherapy Debate: Models, Methods and Findings. Mahwah, New Jersey:
Lawrence Erlbaum Associates.
Weisz, J.R., Huey, S.J., Weersing, V.R. (1998) Psychotherapy outcome research with children and adolescents: The
state of the art. Advances in Clinical Child Psychology 20: 49–91.

23
The Training and Supervision
of Individual Therapists
Greg Nolan, Jane Macaskie and Bonnie Meekums
1 INTRODUCTION
This chapter is structured to explore aspects of what it can mean for a student to study and train
as an individual therapist. Core elements of academic study, personal development, professional
practice, clinical supervision and personal therapy can be largely similar, but there will be differ-
ences of focus in theoretical approach, organisational provision and structure (part-time regular
weekly meetings; blocks of days; full-time etc.) and continuing changes are likely in costs and
funding. Additionally, in recent years, there has been a significant shift towards professional
training at degree level, whether at first degree or postgraduate levels. This emphasis on aca-
demic training highlights the impact of research findings, some of which will have been initiated
through current masters and doctoral training programmes, and their potential for influencing
evolving practice. All therapy training in the UK acknowledges the needs of professional regis-
tration as required by professional lead bodies, some details of which are addressed below.
There has been a substantial body of individual therapy research published in the UK and
North America in recent years. This has enabled mental health providers to demonstrate and
provide evidence for how and why therapy ‘works’ in practice (Norcross and Wampold,
2011a, 2011b), a necessary resource in arguing for the funding and provision of professional
therapy services in the UK through the NHS, GP practices, Employer Assistance Programmes
(EAPs), third-sector voluntary agencies and private practitioners.

A significant recent development has been the UK government funded initiative, Improving
Access to Psychological Therapies (IAPT), which has affected ways in which mental health
and well-being might be addressed by professional practitioners through the provision of
‘treatments’ aimed at alleviating psychological distress. This has had an impact on the British
Association for Counselling and Psychotherapy (BACP), British Association for Behavioural
and Cognitive Therapy (BABCP) and other professional body guidance on training pro-
grammes, with consequent changes in how training programmes might be structured. This
has led to pressures for a paradoxical shift away from recent trends towards integration of
psychotherapy approaches, and into a separation of therapeutic models as definable ‘treat-
ments’ for specific conditions.
The trend towards ‘medicalising’ psychological distress into specific evidence based treat-
ments validated through randomised controlled trials (RCTs), regarded as the ‘gold standard’
for recommendation and funding of NHS treatments by National Institute for Clinical
Excellence (NICE), has led in the first instance to a focus on cognitive-behavioural therapy-
based (CBT) approaches that are readily measurable using quantitative statistical analysis of
patient outcomes. This initial focus has been additionally informed through the development of
Skills for Health National Occupational Standards for Psychological Therapies. This was the
first time that the skills applicable across the ‘talking therapies’ profession had been systemati-
cally itemised. With the aim of recognising skills across theoretical perspectives, a structure was
defined that moved away from an integration of psychological approaches, separating key
principles of practice into humanistic, psychodynamic, CBT and family and systemic therapies.
2 SELECTION
Students are selected for training as individual therapists according to an evolving set of
criteria. These relate largely to the potential for development as a psychological therapist.
Broadly, they can be seen to fall into three categories: knowledge and skills; personal quali-
ties; and reflective capacity. The first two of these may be assessed in one form or another
for entry to a higher education or further education course in any subject. In the case of stu-
dents applying to study an undergraduate course in most academic subjects, for example,
knowledge and skills are both assessed through the state examinations system, and personal
qualities are evidenced in the UK through the personal statement made on the Universities
and Colleges Admissions Service (UCAS) form. What makes therapy training so different is
the need to assess aspects of the individual that cannot be evidenced solely through the writ-
ten application, and so trainers have necessarily developed ways to identify students who
have a good chance of succeeding.
One method might be to invite up to four candidates to a selection event. Whilst demanding
of staff time, this procedure is usually evaluated positively by candidates and associated with low
attrition rates over time, as trainers learn from experience. The selection process should be two-
way. To this end, current therapy student representatives can be asked to offer attendance at the

THE TRAINING AND SUPERVISION OF INDIVIDUAL THERAPISTS 605
selection event in order to answer questions ‘from the horse’s mouth’ about their training experi-
ences. The student representative may spend ten to fifteen minutes with candidates, while the
interviewing tutors withdraw. This aspect of the selection process would not be assessed, and the
student representative should not offer feedback to staff concerning individual applicants.
The selection event can be divided into several activities designed to assess different
aspects of the candidates’ suitability for training, which might involve the following:
1. A group discussion where the candidate group is asked to self-time for 20 minutes, to discuss three topics;
the precise topics are less important than how the individual engages both with reflection and with the
other group members. However, tutors are also interested to hear the level of their thinking about the
topic. Topics may be deliberately ambiguous, in order to encourage creativity and engagement; an exam-
ple is ‘Is therapy compatible with personal faith?’ Tutors may use a proforma that is scored numerically;
the precise numerical score is used as a guide only, and this is compared with other aspects of the selec-
tion process at the end of the selection event, in a staff meeting.
2. A second aspect of the selection process is therapy skills practice, in which tutors assess candidate
readiness to see clients from the start of the course (a usual entry requirement for therapy trainings is a
Certificate in Counselling Skills, which will also involve observation and assessment of skills). The format
should enable candidates to demonstrate skills of opening and closing of the session, time keeping, listen-
ing skills including use of creative silences, reflection of both content and affect, paraphrasing (used
sparingly), use of open questions (which further the client’s focus and reflection), empathic engagement,
and also the ability to work with nonverbal phenomena.
3. While some candidates are engaged in skills, others will be asked to attend a face-to-face interview. This
is usually conducted by two staff members, one of whom scribes in order to leave the other free to engage
in a meaningful conversation with the candidate. This also means that there are two perspectives on the
interview process, since interviewers might have strong feelings about an applicant that are best explored
through collegial reflective practice before making recruitment decisions. Most trainers use a series of
questions that have evolved over several years’ experience together with reference to scholarly writings.
These might include: what led the candidate to apply for this particular course; skills, experience and
personal qualities including what aspects of self-learning might usefully be developed during training; life
events that might have contributed to the candidate’s capacity to self-reflect; previous counselling train-
ing undertaken and the impact of undertaking this; what client groups the candidate might feel drawn
towards or would wish to avoid, and whether plans are in place for the practice part of the course (a
potential student’s readiness to engage actively with prospective practice agencies being a vital personal
skill); how the applicant deals with stress; and the degree of reflection on the potential impact of training
and personal change on immediate and wider relationships.
Trainers may find that their views about particular applicants are influenced by their experiences
during the selection process. Strong feelings can result as part of the interpersonal dynamics
engendered by being in a highly emotionally charged setting. A meeting of tutors at the end of
each selection event provides the opportunity to challenge collegially and reflect on strongly held
views, and to consider carefully those candidates about whom it might be more difficult to make
a selection decision. It is sometimes helpful to arrive at an overall score out of 10 for each candi-
date, with an understanding that, for example, all of those scoring 8 and above are ‘appointable’.
This is especially helpful if decisions are not going to be made on a first come, first served basis

but on the basis of selecting the ‘best of the bunch’. Those with lower scores, including 6 and 7,
may be held on a waiting list, but 5 and below may result in a rejection. When a decision is made
to reject a candidate, this must be done with sensitivity, with a personal letter that sets out their
strengths as observed together with reasons that recruitment was felt not to be the right course of
action at this point in time.
Below we present three fictional applicants. As with all potential trainees, each has unique
features that need to be recognised and acknowledged within the selection process. Some key
factors that might emerge from these examples are discussed later on in this chapter.
Box 23.1 Sylvia: No formal qualifications, access to higher education
It is important for both applicants and trainers to be mindful of how intimidating such a
thorough process of selection for counselling and psychotherapy training might be to
someone who has real potential to develop as an excellent therapist, but who does not
have a formal, ‘high-flying’ academic or professional background. The first fictional appli-
cant, Sylvia, who has completed an Access course, said about her interview, ‘It’s almost
intimidating, coming into the building; it’s something that I know is important for me to
pursue, and it feels do-able even though I’m struggling sometimes to overcome the sense
of “what am I doing here?”’
She made the assumption that other students would be more in tune with what is
required academically. She talked of early experiences of ‘not succeeding’ that had felt as
if she was letting her parents and herself down, and of losing contact with friends who
had passed their exams, ‘the rest of the world that is going on ahead of you’ (here Sylvia
made a non-verbal gesture of something tumbling over, up and away). Such experiences
add to the investment, but also to the stakes associated with selection processes. However,
sensitive interviewing can help applicants connect with their belief that they can succeed.
Box 23.2 Agymah: business school graduate
Our second fictional person is a Ghanaian man, Agymah, who ‘wished to give something
back, knowing that others were less fortunate’. Very self-assured, he held his teachers in high
regard, owning a focused attention to study and diligence towards measurable success. His
evident strength of religious belief was a source of grounded assuredness, yet leading to a
dependency on the judgement and ‘advice/guidance’ of respected others. Ambivalent
towards self-determination, he readily assumed responsibility in business terms, enabling him
to reflect on the different meanings of ‘advice’ and ‘authority’. Respectful of others, he said
that family relationships were centrally important to him, and although he had left his wife
and family in his home country Ghana, the use of Skype ensured a daily link. He disclosed

that, as a child, he had been sent away from home to boarding school and acknowledged
his distress when remembering this time.
Evidently deferential towards the interviewers, his expressed need was to offer advice
and guidance to others. Academic study, qualifications and status seemed centrally impor-
tant. When experiencing ‘doubt’ he relied on his pastor’s judgment/permission. The notion
of ‘autonomy’ was difficult for him. The interviewer observed the self-determination neces-
sary for him to have arrived in the UK – Agymah avoided responding to this, but acknowl-
edged his responsibilities as a business person, accepting advice from family whilst making
his own decisions and that ‘the buck stops here’.
On qualifying he would return to Ghana, where there was a distinct need for profes-
sional counsellors. He knew a Ghanaian counsellor ‘who studied with you’, admiring her
qualities, ‘her smiling face … she would never make me feel cross – if so, I would probably
say sorry … as it would be likely to have been my own fault’. It was not easy for Agymah
to own vulnerability, to recognise that he too had feelings. A client who was ‘a mother’
would be challenging, he felt likely to defer to the ‘mother’ role rather than relate to her
as his client. It would be difficult to work with a distressed child, reminding him of his fam-
ily and his own emotional struggle on being sent away to boarding school, acknowledging
difficulty in being away from his family. Evidently with much that he might add to a train-
ing group, those involved in selection decisions would be mindful of what Agymah might
teach them as well as the potential gift to the learning of others that he might offer on his
journey towards professional status.
Box 23.3 Emma – psychology graduate, ‘2.1’
The third applicant, Emma, with a first degree in ‘very scientific’ studies, for the last five
years has been with a high-street retail chain as a graduate trainee in their management
team. Finding this role no longer satisfying or able to engage her interest, she sees her
initial drive in studying psychology hadn’t helped her understand ‘what makes people tick’
and ‘didn’t know much about the human mind’, her degree ‘didn’t tell me who I am’ and
that this didn’t make others the way they are.
Emma disclosed the emotional challenge of life experiences and occasions of grief,
separation and loss. Support from her employer provided counselling through an
Employee Assistance Programme (EAP) that enabled a ‘surprising’ shift. The counsellor
‘listened to my story’, ‘it was wonderful and scary … like walking the edge of a plank …
should I fall into the water or not? It taught me that I don’t know much.’ She had recog-
nised problematic behaviour without having an explanation. Aware of a ‘split’ in different
aspects of self, she ‘needed to join them up’. Her ‘crack-up’ (as she termed it) was not so
much about an event but rather a challenge to who she was, to her sense of identity.
Mentioning ‘new insight’, she acknowledged the fragmented ‘bits’ of self: a thinking
(Continued)

(Continued)
brain, an emotional experience that didn’t quite synthesise, and a wish for greater emo-
tional literacy. Offered the notion by one interviewer of a provisional self that might yet
contain instructions for ‘assembly’, Emma felt both ‘radical uncertainty’ and some excite-
ment in not knowing how the assembled ‘form’ might evolve. To what extent do most
people experience times of challenge to their sense of mental health and well-being? Here
Emma has openly disclosed such times to her interviewers, perhaps understanding that
her own path might offer insight into others’ sense of confusion and challenge to find
greater meaning in everyday life.
3 MODELS OF TRAINING
3.1 Psychodynamic approaches

Training in psychodynamic and psychoanalytic therapy varies considerably in length and in
the degree of integration between the three main elements of theory, supervised practice and
personal therapy. As the terms ‘psychodynamic’ and ‘psychoanalytic’ are often confused, it
may be helpful here to draw a distinction between them: psychoanalysis typically involves
sessions four or five times a week, while psychoanalytic psychotherapy is less frequent,
usually two or three times a week; psychodynamic therapy is more likely to involve once or
occasionally twice-weekly sessions. Trainees are usually expected to have personal therapy
at the same frequency as their intended practice. Seeing a therapist for multiple sessions
each week has clear cost implications and is largely confined to private practice, while the
NHS and voluntary-sector organisations usually offer weekly psychodynamic therapy.
A further distinction involves the theoretical breadth and depth of trainings. Psychoanalytic
trainings in Britain typically follow a Freudian, Kleinian or Independent route (see Chapters
2, 3, 4 and 5), focusing on the theoretical and clinical thinking of major figures within these
schools. The Independent school includes the work of British object relations theorists such
as Winnicott, Fairbairn and Guntrip. There are significant contemporary developments in
theory and practice in all these schools, so that although the work of their founding figures
remains central, it is continually being elaborated. Analytical psychology, which is the name
given to Jungian therapy to distinguish it from psychoanalysis deriving from Freud and his
followers, has separate trainings among which several ‘schools’ are again identifiable.
Psychoanalytic trainings are mainly offered by private psychotherapy associations, whereas
psychodynamic trainings, which are more likely to refer to theories across all the psychoana-
lytic schools, are also offered in these settings and by the NHS and some universities.
Understanding and applying theory in practice is considered very important in psychoana-
lytic and psychodynamic trainings. Students are typically asked to discuss theoretical reading
as a means to gaining insight into their practice and conversely to consider their clinical work
in the light of relevant theoretical perspectives. Besides psychodynamic concepts, the range

of theory explored may include developmental perspectives and increasingly, psychody-

namic trainings link theory to findings stemming from infancy studies and recent neurosci-
entific research on intersubjective brain development (Wilkinson, 2010).
The early psychoanalysts, Freud, Jung, Adler and their associates, had no training other
than their medical background and the intense self-analysis which their clinical work led
them to undertake. However, it quickly became normal practice for would-be analysts to seek
a ‘training analysis’ for themselves with one of the established practitioners, and this personal
work was seen as the central factor in professional development. This remains the case, and
psychoanalytic and psychodynamic trainings today typically require students to be in therapy
throughout the training period so that they can develop reflexive self-awareness and become
more alert to transference and countertransference within the therapeutic relationship. The
supervision of clinical practice with an experienced practitioner is another key element in
psychodynamic training, and often involves attention to the fine detail of interactions with
clients through the use of verbatim accounts of therapy sessions. Supervision is the place
where theory and practice come together in understanding the client’s history, their internal
world and its manifestation in the dynamics of the therapy.
3.2 Humanistic approaches

Humanistic approaches to individual therapy (e.g. person-centred, gestalt, existential) are funda-
mentally centred within the existential-phenomenological tradition, a paradigm of thinking that
describes how making sense of being and living is an essentially individual enterprise. No-one
else can perceive the world in the same way because others’ experiencing of being can only be
uniquely contextualised and processed through their embodied minds, seeing the world and mak-
ing best sense of it through the moment-by-moment experience of ‘being’. This can be experi-
enced by trainees as fundamentally challenging to their sense of meaning and negotiation of
relationships with significant others. Essential to the existential-phenomenological core of this
approach, which also informs much of contemporary relational analytic theory, is the necessity for
practitioners to be continually mindful of their own existential ‘reality’ and how reflection on
moment-by-moment experiencing can effect unfolding change in perception of self and others.
This fundamental root of approaches in the humanistic tradition can be seen as centred
upon establishing a trusting and professionally intimate therapeutic relationship, where each
is negotiating good-enough meanings in the dialogic exchange. On occasion these might be
momentarily be experienced as phenomena that transcend everyday experiencing, variously
described as ‘relational depth’ (Wiggins, Elliott and Cooper, 2012), ‘transpersonal’ (see
Chapter 19) or ‘spiritual’ (West, 2011) – potentially transformational for the client, and also
the therapist.
One common misperception is to conflate humanistic and person-centred schools of
thought. While person-centred therapy is one of the many versions of humanistic therapy, it
is by no means the only one. It is inaccurate, for example, to assume that all humanistic
therapists strongly reject the idea of transference and countertransference.

3.3 Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) evolved from the Behaviourist school and is an
approach that was seen to offer a useful way of applying a formulated structure to treat-
ment. A key feature of CBT is that it is based on scientific principles of experimentation
and measurement, focusing on the individual in their environment: thoughts and images,
mood, behaviour and physical reactions are each addressed, sometimes through between-
session homework and the keeping of a diary. This approach can be seen as a little prescrip-
tive to some potential trainees; for others, however, this can be very reassuring. Training
in CBT programmes will encourage active and collaborative negotiating of therapeutic
tasks and processes. More recent developments emphasise the importance of the interper-
sonal relationship, enabling trust and ‘compassion’ (see Chapter 12) and, increasingly, the
notion of ‘mindfulness’ (see Chapter 17), a capacity to clear the mind of extraneous
thoughts, attending to in-the-moment bodily sensations, such as breathing, tasting and a
capacity to be ‘still’.
It is important that the reader engages in a more detailed consideration of the therapeutic
approaches within these broad paradigms, which may be found described elsewhere in this
volume.
3.4 Pluralism and its evidence base

Challenges to the proliferation and fragmentation of theories of psychology and the pro-
motion of discrete models of practice, or ‘schoolism’, have led in recent years to initia-
tives towards integration across competing theories of individual therapy. This move has
also been developed through the Society for Psychotherapy Integration (SEPI) and
notions of transtheoretical practice. Training providers have attempted to reflect this trend
with diplomas, degrees and masters level courses in integrative and pluralistic therapy
(see Chapter 20).
The move towards theoretical integration and pluralism has gained considerable ground
on the basis of evidence that no single model of therapy is necessarily more successful
than any other. Numerous articles and research papers on competing theories informing
approaches to counselling and psychotherapy cite the well-used notion of the ‘dodo bird
verdict’, that ‘all must have prizes’ and that no one therapy model in itself has any clear
advantage over others. This finding has encouraged the development of pluralistic train-
ings without a particular theoretical allegiance, but based rather on the view that no single
perspective can be privileged over others (see Chapter 21). Cooper and McLeod distin-
guish between a ‘pluralistic perspective’, which is ‘the belief that there is no, one best set
of therapeutic methods’ (2011: 7, italics in original), and ‘pluralistic practice’, which
‘refers to a specific form of therapeutic practice which draws on methods from a range of
orientation[s], and which is characterised by dialogue and negotiation over the goals,
tasks and methods of therapy’ (2001: 8, italics in original). They point out that pluralistic
belief and pluralistic practice may be independent from each other. They acknowledge the

close similarity with integrative and eclectic approaches, but specify that pluralism, in
their understanding, potentially embraces an infinite number of perspectives and practices
and is fundamentally concerned with negotiating and tailoring practices to the needs of
individual clients.
In spite of this tendency towards integration and pluralism, the continuing requirement of
NICE in the UK for evidence-based treatments has promoted research aimed at demonstrat-
ing that individual therapies ‘work’ for specific symptoms. Consequently, protocol-based and
symptom-focused therapies evidenced by the ‘gold standard’ of randomised controlled trials
continue to proliferate, particularly in the IAPT services of the NHS. Training in these thera-
pies is normally only available to practitioners already holding an initial qualification in
counselling, psychotherapy or a core health profession. Training in the recently developed
model Counselling for Depression, for example, is open only to experienced person-centred
or humanistic counsellors.
A considerable body of work in the USA has explored what works in the integration
of individual therapeutic and psychoanalytic modalities, where North American research-
ers have demonstrated a different view of ‘what works’ in terms of the elements present
in successful therapy outcomes irrespective of model. Common factors such as the
therapeutic alliance, client motivation, the structuring of therapy and the role of the
therapist, as well as ongoing feedback from client to therapist, have been shown to be
major influences on the successful outcome of therapy. Norcross and Wampold (2011a:
99) encourage individual therapy training programmes ‘to provide competency-based
training in the demonstrably and probably effective elements of the therapy relationship’.
According to research cited by Norcross and Wampold (2011a), these include the thera-
peutic alliance, empathy and client feedback (demonstrably effective) and goal consen-
sus, collaboration and positive regard (probably effective). Norcross and Wampold
(2011b) highlight consistent evidence that reinforces what therapists have always intui-
tively understood: that therapeutic relationships which are responsive to individual cli-
ents rather than to symptoms, lead to successful therapeutic outcomes. Building on this
work, Mozdzierz, Peluso and Lisiecki (2011) emphasise the need for training in indi-
vidual therapy to avoid ‘silos’ of learning such as theoretical models and skills in isola-
tion from each other, and to integrate understanding of the common domains of therapy
with both linear and non-linear thinking. Non-linear thinking has long been known to
underlie the kind of therapeutic listening and presence which enables practitioners to
attune to clients emotionally and symbolically, and developing this capacity is a signifi-
cant aspect of most therapy trainings.
In the UK, trainings accredited by BACP are based on their Core Curriculum, which
specifies the competencies therapists need in key domains of knowledge, skill and applica-
tion. These domains are: the professional role and responsibility of the therapist; under-
standing the client; the therapeutic process; and the social, professional and organisational
context for therapy. The competencies described in each domain are generic and may be
elaborated distinctively by training courses in accordance with their particular philosophy.
This competency-based approach allows for the integration of a common factors perspective

on ‘what works’ in therapy with different theoretical models and encourages pluralistic or
trans-theoretical thinking. The recent Subject Benchmark Statement for Counselling and
Psychotherapy (Quality Assurance Agency for Higher Education, 2013) also impacts on
therapy trainings in higher education at undergraduate and postgraduate levels. It is likely
that professional bodies will soon endorse a requirement for all initial counselling trainings
to be at least at NVQ level 6 or honours graduate equivalent, and psychotherapy trainings
at level 7 or postgraduate.
The other major professional body in the field, the United Kingdom Council for
Psychotherapy (UKCP), does not specify a training curriculum since it acts as an umbrella
organisation for nine modality-based colleges, each determining its own training require-
ments. This way of structuring psychotherapy training and practice tends to maintain alle-
giance to single modalities and to mitigate against integration and pluralism in practice,
although the Humanistic and Integrative College (HIPC) aims to integrate different perspec-
tives within the humanistic paradigm and other approaches, such as cognitive analytic
therapy (CAT). It is usual for trainings leading to registration with the UKCP to specify a
theoretical approach in the title which practitioners may use, for example psychodynamic
psychotherapist or cognitive-behavioural psychotherapist.
A helpful way of thinking about professional training as induction into a community of
practice is suggested by Lave and Wenger (1991). They distinguish between closed com-
munities in which adherence to orthodox practice is inculcated, and more open communities
which allow ‘legitimate peripheral participation’ (1991: 35). The periphery is a legitimate
position to occupy, since it allows a critical perspective and the possibility of fresh thinking.
Since learning is an inherent aspect of many social practices, the critical encounter of learn-
ers (who may include experienced practitioners as well as trainees) with established theory
and practices offers an opportunity for the professional group as a whole to be transformed.
Trainings which value the mutual learning of students and teachers through reflexive critical
educational practices have the potential to foster a similar approach to therapeutic practice,
in which there can be recognition of the intersubjective nature of the therapeutic encounter
(Macaskie, Meekums and Nolan, 2012).
4 CULTURAL COMPETENCE
Most therapy trainings include sessions intended to develop awareness and competence in
working with clients of different cultures. While the relationship between therapist and client
is accepted as being central to all approaches, an emphasis on the intersubjective recognition
of the other implies that ethical relating demands of therapists that they willingly engage with
the ‘otherness’ of clients as individuals who are both shaped by, and participate in shaping,
their culture(s). Individuals are subjects with their own experiences and values, equally
important to our own, and not merely objects in our cultural worlds. This recognition is a
radical counter to the tendency we often have to objectify the other and their culture.
However, the complex ways in which we identify and belong to cultural spaces require a

highly developed sense of our own multiple identities, how they may change over time and
how we perform them in particular settings.
‘Culture’ here is used to include reference to aspects of difference and identity such as
‘race’, gender, class, sexual orientation, age, ability, language and spirituality, to name per-
haps the most salient. This is not intended to deny the importance of issues related specifi-
cally to each of these dimensions of being human, but to highlight the ways in which they
intersect (Chantler, 2005). A person is never ‘just’ female, or black, or middle-class, but some
or all of these and more, and how she lives these ways of being herself in various situations
will be partly to do with her relationships with others, whose own multiple identities interact
with hers.
In a training setting, for example, the way one individual presents and performs who she
is will inevitably be influenced intersubjectively by the presentation and performance of
other students, tutors, the training institution itself, and the professional and educational cul-
tures in which they are located. How people are positioned as belonging to particular groups
may be thought of as an active process of ‘minoritisation’ (Chantler, 2005), which draws
attention to the power relations between dominant and minority social groups that are often
ignored by a focus on individual cultural identity.
White suggests that notions of identity in Western culture are typically associated with ‘the
construction of an encapsulated self, one that emphasises norms about self-possession, self-
containment, self-reliance, self-actualisation, and self-motivation’ (2007: 137). These values
are inherent in some therapeutic approaches and may be uncritically assumed by therapists
who have not worked to develop cultural self-awareness and competence in working
transculturally. Awareness of dominant values is especially important, as White (2007)
argues:
These contemporary Western social and cultural forces that promote isolated, single-voiced identities
actually provide the context that generates many of the problems for which people seek therapy. (White,
2007: 137)
However, it might also be suggested that an individual’s identity can be seen as a more
socially interactive framework, which is less individually focused as it implies belonging to
a group – albeit fluidly constructed through contextually driven social practices.
Narrative therapies (see Chapter 18) seek to help clients question and re-author stories
which keep them trapped in narrow or self-defeating identities. Whatever the therapeutic
approach, it is essential for trainees to learn to recognise what kind of stories clients tell
about themselves, and what kind of stories the model they are learning constructs about
clients. Models of therapy, like any other theories, are situated in their time and cultural
context and if we are to be really open to clients we need to have the tools to critique the
assumptions underlying our model/approach, thus allowing them to evolve. All therapeu-
tic theories are historically situated and influenced by the class (usually middle to upper),
gender (often male) and dominant cultures (mainly European and American) of their
authors. Therapists need to be able to recognise and deconstruct these influences on their

theoretical understanding. This is a complex task in training, and one which all three of
the fictional applicants will need to engage with. Our fictional applicant, Agymah, com-
ing from a West African country, may face a dual task of learning theories which derive
from Western cultural norms that have influenced his education and to some degree
colonised his own culture, but which emphasise an isolated self that may be in contrast
to his more family-oriented values. He may also find it unusual at first to facilitate cli-
ents’ self-determination rather than offering advice and guidance. He speaks with respect
for the authority of gifted teachers who have inspired him in the past; now he will join a
learning community where teachers and students are all potentially engaged in trans-
forming their knowledge and practice through challenge and critique. Emma, the psy-
chology graduate, is also joining a new kind of learning community where two kinds of
knowledge, cognitive and emotional, are valued. In her first degree, cognitive knowledge
was based on scientific experiment and theory, while now she will be challenged by the
radical uncertainty of synthesising cognitive knowing with emotional intelligence and
the experience of ‘not knowing’. Sylvia has experienced not succeeding in the school
system and the educational and social categorising that often follows from that, and she
needs a deep sense of self-belief to help her enter the cultural world of the university and
professional training. While she may need support to engage with academic practices, it
will be surprising to her to find that her tutors value her personal authority, derived from
her own experiencing.
Therapeutic approaches which emphasise cultural awareness have been variously
labelled multicultural, transcultural and intercultural, and the usage of the authors referred
to is followed here. Within the North American context much has been written since the
early 1980s on the concept of culture and the development of multicultural counselling
competencies. However, the separation of multicultural from general professional compe-
tence is critiqued by Collins and Arthur (2010) who adopt a broad definition of culture
and argue that ‘all encounters are, on some level, multicultural interactions’ (Collins and
Arthur, 2010: 204). These authors therefore propose the term ‘culture-infused counsel-
ling’ to denote the recognition of culture at the heart of therapy. They suggest a framework
organised around the working alliance, the collaborative aspect of the therapeutic rela-
tionship that enables client and therapist to agree on goals and methods and to develop a
bond that can withstand relational difficulties. In such a framework, the personal cultural
identity of counsellor and client, built up from personal, contextual and common factors,
can intersect with core competencies of cultural awareness in relation to self and other
within a culturally sensitive working alliance.
Lago (2011) provides helpful ways of thinking about cultural issues in the UK therapy
context, which overlaps with but is distinct from North American experience; he argues that
therapists need to extend their empathic capacity in order to develop transcultural compe-
tence. For Lago, competence depends on seven domains:
• personal and professional or therapeutic relational qualities;

• primary knowledge and understanding of how diversities, ‘isms’ and power operate and affect us;

• knowledge and understanding of specific communities local to the therapist and from which their clients
may come;
• awareness of our own cultural origins and identity, communication style and influences on our thinking
such as the media;
• professional competencies such as the ability to work with interpreters, learn key words in relevant
languages, work with groups and critique the values underpinning theoretical models from a transcultural
perspective;
• professional commitment to ongoing development and learning; and
• understanding the impact on clients of the therapeutic context and environment. (Adapted from Lago,
2011: 12–14)
This last domain might be extended to include the training context, which impacts on stu-
dents in certain ways according to its ethos and their expectations, and previous experiences
of education and training. Therapy training in a university context, for example, may rein-
force an academically inclined student’s expectations of developing theoretical knowledge
and research competence, and the discovery that it also requires reflexivity, self-disclosure
and a more personally engaged way of writing essays may come as a shock, particularly to
our fictional applicant Agymah. Some students (such as Sylvia), may find training disem-
powering if it re-activates past experiences of being devalued or humiliated in an educational
setting, and trainers need to be able to help students recognise, name and challenge the impact
of such experiences.
Training courses in individual therapy often have an obvious majority of white female
students and teachers, which reflects a similar predominance in the profession as a whole. It
is easy for whiteness to be ignored because it is felt to be ‘normal’, with consequent blindness
to the way it reinforces the structural power inherent in the role of therapists. Trainings that
include and seek to understand the experience of ‘minoritised’ (Chantler, 2005) students,
therapists and clients are essential if therapy is to offer more than just a reflection of European
cultural assumptions and values. However, a counselling training curriculum that recognises
but does not just rely on examples of the diversity within the student group, would also reflect
the trainers’ ability to create opportunities for students to reflect on the cultural implications
of counselling theories and practices, and of their own experience and behaviours.
Transcultural competence will remain an abstract idea unless it is made real and alive by
challenging cultural norms in the student group and by encouraging reflection on the experi-
ence of students themselves.
5 SUPERVISION FOR TRAINEES AND EXPERIENCED PRACTITIONERS
To meet the current training requirements of BACP and the Professional Standards
Authority for Health and Social Care (PSAHSC) for 100 hours of supervised clinical prac-
tice pre-registration, trainees would normally accrue a minimum 12.5 hours’ supervision
before qualifying. Students are usually expected to arrange clinical supervision external to

the training programme, acting autonomously in making contact with their supervisor,
preferably from a catalogue of supervisors recommended by the training centre who will
have met prerequisite criteria for inclusion.
However, in some agencies, particularly NHS settings, clinical supervision may be pro-
vided by a placement line manager or other colleague. This is a dual relationship that can
present potential difficulties. In these cases it might be advisable for students to have access
to someone else as a consultant in order to talk through any organisational issues that arise.
Students are expected to make contact with a supervisor before beginning practice and to
agree arrangements for individual supervision. This may be in the ratio of supervision to cli-
ent hours recommended by BACP of not less than 1 to 8; however, some trainings require
more intensive supervision. Opportunities for group supervision that might be offered by the
placement agency are deemed extra. Supervision would be increased proportionately if, as
she or he progresses, a student were to see more clients.
Trainees should plan ahead of supervision: what might they want from each session?
Which client(s) do they want to discuss? Are there other issues that need addressing such as
developing skills, awareness of countertransference, or the relationship with the agency
where they are practising? They need to keep a log of supervision sessions, updating a record
of which client was presented and when, being careful to code their entries to maintain con-
fidentiality. Supervisors are usually expected to complete reports on their supervisees, for
example using a pro forma containing a series of questions pertinent to key developmental
stages in the training.
The welfare and well-being of the client/patient, their social context and worldview, and
the personal and professional development of the therapist/supervisee are the collegial, ethi-
cal and educational purposes of clinical supervision. The supervisory process helps recon-
struct and present relational scenarios, contemplated in shared reflection in order to clarify
confusion, understand process and foster insight; it enables the deconstruction of clinical
material contained within the therapist’s narrative, and encourages further clarity arising
from the relational dynamics enacted between practitioner and supervisor.
Supervision … stands at an interface between disciplines. Its task is to enable learning but not necessarily
to teach directly. Its task is to enable internal shifts of perception and awareness in order to understand
patients and their internal world and yet not become therapy. (Driver, 2005: xvi–xvii)
Crook Lyon and Potkar (2010: 16) offer a description of the supervisory working alliance as
a ‘collaboration for change’ that involves the supervisor and supervisee’s mutual agreement
and understanding on three distinct aspects:
• the tasks and goals of the supervision;

• the tasks of the supervisor and supervisee; and
• the emotional bond.
These aspects are echoed in many texts on supervision practice and processes and research
published in the UK and North America (see, for example, Hawkins and Shohet, 2012),

which recognise the notion of a supervisory emotional bond that facilitates the interpersonal
co-creation of meaning.
Supervision in the training context has a different emphasis, recognised in the literature as
necessarily intrinsic, clearly described in Hawkins and Shohet’s (2012) ‘Developmental
Process Model’. The needs of the ‘novice’ at ‘Level 1’ are acknowledged as an integral stage
of therapist development and as the training experience progresses, students experience an
extension in their developmental process. Individual external supervision is additionally seen
as being centrally important in the evaluation of trainees’ fitness-to-practise. Observations and
assessments of indicative use of the supervisory relationship made within periodic supervi-
sors’ reports are a necessary indication of practice development and can serve as arbiter
towards meeting professionally qualified status.
With accumulating clinical practice hours, trainee and novice practitioners’ supervision
can change in character towards a more open-ended ‘consultative’ frame, increasingly
relaxed in the process of discovery around clinical storied events. With accumulating experi-
ence the supervisory learning process can become more collegial and a space for mutual
professional exploration. Comfort with indwelling in clinical material can promote ease in
contemplating discomfort within therapeutic and supervisory frames. Ward and House (1998)
elaborate a four-stage developmental supervision process model facilitating reflective dia-
logue, which they name as: contextual orientation; trust establishment; conceptual develop-
ment; and clinical independence. The degree to which this process is enabled, however,
depends on a level of awareness, experience and learning-to-date in order to develop suffi-
cient insight, without which therapists may carry an ‘afterimage’ of dissonance and unre-
solved meaning.
An effective supervisory alliance within training and practice can enable a shift towards
resolution of some of these dissonances, through learning accruing from trust in the reflective
process and experienced at a level beyond stage-four clinical independence (Ward and
House, 1998). Each may dwell in hovering free-floating attention, jointly contemplating the
felt experience and exploring new perceptions rather than seeking immediate answers or
meanings. The learning experience of mutual discovery can help perception and understand-
ing of some new territory. It may be particularly useful for a supervisee to know that the other
(the supervisor) was both witness to, and facilitator of, an unfolding moment of insight and
the co-creation of new meaning – this experience arising from the supervisory alliance and
within a mutually reflective space. This may open up access to the experiencing of parallel
process (Doehrman, 1976), a form of insight arising when aspects of the therapeutic relation-
ship become re-enacted, echoed in the supervisory relationship. These phenomena can also
be experienced and noted in training group supervision.
Managing this ‘matrix’ of relational complexity and empathic understanding is a challenge
for both supervisor and supervisee; enabling conscious engagement with the ‘unconscious
imagination’ of countertransference phenomena ‘is therefore key not only to the successful
therapeutic process, but also its supervision’ (Wilkinson, 2010: 165).
Michael Carroll’s (1996) Counselling Supervision: Theory, Skills and Practice and
Hawkins and Shohet (2012) Supervision in the Helping Professions each offer generic

perspectives on clinical supervision that directly acknowledge ideas of Elizabeth Holloway,

Francesca Inskipp and Brigid Proctor, Steve Page and Val Wosket, and others in drawing
together ‘integrative’ approaches towards clinical supervision. Carroll (1996) describes a
format within which practitioners (from ‘novice’ trainees through to ‘journeyman’, ‘inde-
pendent craftsman’ and ‘master craftsman’) might develop and explore supervisory prac-
tice. This structure incorporates
• the purposes of supervision: managing the client welfare and supervisee professional development;
• the functions of supervision: educative (formative), supportive (restorative) and administrative
(normative);
• the generic tasks of supervision: evaluating and enabling a learning/teaching relationship, monitoring
professional and ethical issues and administrative tasks, to counsel and consult;
• managing the supervisory process through: pre-assessment; assessing; contracting for supervision;
engaging in supervision; evaluating supervisee, supervisor, the supervision process; terminating the
supervisory relationship.
Carroll (1996) emphasises that these be seen as ‘a guide’ in balancing between supervision
that would otherwise be either ‘overmanaged’ or ‘understructured’. The former removes all
spontaneity while the latter can result in chaos, especially for beginning supervisees.
Checklists, frameworks and methodologies are at our service and useful when they guide us, not when
they imprison us. (Carroll, 1996: 89)
Carroll’s words are prescient when sometimes the only clinical supervision provided for talk-
ing therapies in some contexts can be overly focused on case management, or checking-in on
the client treatment process, but allows little (if any) time for reflection on therapeutic rela-
tional processes.
Supervision within organisational contexts can bring added relational complexity, where
management dynamics, external funding, interpersonal- and dual-relationships can each add
considerable challenge to professional and ethical practice. Whilst each of these influences
might be seen as outside of the therapeutic frame, they can impose a dis-abling impact on
effective interpersonal engagement (Nolan and Walsh, 2012).
Practitioners may require supervision as container for their clinical work within a particu-
lar professional modality or context, and as described elsewhere in this handbook. Examples
might include the specific supervision demands of ‘safeguarding’ when working with vulner-
able adults or with children and issues of child protection; strategies within art therapy or
dance movement therapy; case formulation in specific psychological approaches such as
psychodynamic practice, person-centred work or CBT theories; or within time-limited solution-
focused or NHS IAPT structured ‘treatments’ that have a specified format: each might need
a way of working that requires specific supervisor skills, experience and training.
Anecdotal discussions between practitioners, along with research findings emerging from
North America and the UK over the last 25 years, indicate that the espoused modality of the
therapist may not necessarily be what is actually being practised in the therapy room, and that

most practitioners will incorporate theories and ideas from across a breadth of psychological
perspectives in order to best serve their clients or patients in their struggle towards sufficient
meaning and purpose. Critically important here is the question of the level of client care and
support that is possible through clinical supervision practice which might otherwise be una-
ble to effectively recognise or support what is meaningful within the therapeutic frame.
Whilst perceptions within supervision are seen as being echoed from the therapy frame, the
interpretations of meanings are dependent on theoretical orientation, individual world-view,
and insight into in-the-moment countertransference and parallel processes. When therapist
and supervisor have differing perspectives on, or access to, each of these factors the effective
managing of clinical material presented in supervision can become either (1) an informing
challenge to all parties, or (2) problematic to the supervision process.
Hawkins and Shohet (2012) link practice across seven process model modes, integrating
developmental levels where supervision integration can progressively inform the maturing
practitioner’s practice with purpose and potential across differing therapeutic approaches. This
means working with ‘an open mind and an open heart’ whilst managing symptom treatment and
being mindful to support the persons with whom we are working, ‘the human beings who are
communicating through these symptoms’ (Hawkins and Shohet, 2012: 250–1).
In response to an apparent dearth of supervision research in the UK (Wheeler and Richards,
2007) the Supervision Practitioner Research Network (SuPReNet) has encouraged interna-
tional cooperation on research projects. The BACP website hosts a link to this group
(SuPReNet, 2013) which encourages supervision research projects and is accumulating ses-
sional evaluation on supervisees’ experience of supervision.
For the trainee the experience of the tutor–student relationship, with tutor as educator,
mentor and practitioner-connoisseur, is therefore centrally important. This relationship helps
to facilitate student learning through the modelling of skills practice and sharing of profes-
sional experience and wisdom, particularly when tutors share instances from their practice
experience as illustration of theoretical ideas and challenges, dilemmas and insights into
clinical practise. It is a joint learning enterprise, where the tutor will also gain insight from
trainees and which recognises the student’s life experiences, their wisdom and their facilitat-
ing ‘presence’. This latter element of emerging self-awareness becomes an increasingly evi-
dent feature that has, after all, led to their selection success and which reflects:
• a substantial commitment of financial and emotional resources;

• trust in risking shifts in personal life and worldview;
• humility that avoids ‘knowing’ yet sustains curiosity and the chance of learning something more from
each other.
6 CONTINUING PROFESSIONAL DEVELOPMENT
Continuing Professional Development (CPD) is a requirement of all practising healthcare

professionals including individual therapists, and involves providing evidence of yearly

updated activities that have supported practice. Good practice within training organisations
may offer guided support for students in maintaining a work-based learning log of therapy-
related activity, comprising training days/courses, workshop attendance and placement
support work. Some training organisations and self-facilitating counselling practitioner
groups offer post-qualifying workshops as CPD opportunities; professional bodies also
provide workshops and conferences on international research findings and current profes-
sional practice.
7 REGULATION OR REGISTRATION?
Individual therapy is currently an unregulated profession in the UK. This means that there is
no single recognised training curriculum or level of qualification for practitioners, and in fact
there is no generally agreed definition or legal power to determine who may or may not be
described as a ‘counsellor’ or ‘psychotherapist’. This situation has led to concerns about qual-
ity assurance, ethical practice and the safeguarding of clients. Since the 1970s, there have
been several attempts to set up a regulatory system that would be legally enforceable, but
none of these has been successful. Most recently, the UK government proposed in 2007 that
counselling and psychotherapy should be regulated by the Health and Care Professions
Council (HCPC) (previously entitled the Health Professions Council (HPC)), which already
regulates psychologists and arts therapists. Arguments were made from various sections of
the profession against this proposal on the grounds either that statutory legislation was unnec-
essary and the voluntary registers already established by professional bodies such as BACP
and UKCP were sufficient to ensure a means to address unethical practice, or that the HPC
was an unsuitable organisation to regulate therapists. At the same time there was considerable
support in principle for the idea of statutory regulation, and BACP in particular took the deci-
sion to support the government’s proposal.
However, after the UK election in 2010, the Coalition Government decided to take no
further action and the proposal for statutory regulation was dropped. Instead, the Health and
Social Care Act (2012) encourages voluntary registers of therapists as the best way to deal
with quality assurance and good practice in a diverse professional field. It therefore falls to
the professional organisations to create a framework for training and to work with a body
responsible for the quality assurance of voluntary registers. Both BACP and UKCP are work-
ing in collaboration with the PSAHSC (previously the Council for Healthcare Regulatory
Excellence). BACP is one of the first organisations to pilot the PSA’s Accreditation Scheme
for Assured Voluntary Registers.
It is important to be clear at this point in the discussion about terminology. To summarise,
regulation of the profession of individual therapy is now set to be a voluntary, not a statutory
process. It will involve practitioners becoming registered via the BACP or UKCP registers
which, in turn, will be ‘assured’ by becoming accredited by the PSA. This is confusing
enough, but the term ‘accredited’ has further meanings. BACP accredits training courses that
meet their rigorous criteria, and it also accredits therapy services and individual practitioners.

Individual accreditation is conferred on practitioners who have made a successful application

and completed a minimum of 450 hours of supervised practice. Some accredited practitioners
go on to become senior accredited practitioners after more than six years of accreditation.
UKCP, however, does not use the term or the process of ‘accreditation’ and simply registers
graduates of its trainings.
BACP has established a register of counsellors/psychotherapists since its position is
that it is not possible to distinguish between these two titles in any generally acceptable
way. The BACP Register of Counsellors and Psychotherapists (previously UK Register
of Counsellors and Psychotherapists (UKRCP)) is open to the following categories of
practitioners:
(a) Graduates of a BACP accredited training course;

(b) Graduates of a non-accredited course who successfully complete an online Certificate of Proficiency;
(c) Practitioners who are currently accredited or senior accredited members of BACP.
The minimum experience required for entry to the register is that required by BACP accred-
ited courses, currently 100 hours of supervised practice. Since the register is accessible to
newly qualified practitioners, registration is seen as the point of entry to the profession, as it
is in nursing or social work. The individual accreditation scheme already operated by BACP
for many years will now be seen as a way of marking a further degree of experience and
competence. Individual accreditation as a counsellor/psychotherapist by BACP will continue
to require a minimum of 450 hours of supervised practice.
Psychotherapists and psychotherapeutic counsellors registered with the UKCP are in a
different situation, though many practitioners in fact hold both UKCP registration and
BACP accreditation. The UKCP, which is made up of modality-based constituent colleges
each with its own training standards and courses, has long maintained its own register,
consisting of graduates of trainings that fall under the auspices of its colleges. This is
expected still to be the case under the PSAHSC. However, UKCP registration as a psy-
chotherapist has always required a longer initial training and more practice hours than
BACP accreditation. It seems likely that this discrepancy between BACP and UKCP reg-
isters will continue under the new system of assured registers. UKCP has recently started
to offer an independent route to registration in addition to the route via membership of a
constituent college.
The aim of assured registers is firstly to protect the public by ensuring that practitioners are
appropriately trained and that an accessible complaints procedure is in existence. A related aim
is to enhance employment opportunities for registered practitioners, since increasingly
employers will make registration as an essential requirement for recruitment.
It is likely that the development of assured registers will have an impact on training courses.
For example, the proposed entry routes to the BACP register of counsellors/psychotherapists
give a clear advantage to graduates of BACP accredited courses, which will make them more
attractive to potential trainees. Courses which are not accredited may find it harder in future
to recruit students and may cease to be viable.

Further information on the development of the registers is available from the BACP and
UKCP websites: www.bacp.co.uk and www.psychotherapy.org.uk.
8 THERAPY RESEARCH AND TRAINING
Therapists and trainees can feel alienated from the world of research, resulting in a defensive
rejection (Meekums, 2010). However, we have also found that students can find conducting
a research investigation personally transformational and can help enhance practice. Many
features of counselling and psychotherapy education and practice are in themselves useful
research skills, for example: reflexivity at every stage of the process; curiosity; searching the
literature; interviewing and attentive listening skills that encourage relational ease, making
probing questions possible; creative techniques that elicit information at the edge, or outside
of, immediate awareness; management of audio and video recordings, their accurate tran-
scription towards understanding and analysis, including ‘listening between the lines’; writing
up case summaries; and presenting ideas to others. The use of research modalities that inform
IAPT services is mentioned earlier in this chapter.
Some trainees who may have previously studied scientific subjects (e.g. Emma, one of our
fictional applicants), and who may struggle at first with a different view of reality (ontology) and
ways of knowing (epistemology), can often find motivation in wanting to understand more
deeply what makes us human. Personal crises and subsequent personal therapy can be a motivat-
ing factor for this shift, sometimes challenging previous self-beliefs about strength and vulner-
ability. Emma, a psychology graduate, learned through this process that she did not ‘know much
about the human mind’. In working with students whose background is in scientific study, it is
important to acknowledge the need for synthesis of these two aspects of self and differing ways
of knowing. It would be a mistake to assume there is a need to throw out left-brain, linguistic,
mathematical and analytic thinking in order to nurture more right-brain, embodied and affective/
creative ways of knowing. Trainers would aim to nurture and celebrate the capacity to think, and
to do so with emotional literacy. However, they would also need to avoid both the rigidity that
comes from a positivist assumption of certainty, and any ‘woolly’ reactions to this that run coun-
ter to the systematic enquiry necessary for both therapy and research. Rather, there should be a
need to cultivate a willingness to suspend certainty, and to remain open to new possibilities; what
Emma, our fictional applicant, described as a ‘radical uncertainty’.
9 CONCLUSION
In this chapter on training and supervision we have presented a summary of some current
thinking on the evolving nature of counselling and psychotherapy training in the UK. We
have also considered what this might involve for the trainee, having arrived at the decision
to follow a personally challenging investment of time, emotion and financial cost, who is

prepared to dwell within others’ confusion and the pursuit of what it means to be human. It
could be helpful to take time at this point to reflect on your initial thoughts on reading this
chapter – perhaps in answer to questions such as:
• What really excites you now about the prospect of training? What is the drive that leads you to this
demanding process?
• What might feel scary to you?
• What do you think might be difficult and a challenge?
• What do you think will be fun and enjoyable?
10 RECOMMENDED READING
Bager-Charleson, S. (2010) Reflective Practice in Counselling and Psychotherapy. Exeter: Learning Matters.
Lapworth, P. (2011) Tales from the Therapy Room. London: Sage.
Palmer, S. and Bor, R. (eds) (2008) The Practitioner’s Handbook. London: Sage.
Reeves, A. (2013) An Introduction to Counselling and Psychotherapy: From Theory to Practice. London: Sage.
Rose, C. (ed.) (2012) Self Awareness and personal Development. Basingstoke: Palgrave Macmillan.
11 REFERENCES
Carroll, M. (1996) Counselling Supervision: Theory, Skills and Practice. London: Sage.
Chantler, K. (2005) From disconnection to connection: ‘race’, gender and the politics of therapy. British Journal of
Guidance and Counselling 33(2): 239–56.
Collins, S. and Arthur, N. (2010) Culture-infused counselling: a fresh look at a classic framework of multicultural
counselling competencies. Counselling Psychology Quarterly 23(2): 203–16.
Crook Lyon, R.E. and Potkar, K.A. (2010) The supervisory relationship. In N. Ladany and L.J. Bradley (eds),
Counselor Supervision: Principles, Process and Practice (4th edn). New York: Taylor & Francis, pp. 15–52.
Doehrman, J.G. (1976) Parallel process in supervision and psychotherapy. Bulletin of the Menninger Clinic 40(1):
9–104.
Driver, C. (2005) Introduction: supervision: the interface of theory and practice. In C. Driver and E. Martin (eds),
Supervision and the Analytic Attitude. London: Whurr.
Hawkins, P. and Shohet, R. (2012) Supervision in the Helping Professions (4th edn). Buckingham: Open University
Press.
Lago, C. (2011) Introduction to part 1: towards enhancing professional competence – from training to research
to practice. In C. Lago (ed.), The Handbook of Transcultural Counselling and Psychotherapy. Maidenhead: Open
University Press.
Lave, J. and Wenger, E. (1991) Situated Learning: Legitimate Peripheral Participation. Cambridge: Cambridge
University Press.
Macaskie, J., Meekums B., Nolan G. (2013) Transformational education for psychotherapy and counselling:
a relational dynamic approach. British Journal of Guidance and Counselling 41(4): 351–62.
Meekums, B. (2010) Moving towards evidence for dance movement therapy: Robin Hood in dialogue with the
King. The Arts in Psychotherapy 37: 35–41.

Mozdzierz, G.J., Peluso, P.R., Lisiecki, J. (2011) Evidence-based psychological practices and therapist training: at
the crossroads. Journal of Humanistic Psychology 51(4): 439–64.
Nolan, G. and Walsh, E. (2012) Caring in prison: the intersubjective web of professional relationships. Journal of
Forensic Nursing 8(4): 163–9.
Norcross, J.C. and Wampold, B.E. (2011a) Evidence-based therapy relationships: research conclusions and clinical
practices. Psychotherapy 48: 98–102.
Norcross, J.C. and Wampold, B.E. (2011b) What works for whom: tailoring psychotherapy to the person. Journal
of Clinical Psychology: In Session, 67(2): 127–32.
Quality Assurance Agency for Higher Education (QAA) (2013) Subject Benchmark Statement for Counselling and
Psychotherapy. www.qaa.ac.uk
Schore, A.N. (2011) The right brain implicit self lies at the core of psychoanalysis. Psychoanalytic Dialogues 21(1):
75–100.
SuPReNet (2013) www.bacp.co.uk/research/networks/SuPReNet.php Retrieved 14.03.13.
Ward, C.C. and R.M. House (1998) Counseling supervision: a reflective model. Counselor Education and
Supervision 38(1): 23–33.
West, W. (2011) Practice around therapy, spirituality and healing. In W. West (ed.), Exploring Therapy, Spirituality
and Healing. Basingstoke: Palgrave Macmillan.
Wheeler, S. and Richards, K. (2007) The Impact of Clinical Supervision on Counsellors and Therapists, Their Practice
and Their Clients: A Systematic Review of the Literature. Lutterworth: BACP.
Wiggins, S.R. Elliott and M. Cooper (2012) The prevalence and characteristics of relational depth events in psy-
chotherapy. Psychotherapy Research 22(2): 139–58.
Wilkinson, M. (2010) Changing Minds in Therapy: Emotion, Attachment, Trauma and Neurobiology. New York:
W.W. Norton.

Appendix 1
Chapter Structure
Note: This appendix reproduces the brief given by the editors of this book to the
contributors of the Chapters 2–19 and 21 on how to structure their chapters.
Your aim here should be briefly to acquaint the reader unfamiliar with your approach with its
context. Start with explaining why the approach is called what it is. You may wish to cover
the approach’s historical origins, its intellectual roots and its sociocultural context.

Outline the basic assumptions made by the approach about the person and human nature.

Explain in detail the major concepts utilised by the approach in accounting for:

Please note that you will have an opportunity to show how practitioners of your approach
assess and conceptualise clients’ problems in therapy.
24_Dryden & Reeves_Appendix.indd 625 08-Oct-13 10:33:48 AM

626 APPENDIX 1

Explain the approach’s view on how psychological disturbance is acquired.

Explain the approach’s position on how psychological disturbance is perpetuated. Cover:

What intrapersonal mechanisms are utilised by individuals to perpetuate their own psycho-
logical disturbance?

What interpersonal mechanisms are recognised as important in the perpetuation process?

What is the role of the environment in the perpetuation process?
2.5 Change
Use this section to outline briefly the approach’s view on how humans change with
respect to movement from psychological disturbance to psychological health. This sec-
tion should orient the reader to what follows under ‘Practice’ but should not be limited
to the change process in therapy (i.e. it should not duplicate Section 3.6). Thus it should
both complete the ‘Acquisition–Perpetuation–Change’ cycle and orient the reader to
what follows.
3 PRACTICE

Outline how the approach conceptualises the goals or aims of the therapy.

What selection criteria are used to determine whether or not clients will benefit from the
approach in its individual therapy format? There are two issues here:

APPENDIX 1 627

Which people (if any) are deemed unsuitable for the particular approach under consideration
(refer back to 3.1 here where relevant).

What criteria are employed in deciding whether or not clients who are suitable for the
approach would benefit from individual therapy (as opposed to couples, family and group
therapy) at the outset.

What qualities should effective therapists of the approach possess? Focus on both of the
following:

Detail the relative importance of personal characteristics vs skill factors here

Here, outline the following:

Here outline the type of therapeutic relationship that therapists of your orientation seek to
establish with their clients.

Here, characterise the interactive style of the therapist in the conduct of the approach in
action. (While you will no doubt use your own dimensions, the following might be kept
in mind: action–passive; formal–informal; self-disclosing–non-self-disclosing; humorous–
serious.) How does the interactive style of the therapist change during the therapeutic
process?

In this section you should do the following:

628 APPENDIX 1
3.5.1 Assessment
Show how therapists carry out an assessment of clients’ problems.
3.5.2. Case formulation

Show how therapists carry out a case formulation. Please note the following:
• You may merge the two sections (3.5.1 and 3.5.2) if this makes more sense.
• If your approach does not carry out formal assessment of clients’ problems and/or a case
formulation, explain why in 3.5.

Please structure this section as follows:

List and describe separately the major strategies and techniques advocated as therapeutic by
the approach. According to Marvin Goldfried, strategies lie at a level of abstraction between
theory and techniques, so techniques are more specific than strategies. Please use this formu-
lation in preparing this section and list the strategies first, showing how the techniques are
specific ways of operationalising the strategies.

Here outline the process of therapeutic change from beginning to end. What reliable patterns
of change can be discerned in successful cases? Outline the major sources of lack of thera-
peutic progress and how these are addressed in the approach.
4 CASE EXAMPLE
Feel free to include examples and vignettes throughout the chapter. However, in this section
you should fully describe a real-life case which shows the approach in action, referring when-
ever possible to the above framework and dividing the section thus:
Please resist the temptation to select a ‘brilliant success’. Choose a case that readers can relate
to, i.e. one that had its difficulties and where the client had a realistic (not an idealistic) outcome.
4.1 The client

Briefly describe the client and his/her presenting concerns.

APPENDIX 1 629
4.2 The therapy

Please use the following structure:

Give a flavour of the type of therapeutic relationship you developed with the client using the
approach’s way of conceptualising relationship variables.

Focus on how assessment/formulation was carried out and its content.

Outline the strategies and techniques used in therapy as covered in Section 3.5. Here the emphasis
should be on describing the process of change (i.e. how the therapy unfolded over time).

Make clear what changes the client made as a result of the therapy. Speculate on the sources
of the therapeutic change. What, with hindsight, might you have done differently?
5.1 Developments
Your aim here should be to outline briefly how the approach has developed over time. Make
your focus an international one if appropriate. In particular, outline developments in:
5.1.1 Brief therapy

What modifications, if any, have had to be made to enable this approach to be used within a
brief/time-limited context.

What modifications, if any, have had to be made to enable this approach to be used with a
diverse range of clients.

Outline the limitations of the approach as seen by you and your colleagues within the
approach. How should the approach develop in the future to deal with such limitations?

630 APPENDIX 1

Outline the criticisms that have been made of the approach by people outside of it? Evaluate
the legitimacy of these criticisms.
5.4 Controversies
Outline the controversies that are currently preoccupying theorists and practitioners within
your approach.
6 RESEARCH
Summarise the research findings concerning the effectiveness of your approach and the pro-
cess variables that may account for such effectiveness.
7 FURTHER READING
Suggest five key texts that readers can consult if they wish to reader further on the approach.
8 REFERENCES

Index
‘ABC’ analysis (in behavioural activation), 332 Aristotle, 76

‘ABC’ model of emotional/behavioural episodes, 273–4, Arnkoff, D.B., 587
277–9, 284–6 Arthur, N., 614
Abernathy, J., 8 Assagioli, Roberto, 15, 497, 502, 511
aboriginal culture, 491 assessment
Abraham, Karl, 101 in behavioural activation, 341–2
Abram, J., 55 in cognitive analytic therapy, 370
abreaction, 21 in cognitive therapy, 253–5
acceptance and commitment therapy (ACT), 266, 333, in compassion-focused therapy, 315
345, 462 in the ‘contemporary Freudian’ approach 30–4
acceptance of counselling and psychotherapy, 5 definition of, 140–1
accreditation of professional registers and training in existential therapy, 167
courses, 620–1 in gestalt therapy, 193
active-directive style of therapy, 283 in the ‘independent’ approach to psychodynamic
active listening, 396 therapy, 61–2
active therapy, 12 in interpersonal therapy, 427–8
actualisation, 130–1, 138 in the Jungian and post-Jungian approaches, 87–8
adherence measures, 582–3 in the Kleinian approach, 112–13
‘adhesive–solvent continuum’, 189 in mindfulness-based approaches, 455–6
Adler, Alfred, 10, 77, 609 in narrative therapy, 479
Adler, Gerhard, 85–7 in person-centred therapy, 140–1
adolescents, interpersonal therapy for, 436 in pluralistic therapy, 561
adult attachment interview, 45 in rational emotive behaviour therapy, 284–5
affect and the affective domain, 78, 260, 304–7, 311–13, in solution-focused therapy 397–8
365, 419, 422–6, 429–30 in transactional analysis, 226–7
affiliative emotions and feelings, 311–12 in transpersonal psychotherapy, 504–5
affiliative relationships, 305–6 assimilative integration, 528
agenda-setting for a session, 253 attachment theory, 6, 45, 96, 363, 416–22
aggression, 25–6 attention
agoraphobia, 318 power and regulation of, 311
Albert Ellis Institute, 295 training in, 316–17
alchemy, 85, 508–9 attention deficit hyperactivity disorder (ADHD), 16, 98–9
Alcoholics Anonymous, 83 audiences for self-stories, 475–6
Aldridge, S., 8–10 authenticity, 159, 163, 192, 424–5, 499, 502–3, 530,
American Psychological Association, 536, 598 533, 560
analusis, 211 automatic thoughts, 246, 256–60
‘analytic settings’, 35 autonomy of the individual, 149, 390, 506–7
analytical psychology, 75, 78, 82, 608 avoidance and escape behaviours, 345
Angyal, Andras, 129–34, 149 awareness
anxiety disorders, 246–9, 253–6, 265–7, 305–8 heightening of, 186, 191, 195
‘anything goes’, 10 inner, outer and middle zones of, 195
Arbours Association, 157 limits to, 200
25_Dryden & Reeves_Index.indd 631 08-Oct-13 10:33:51 AM

632 INDEX
awareness continuum, 188–9 Bowlby, John, 363, 416–18

Ayer, A.J., 520 Bozarth, J.D., 135–6, 142–3, 151–3
bracketing, 192, 202
‘background of safety’ (Sandler), 27 Brailler, L.W., 189
Baer, R., 448 Bravesmith, Anna, 94
Bakhtin, Mikhail, 380 Brazier, David, 507
Balint, M., 50, 54–7, 69, 71 Breuer, Josef, 77
Barley, D., 525–6 Brief Behavioural Activation Treatment for Depressions
Barrett, M.S., 588–9 (BATD), 351
Bateson, Gregory, 390, 470, 490 brief therapy
Bazzanno, M., 466 in behavioural activation, 351
Beck Depression Inventory, 341 in cognitive analytic therapy, 380
Beck, A.T., 244–7, 267 in cognitive therapy, 265–6
Bedi, R.P., 586–7 in compassion-focused therapy, 323
behaviour change, 429–30 in the ‘contemporary Freudian’ approach, 42
inside-out and outside-in models of, 338 in existential therapy, 175
techniques used in REBT, 287 in gestalt therapy, 199
behavioural activation, 11–12, 329–55 in the ‘independent’ approach to psychodynamic
controversies around, 352–3 therapy, 69
criticisms of, 352 in interpersonal therapy, 437
limitations of, 352 in Jungian and post-Jungian approaches, 94–5
research on, 353–5 in the Kleinian approach, 120
Behavioural Activation for Depression in mindfulness-based approaches, 461
Scale (BADS), 341 in narrative therapy, 491
behavioural learning theory, terminology of, 331 in person-centred therapy, 147–8
behavioural theory and therapies, 12, 136, 243, 245, in pluralistic therapy, 569
258–60, 267 in rational emotive behaviour therapy, 292
Beisser, A., 185–6 in solution-focused therapy, 408–9
belief in therapy and the therapist, 527 in transactional analysis, 234
Bennett, D., 383 in transpersonal psychotherapy, 514
Bentine, Michael, 277 British Association of Behavioural and Cognitive
Béres, L., 490, 494 Psychotherapists, 9
Berg, Astrid, 95 British Association for Counselling and Psychotherapy
Berg, Insoo Kim, 387, 389, 397, 399, 409 (BACP), 9, 583, 611, 615–16, 619–22
Bergin, A.E., 585, 591 British Psychoanalytic Council, 9
Berman, J.S., 588–9 British Psychoanalytic Society, 21–2, 42, 49–51, 70–1
Berne, Eric, 207–11, 218, 222–9, 235–8 British School of existential therapy, 177
‘best practice’ guidelines, 14 British School of object relations theory, 361
Beyebach, M., 398 Britton, Ronald, 119
Bien, T., 449 Brodley, B.T., 142
‘big q’ research, 516 Brody, A., 142
‘biological hypothesis’ (Ellis), 273 Brook, C.A., 308
bipolar disorder, 4, 265, 437, 585 Bruner, Jerome, 470
‘blaming and shaming’, 306 Buber, Martin, 179, 192
Bleuler, Eugen, 76 Buddhism and the Buddha, 4, 445–9, 456, 464, 466
‘bodying forth’, 193
Bohart, A.C., 588 Cambray, Joe, 81
Bollas, Christopher, 51 ‘can do’ attitude, 236
borderline personality disorder, 267 ‘canonical life styles’, 470–1
Bordin, E.S., 225, 279, 293, 586 capitalism, 448
Borkovec, T.D., 583 Carr, A., 11
Boss, Medard, 156–7, 177 Carroll, Lewis, 152, 590

INDEX 633
Carroll, Michael, 617–18 causal self, 499, 502, 507, 511, 515–16
Carter, J., 440 Cavalli, Alessandra, 87–8
Carvalho, Richard, 84 centres of excellence, 595–6
case examples ‘chair work’, 194, 319, 505, 524
of behavioural activation, 347–51 Chambless, D.L., 590
of cognitive analytic therapy, 376–80 Champion, L., 440
of cognitive therapy, 261–4 Chanen, A.M., 383
of compassion-focused therapy, 320–3 change and change processes in therapy
of the ‘contemporary Freudian’ approach, 38–42 for behavioural activation, 336–7, 346
of existential therapy, 170–5 for cognitive analytic therapy, 367, 376
of gestalt therapy, 196–9 for cognitive therapy, 249, 260
of the ‘independent’ approach to psychodynamic for compassion-focused therapy, 309, 319–20
therapy, 66–9 for the ‘contemporary Freudian’ approach, 27–8, 37–8
of integrative therapy, 538–43 for existential therapy, 162, 169–70
of interpersonal therapy, 432–5 for gestalt therapy, 185–6, 195–6
of Jungian and post-Jungian approaches, 91–4 for the ‘independent’ approach to psychodynamic
of the Kleinian approach, 116–19 therapy, 57–8, 64–6
of mindfulness-based approaches, 457–61 for interpersonal therapy, 421–2, 431–2
of narrative therapy, 486–9 for Jungian and post-Jungian approaches, 81, 89–90
of person-centred therapy, 145–7 for the Kleinian approach, 107–8, 115–16
of pluralistic therapy, 564–9 for mindfulness-based approaches, 451–2, 457
of rational emotive behaviour therapy, 288–92 for narrative therapy, 475–6, 485–6
of solution-focused therapy, 405–8 for person-centred therapy, 134–6, 144–5
of transactional analysis, 229–34 for pluralistic therapy, 554, 563–4
of transpersonal psychotherapy, 512–14 for rational emotive behaviour therapy, 277–8, 287–8
case formulation for solution-focused therapy, 394–5, 404–5
for behavioural activation, 342 for transactional analysis, 222, 228–9
for cognitive analytic therapy, 370 for transpersonal psychotherapy, 501–2, 508–12
for cognitive therapy, 255–6 Chantler, K., 613
for compassion-focused therapy, 315 Charcot, Jean-Martin, 77
for the ‘contemporary Freudian’ approach, 34–5 Cheyne, George, 6
for existential therapy, 167 child abuse, 366
for gestalt therapy, 193 child ego states, 210, 217
for the ‘independent’ approach to psychodynamic child self, 506
therapy, 62 childhood experiences, impact of, 23–4, 362–3, 417
for interpersonal therapy, 428–9 children’s feelings and awareness, 102–3, 121, 222
for Jungian and post-Jungian approaches, 88 children’s sexual drives, 24–5
for the Kleinian approach, 113 Clarkson, P., 535–6
maintenance-type or developmental, 255 Cleveland Institute for Gestalt Therapy, 180
for mindfulness-based approaches, 456 client preferences, 557
for narrative therapy, 479–80 client-centred therapy see person-centred therapy
for person-centred therapy, 141 clinical interviews, 33
for pluralistic therapy, 561 Clinical Outcomes in Routine Evaluation (CORE), 202
for rational emotive behaviour therapy, 284–5 outcome measure (CORE-OM), 584
for solution-focused therapy, 398 clinical psychology, 5, 522
for transactional analysis, 227 closing question, 402
for transpersonal psychotherapy, 505 Clougherty, K., 439
usefulness of, 123 cognitive analytic therapy (CAT), 12, 361–83, 525
Casement, A., 81, 97 controversies around, 382–3
Casement, P., 51, 71 criticisms of, 382
Cassell Hospital, 50 limitations of, 381–2
Cathexis school of transactional analysis, 223, 226, 228 research on, 383

634 INDEX
cognitive-behavioural therapy (CBT), 4, 10–11, 14–16, confidentiality, 11

22, 122, 244, 249–51, 255, 265–8, 306, 315, 361–2, confluence in human relating, 187–8, 200
380, 553, 579, 582, 590–1, 604, 610 confrontations with patients, 35
criticisms of, 265 congruence, 132–5, 139
cognitive change techniques (in REBT), 286 external and internal, 142–3
cognitive competencies, advantages and disadvantages of Connolly-Gibbons, M.B.C., 440
having, 303 constructivist transactional analysis, 223
cognitive distortions, 245–6, 431 contact boundaries, 181–3, 187–8
cognitive–emotion mismatch, 301 contamination of an ego state, 223
cognitive psychology and the cognitive domain, 2, 243–4, ‘contemporary Freudian’ approach to therapy, 21–46
362, 429 controversies around, 44
cognitive restructuring, 257, 260 criticisms of, 43–4
cognitive therapy, 11–12, 243–68, 303 limitations of, 43
controversies around, 267 research on, 44–6
criticisms of, 266–7 context for therapy, 554–5
for depression, 330 contextualism, 332–3
limitations of, 266 contingency management, 346
research on, 267–8 continuing professional development (CPD), 619–20
second and third waves of, 266–7 Continuum Technique for challenging all-or-nothing
see also cognitive analytic therapy; cognitive- thinking, 259
behavioural therapy controlled outcome studies, 383
‘cognitive turn’, 470 ‘conversational therapy’ (Hobson), 525
collaboration between therapist and client, 252, 255, 369, conversations, 478, 481, 548
397, 530–1, 537, 559, 561, 570, 586–7 Cooper, M., 151, 153, 177, 547, 581, 584, 588–94,
Collins, S., 614 597–8, 610–11
Combs, Alan, 511 core beliefs, 260
Combs, Gene, 479 core conditions, 283, 455, 536
common factors between different psychotherapies, 45, Core Conflictual Relationship Theme (CCRT), 45
425, 525–7, 554, 592, 611–12 core pain (in CAT), 365
common humanity, 302–3 core skills, 598
communication analysis, 430 Corten, N., 325
communities of practice, 612 couches, therapeutic use of, 35, 89, 112
comparative research, 493 Council for Healthcare Regulatory Excellence see
compassion attributes and compassion skills, 310 Professional Standards Authority
compassion-focused therapy (CFT), 12, 301–25 Counselling for Depression model, 611
controversies around, 324–5 counselling psychology, 5
criticisms of, 324 counselling and psychotherapy
limitations of, 324 emerging and future trends in, 14–15
research on, 325–6 history of, 9–10
compassionate behaviour, 311–12, 320 numbers of clients for, 5
compensation, 89 countertransference, 36–7, 51, 63–4, 89, 226, 536, 588
compensation neurosis, 27 couple therapy, 83, 90, 114, 423–4
competence of clients, 399 courage, concept of, 312
competency frameworks, 582–3 Crane, R., 447, 452
complainant clients, 404 creative adjustment process, 181–8
complementary transactions, 218 critical psychology, 7
complexes, 77–80, 97 Crook Lyon, R.E., 616
compromise formations, 24 crossed transactions, 218–19
conceptualisation of a client’s problems, 256, 260 Cuijpers, P., 353–4
concrete thinking, 58 cultural awareness, 614
conditioned patterns of thought and response, 452 cultural competence, 612–15
‘conditions of worth’, 131–5, 140–1, 150, 500 cultural identities of clients, 570

INDEX 635
cultural norms, 365 ‘discomfort disturbance’ (Ellis), 276

‘cultural resources’ concept, 553 distortion in response to experience (Rogers), 133–4
Cushman, P., 5 distress tolerance of the therapist, 314
customer clients, 405 disturbance about disturbance, 276
‘cycle of experience’ model, 183 diversity, working with
in behavioural activation, 339, 351–2
Darwin, Charles, 50 in cognitive analytic therapy, 381
Daseinsanalysts, 177 in cognitive therapy, 265–6
death instinct, 25–6 in compassion-focused therapy, 323–4
decatastrophising, 258 in the ‘contemporary Freudian’ approach, 42–3
de-centring the therapist, 478–9 in existential therapy, 175
decision analysis (in interpersonal therapy), 430 in gestalt therapy, 199–200
deconfusion process, 223 in the ‘independent’ approach to psychodynamic
decontamination process, 222 therapy, 69–70
defence mechanisms, 24, 28, 36 in interpersonal therapy, 437
definitional ceremony sessions, 484–5, 492 in Jungian and post-Jungian approaches, 95–6
deflection, 187 in the Kleinian approach, 120–1
‘deintegration’ (Fordham), 80 in mindfulness-based approaches, 461–3
Del Re, A.C., 592 in narrative therapy, 491
‘demandingness’, 295–6 in person-centred therapy, 148–9
Denborough, David, 490 in pluralistic therapy, 570
Denham-Vaughan, S., 196 in rational emotive behaviour therapy, 292
denial in response to experience (Rogers), 133–4 in solution-focused therapy, 409
depression, 6–8, 55, 79, 244–56, 259, 265, 267, 303, 306, in transactional analysis, 235
329–36, 340–4, 351–5, 415, 418–21, 427–8, 439, in transpersonal psychotherapy, 514
462, 474, 554, 561, 570, 583 documents, therapeutic, 483
behavioural activation formulation for, 334–5 ‘dodo bird verdict’, 152, 590, 610
behavioural and cognitive models for, 329–30 dog phobia, 248
first-line therapy option for, 338 Drama Triangle, 220
see also perinatal depression dreams and dream work, 36, 65, 89, 101, 168, 505
‘depressive position’, 104 drive-seeking system, 304
‘description’ (Husserl), 192 drive theory (Freud), 23–4
desensitisation, 187, 287 Driver, C., 616
de Shazer, Steve, 387–9, 397, 399, 402, 410, 492 drivers (in transactional analysis), 213
de Silva, P., 445 Dryden, Windy (co-editor), 272, 284–5, 292, 543
determinism, principle of, 27 Dulwich Centre, Adelaide, 470, 490–1, 494
developmental psychology, 237 Duncan, B., 527
Dewey, John, 129 Dunn, M., 383
Dharmakaya, the, 511 Durkheim, Émile, 75
diagnosis in psychotherapy, 253, 255, 427 Duvall, J., 490, 494
Diagnostic and Statistical Manual of Mental Disorders dying patients, 84
(DSM), 8, 226, 410, 473 dynamic interpersonal therapy (DIT), 42
dialectical behaviour therapy (DBT), 15–16, 266, dysthymia, 436
324, 462
dialectical logic, 501 eating disorders, 436
dialogue (in gestalt therapy), 190, 192 eclecticism, 520–1, 547
diary-keeping by clients, 372, 483 technical, systematic and haphazard, 522–5
DiClemente, C.C., 405 Edinger, Edward, 94
DiGiuseppe, R., 283 effective therapists, qualities of
dilemmas (in CAT), 362, 366 for behavioural activation, 339–40
Dimidjian, S., 267 for cognitive analytic therapy, 368–9
directive techniques in therapy, 430 for cognitive therapy, 251–2

636 INDEX
effective therapists, qualities of cont. environmental factors in therapy cont.

for compassion-focused therapy, 313–14 for the ‘independent’ approach to psychodynamic
for the ‘contemporary Freudian’ approach, 30 therapy, 57
for existential therapy, 164–5 for interpersonal therapy, 421
for gestalt therapy, 190 for Jungian and post-Jungian approaches, 80
for the ‘independent’ approach to psychodynamic for the Kleinian approach, 107
therapy, 59–60 for mindfulness-based approaches, 451
for integrative therapy, 530–1 for narrative therapy, 475
for interpersonal therapy, 424–5 for person-centred therapy, 134
for Jungian and post-Jungian approaches, 83–4 for pluralistic therapy, 553
for the Kleinian approach, 110–11 for solution-focused therapy, 394
for mindfulness-based approaches, 454–5 for transactional analysis, 221–2
for narrative therapy, 477–8 for transpersonal psychotherapy, 501
for person-centred therapy, 138–9 Environmental Reward Observation Scale (EROS), 355
for pluralistic therapy, 558–9 Epictetus, 4, 271
for rational emotive behaviour therapy, 281–2 epidemiology of psychological distress, 7–8
for solution-focused therapy, 396 epigenetics, 16
for transactional analysis, 224–5 Epstein, Mark, 507
for transpersonal psychotherapy, 503–4 Epston, David, 390, 470, 475, 478–9, 484, 490–3
Egan, Gerard, 522 ‘equivalence paradox’, 45, 152
ego, the, 23–5, 28–9, 32, 52–6, 65, 81–2, 86 Erickson, Milton, 390–1
ego states, 207, 210–13, 217–19, 223, 227–8 erotic transference, 31
functional modes of, 217–18 erotogenic zones, 24
ego strength, 29, 53, 57, 59, 189, 199, 423 Esalen Institute, 180, 200
egotism, 187 Etchison, M., 493
Einsengart, S., 411 European Brief Therapy Association, 388
Elias, D., 447, 452 evaluative beliefs, 244
Ellenberger, H.F., 4 evidence, ‘ownership’ of, 581
Ellis, Albert, 4, 243–4, 271–83, 287, 293–7, 515 evidence-based practice, 8, 14, 16, 72, 124, 265,
embodiment, aspects of, 550 580–2, 611
emotional compass, 169 exceptions in problem experience, 399, 401
emotional intelligence, 3 existential phenomenology, 192
emotional literacy, 190 existential therapy, 3, 11–12, 155–77
emotions, 2, 304–5, 318–19 controversies around, 176–7
emotive-evocative change techniques (in REBT), 286–7 criticisms of, 176
empathetic understanding, 135–6, 139–43 limitations of, 176
definition of, 140 research on, 177
empathy, 311, 314, 511, 588–9 expectations of clients, 593
empirically-supported treatment (EST), 14, 124, 598 experience–perception gap, 448
employment of therapists, 8–9, 14 experiential avoidance, 308
empty-chair technique see ‘chair work’ experiential change techniques, 267
enantiadromia, 75 experimentation in the course of therapy, 194, 258–60,
ending of therapy, 66, 375–6, 425, 509 266, 400
engagement psychology, 310 ‘expert’ role, 425
English, Fanita, 216 externalising conversations map, 481–2
environmental factors in therapy Eysenck, Hans, 13
for behavioural activation, 336
for cognitive analytic therapy, 367 facilitation of change processes, 559
for cognitive therapy, 249 failure conversations map, 482
for compassion-focused therapy, 309 failures in therapy, 293–4
for the ‘contemporary Freudian’ approach, 27 Fairbairn, C., 436
for existential therapy, 161–2 Fairbairn, W.R.D., 363

INDEX 637
fakirism, 510 Germer, C., 450, 453, 462–3

family therapy, 83, 477, 491–2 gestalt, pillars of, 190
Farhi, Nina, 83 gestalt therapy, 11–12, 179–204
fears, blocks and resistances (FBRs) to compassion, 320 controversies around, 201–2
feedback to therapist or client, 253, 400, 403, 426 criticisms of, 200–1
feminism, 491 limitations of, 200
Ferenczi, Sandor, 101 research on, 202–4
Ferrer, J., 516 Ghent, Emmanuel, 226
Ferster, C.B., 329 Giegerich, Wolfgang, 84–5, 97, 99
field theory, 179, 190–1 Gila, Ann, 511
figure formation, 181–2 Gilbert, P., 325
Finn, S.E., 551 Gill, M., 140
Firman, John, 511 Gingerich, W.J., 411
Fisch, R., 404 Gizynski, M.N., 588
Fischer, C.T., 551 Glass, C.R., 587
Fish, V., 492 Glass, G.V., 296–7, 585
fixed gestalts, 182, 184, 188 goals of therapy
fixity, 134–7 for behavioural activation, 337–8
flexible beliefs promoting psychological health, 275 for cognitive analytic therapy, 367
Flournoy, Théodore, 76 for cognitive therapy, 250
Fonagy, Peter, 43, 71–2, 585, 590 for compassion-focused therapy, 312
Fordham, Michael, 80–3 for the ‘contemporary Freudian’ approach, 28–9
Fosbury, J., 383 different types of, 278–9
Foucault, Michel, 470, 490, 492 for existential therapy, 162–3
Frank, Ellen, 437, 439 for gestalt therapy, 186–9
Frank, Jerome, 4, 521–2 for the ‘independent’ approach to psychodynamic
Frankl, V.E., 157, 176–7 therapy, 58
free association, 21, 35, 114 for integrative therapy, 530–1
Freedman, Jill, 479 for interpersonal therapy, 422
Freeman, A., 296 for Jungian and post-Jungian approaches, 81–2
Freire, E., 583 for the Kleinian approach, 108–9
French, T.M., 521 for mindfulness-based approaches, 452
Freud, Anna, 22, 24, 31, 49–51, 121 for narrative therapy, 476
Freud, Sigmund, 1, 3, 5, 9–10, 12, 15, 21–31, 35–7, 63, for person-centred therapy, 136
76, 96, 104, 114, 151, 181, 501, 504, 609 for pluralistic therapy, 555–6
Freudian therapy, 12, 22–3, 35–6; see also ‘contemporary for rational emotive behaviour therapy, 278–9
Freudian’ approach to therapy for solution-focused therapy, 395
Friedlander, Siegmund, 179 for transactional analysis, 224
Frosh, S., 72 for transpersonal psychotherapy, 502–3
‘frozen therapists’, 69–70 Goffman, Erving, 470
Fukuyama, M.A., 514 Goldberg, P., 508
‘fully functioning person’ (Rogers), 132–3, 149 Goldstein, Kurt, 179
functional analysis, 306, 331–3, 336, 340–2 Goodman, Paul, 180, 183–5
functional analytic psychotherapy (FAP), 340, 353 Gordon, Rosemary, 82
Gordon-Brown, I., 505
Gabbard, G.O., 38 graded task assignments, 259
Gale, C., 325 Graf, M., 329
games (in transactional analysis), 220 Green, André, 71
Geertz, Clifford, 470 Greenson, R., 31
George, Evan, 388 Grepmair, L., 465
Gerber, A.J., 123 grief, 483–4
Gergen, Kenneth, 470 unresolved, 419, 431

638 INDEX
group therapy, 138, 251, 313, 423 Historical Review of Schemas, 259
‘GROW’ model of coaching, 341 HIV/AIDS, 437
‘guided fantasy’, 505 Hobbes, R., 236
Guntrip, Harry, 51 Hobson, Robert, 525, 533–4
Holdstock, T.L., 148–9
Halmos, P., 6 Hollon, S.D., 590
Handler, L., 551 homeopathy, 4
Hansen, J.T., 552 homonomy, 132, 149
‘happenings’, experiential, 529 homosexuality, 95, 122, 473, 490
happiness, 6, 272 ‘horizontalisation’ (Husserl), 192
Hargaden, H., 227 Horjus, M., 437
Hart, Tobin, 511 Horney, Karen, 179
Hawkins, P., 617–19 House, R.M., 617
Hayes, S.C., 266 Houston, Jean, 511
Hayward, M., 493 Hovarth, A.O., 586–7
‘healing context’ (Wampold), 527 Hubble, M., 527
Health (and Care) Professions Council, 9, 620 Hubert, Henri, 75–6
Health and Social Care Act (2012), 70, 620 human existence, dimensions of, 158, 168
healthy negative emotions (in REBT), 274–5 human nature, 3–4, 157, 472
hedonistic behaviour, 272 human species, development of, 2
Hedtke, L., 490 Humanistic and Integrative College, 612
Hefferline, R., 183–5 humanistic psychology, 157, 208–9
Hegel, G.W.F., 508 humanistic therapy, 10, 16, 510, 582, 609
Heidegger, Martin, 156–7, 177, 179, 192 humour, use of, 287, 370, 397
Heimann, Paula, 63 hungers, psychological, 209–10
Heraclitus, 75, 180 Husserl, Edmund, 156, 192, 202
‘here and now’ experience, 181 hypnosis and hypnotherapy, 410, 503
‘high contact’ therapy condition, 415 hypochondriasis, 246
Hillman, James, 96 hypothesis-testing, 252, 259, 361
Hinrichsen, G., 439 hysteria, 21
Hinshelwood, R.D., 543
historical context and the development of therapy id, the, 23–4, 28
for behavioural activation, 329–30 ‘ideal compassionate images’, 317
for cognitive analytic therapy, 361–2 idealisation and Idealist philosophy, 76, 114
for cognitive therapy, 243–4 ‘If–then theory’, 137
for compassion-focused therapy, 301–2 ‘’I–It’ relating and ‘I–Thou’ relating, 192
for the ‘contemporary Freudian’ approach, 21–2 image of the person
for existential therapy, 155–7 in behavioural activation, 330–3
for gestalt therapy, 179–80 in cognitive analytic therapy, 362–3
for the ‘independent’ approach to psychodynamic in cognitive therapy, 244–5
therapy, 49–51 in compassion-focused therapy, 302–5
for integrative therapy, 521–2 in the ‘contemporary Freudian’ approach 22–3
for interpersonal therapy, 415–16 in existential therapy, 157-9
for Jungian and post-Jungian approaches, 75–6 in gestalt therapy, 180–1
for the Kleinian approach, 101–2 in the ‘independent’ approach to psychodynamic
for mindfulness-based approaches, 445–7 therapy, 52–3
for narrative therapy, 469–71 in interpersonal therapy, 417–18
for person-centred therapy, 129–30, in Jungian and post-Jungian approaches, 76–7
for pluralistic therapy, 547–9 in the Kleinian approach, 102–3
for rational emotive behaviour therapy, 271–2 in mindfulness-based approaches, 447–9
for solution-focused therapy, 387–9 in narrative therapy, 471–2
for transactional analysis, 207–9 in person-centred therapy, 130–1
for transpersonal psychotherapy, 497–8 in pluralistic therapy, 549–50

INDEX 639
image of the person cont. interpersonal and intrapersonal mechanisms at work in

in rational emotive behaviour therapy, 272–4 therapy cont.
in solution-focused therapy, 389–92 in narrative therapy, 474–5
in transactional analysis, 209–11 in person-centred therapy, 134
in transpersonal psychotherapy, 498–9 in pluralistic therapy, 553
imagery, 311, 317; see also rational emotive imagery in rational emotive behaviour therapy, 276–7,
imagery re-scripting, 260 in solution-focused therapy, 393–4
‘I’m OK – You’re OK’, 209, 223 in transactional analysis, 215–21
implicit learning, 98 in transpersonal psychotherapy, 501
Improving Access to Psychological Therapies (IAPT) interpersonal inventories, 427
initiative, 5, 265, 416, 583, 604, 611, 618 interpersonal therapy (IPT), 11–12, 410, 415–40
incongruence, 132–3, 141 controversies around, 438
definition of, 132 criticisms of, 438
‘independent’ approach to psychodynamic therapy, 49–73 limitations of, 438
controversies around, 71 research on, 439–40
criticisms of, 70 interpretations, psychoanalytic, 35–7
limitations of, 70 introjection, 187, 200
research on, 71–3 intuition, 504–8
indifferentism, 548 in vivo desensitisation, 287
individuation, 81–2, 96 irrational beliefs (IBs) in REBT, 272–8, 286, 295–6
inferences, 273–4 Iveson, Chris, 388
information-gathering by therapists, 371, 427–8
informed consent, principle of, 557 James, William, 76, 548
Ingersoll, R.E., 501 Janet, Pierre, 76–7
Ingram, Barbara, 505 Jaspers, K., 156
initiation rites, 95 Johnson, S., 393–4
innatism, 97 Jones, Jason, 272
Integral (AQAL) system, 501 journals, academic, 204
integration of psychological theories, 361–2, 380–2, 395 Jung, Carl Gustav, 10, 15, 75, 85, 88, 502, 511, 609
levels of, 528–9 Memories, Dreams, Reflections, 96
theoretical, 525 Jungian and post-Jungian approaches to therapy, 12, 75–99
integrative approach to life, 532–5 controversies around, 97
integrative therapy, 11–12, 519–44, 547, 604, 610–11 criticisms of, 96
limitations of, 543–4 limitations of, 96
philosophical strands in, 523–4 research on, 97–9
research on, 544
routes towards, 524–8 Kabbat-Zin, Jon, 445, 461–2, 465
internal working model (IWM) of relationships, 417–22 Kachele, H., 123
interpersonal and intrapersonal mechanisms at work in Kahn, M., 535–6
therapy Kant, Immanuel, 76
in behavioural activation, 335–6 Kanter, J.W., 344, 353
in cognitive analytic therapy, 366 Kareem, J., 51, 70
in cognitive therapy, 247–9 Karpman, S., 220
in compassion-focused therapy, 308–9 Kelly, George, 243, 390
in the ‘contemporary Freudian’ approach, 26–7 Kernberg, Otto, 51
in existential therapy, 161 Khan, Massud, 51
in gestalt therapy, 184–5 Kierkegaard, Søren, 155–6
in the ‘independent’ approach to psychodynamic Kirshner, L.A., 51
therapy, 55–7 Klein, Melanie, 22, 49–51, 101–2, 106, 113–16, 120–1
in interpersonal therapy, 421 Kleinian approach to psychodynamic therapy, 3, 12, 22,
in Jungian and post-Jungian approaches, 78–9 31, 36–7, 56, 63, 101–24
in the Kleinian approach, 107 controversies around, 122
in mindfulness-based approaches, 450–1 criticisms of, 121–2

640 INDEX
Kleinian approach to psychodynamic therapy cont. Madigan, Stephen, 490

limitations of, 121 magic-mythic-membership self, 506
research on, 122–4 Maguire, K., 514
Kleist, D.M., 493 ‘mainstream home base’ for therapy, 527–8
Klerman, Gerald, 415 Malan, D.H., 69, 123
Knekt, P., 411–12 Manning, Bernard, 9
Knox, Jean, 80, 96 Manos, R.C., 334, 354–5
koan, the, 511 ‘maps’ of therapy, 480–2
Kohon, G., 49–50, 64 Marcus Aurelius, 271
Markowitz, J., 436, 438
Lago, C., 148–9, 614–15 marriage, 90
Laing, R.D., 6, 69, 157, 160, 505 Marshall, I., 532
Laithwaite, H., 325 Martell, C.R., 345, 351
Lambert, M., 11, 525–6, 584–5, 591 Marx, Karl, 3
Lampropolous, G.K., 554 Masson, J.M., 13–14
language of therapy, idiosyncracies in, 201 ‘master therapists’, 558
Lapworth, P., 211, 238 mastery, feelings of, 259
Lave, J., 612 Mathias, Sonia, 225
Law of Pragnanz, 183 Maupassant, Guy de, 195
Layard, Richard, 6, 8, 14–16 Mauss, Marcel, 75–6
Lazar, S., 16 May, Rollo, 157
Lazarus, Arnold, 522 Mayhew, S., 325
learning how to learn, 563–4 Mazzucchelli, T., 354
learning style, 554 meaning, social and psychological levels of, 218
Leichsenring, F., 123 mediating goals, 279
Leiman, Mikael, 380 medical model of psychotherapy, 141, 596, 598
Lejuez, C.W., 351 ‘medicalisation of distress’, 8
letter-writing, 319 medication, 4, 15–16
Levine, B., 570 meditation, 453, 465–6
Lewin, Kurt, 179, 201 memories, working with, 319
Lewinsohn, P.M., 329 Mental Research Institute (MRI), Palo Alto, 387, 390
Liber Novus see Red Book mentalisation, 43, 419–20
Limentani, A., 50, 71 Meredith-Owen, William, 96
Lindfors, O., 411–12 Merleau-Ponty, M., 181, 192
Lisiecki, J., 611 Messer, S.B., 1
literary theory, 475 meta-analysis, 297, 353–4, 411, 585, 591
‘little q’ research, 516 meta-emotional problems, 276
Littlewood, R., 51, 70 Metanoia Institute, 238
locus of evaluation, 136, 141, 149 metaphor, use of, 474, 514
definition of, 132 meta-strategies, 563
‘logical errors’ associated with psychological meta-therapeutic perspective, 548
disorders, 245 Meyer, Adolf, 416
logotherapy, 157 Miller, Barry, 95–6
Longmore, R.J., 352 Miller, S., 527
low frustration tolerance (LFT), 276 Milwaukee Brief Therapy Centre, 387
low-intensity (LI) interventions, 351 mind, theories of, 362, 364
Luborsky, L., 590–2 mindfulness, definition of, 447
Lucre, K., 325 mindfulness-based approaches (MBAs), 445–66
controversies around, 464–5
McKeel, Jay, 412 criticisms of, 464
MacKewn, J., 188 limitations of, 463
McLeod, J., 471, 547, 579–80, 596–7, 610–11 research on, 465–6

INDEX 641
mindfulness-based cognitive therapy (MBCT), 15–16, Ockham, William of, 391

266, 456, 462, 465 O’Connell, Bill, 388
‘minoritisation’ (Chantler), 613, 615 O’Connor, N., 51, 70–1
miracle question (MQ), 399–403 Oedipus complex, 24–5
Mitchell, Juliet, 51, 69–70 O’Hanlon, Bill, 397
modelled behaviour, 213 older people, therapy for, 437, 439
modernism, 523 ontological security, 160–1
moment-to-moment experience, 447, 457, 480, 609 openness to experience, therapists’, 533
monism, 548, 558 operant learning principles, 329
Moodley, R., 4, 15 Orlinsky, D., 531, 579, 593
mother–infant relationship, 26, 51–7, 70, 78, 95, 104–5, Otto, Rudolf, 76–7
191, 213, 305, 363–4 outcome goals, 278
motivation, 307, 338, 422, 593 outcome measures, 123, 296–7, 425, 438, 583–4
Mozdzierz, G.J., 611 ‘outsider witnesses’, 484–5
multicultural counselling, 614
Muran, J.C., 534–5 Palmer, Stephen, 272
mutuality between analyst and analysand, 86–7 panic attacks, 246, 248, 251–8, 305–6
Myerhoff, Barbara, 470 Panksepp, J., 304
mysticism, 511 ‘paradoxical theory of change’ (Beisser), 185
‘paranoid-schizoid position’, 104
narcissism, 93–4, 382, 449 parent ego states, 210–11, 217
narrative therapy, 11–12, 469–94, 613 ‘parents in the head’, 107
controversies around, 493 Parfitt, Will, 502
criticisms of, 492–3 Parry, G., 383
limitations of, 491–2 ‘passive’ therapy, 12
research on, 493–4 pathworking, 505
National Health Service (NHS), 14, 16, 22, 42, 44, 152, Pauli, Wolfgang, 76
238, 362, 368, 380, 382, 416, 603, 611, 616, 618 Pavlovian conditioning, 521
National Institute for Health and Clinical Excellence pay-offs for psychological disturbance, 277
(NICE), 14, 265, 267, 416, 583, 596, 604, 611 Peluso, P.R., 611
National Institute of Mental Health, 439 perception–experience gap, 448
nature-nurture debates, 3 perinatal depression, 436
negative automatic thoughts, 246, 256–7 Perls, Fritz, 179–88, 194, 199–201
negotiation of next step (in solution-focused therapy), 403 Perls, Laura, 11, 179–81
networking see practice–research networks person-centred therapy, 11–12, 129–53, 579, 609
neural networks, 393–4, 422, 450, 499 controversies around, 150–1
neuroception, 449–50 criticisms of, 138, 150
neuro-linguistic programming (NLP), 507 limitations of, 149
neuroscience, 16, 124 research on, 151–3
neurosis, 24, 29, 82, 97 ‘personal domains’, 245
New Age thinking, 510 ‘the personal is political’, 69
New York Institute for Gestalt Therapy, 180 personality, development of, 210
Nietzsche, Friedrich, 76, 156 personality change, conditions necessary for, 135
Nondual, the, 511–12 personality disorders, 249, 255–6, 260, 265–7, 365, 368,
Norcross, John, 526, 543, 584, 588–9, 611 373; see also borderline personality disorder
‘noticing experiments’, 400 pervasive developmental disorders (PDDs), 98–9
‘not your fault’ approach, 302–3, 309–11 phantasies, 104–8, 115, 121, 124
numinous experiences, 88–9 phenomenology, 156, 177, 181, 190–2, 202, 383
Philadelphia Association, 157
obesity, 6 Physis (Berne), 222
object relations theory and therapy, 6, 51, 57, 70–1, 211, Pickering, Judith, 89–90
361–4 Pilgrim, D., 9

642 INDEX
Piper, W.E., 588 problem acknowledgement, 402

planning of counselling services, 8 problem-focused therapies, 395, 404
pleasure ratings, 259 problem-free talk, 398–9
pluralism, 15, 547–8, 520, 560, 596 ‘problem narratives’, 553
pluralistic belief as distinct from pluralistic practice, 610 problem-oriented therapies, 250–5
pluralistic therapy, 547–71 ‘problems in living’ concept (Szasz), 550–1
controversies around, 571 Procedural Sequence Object Relations Model (PSORM),
criticisms of, 570–1 363–4, 380
limitations of, 570 procedures (In CAT), 363–4, 382
research on, 571 process goals, 278
training in, 610 Prochaska, James, 405, 532–3
politics, 6 Procter, S., 325
Pollard, J., 8–10 Professional Standards Authority (PSA) for Health and
Pollock, P.H., 383 Social Care, 9–10, 615, 620
Portman Clinic, 42 professionalisation of therapy, 9
Positive Data Log, 259 ‘profound philosophic change’ (Ellis), 287–8
positive psychology, 16, 236, 497–8 projection, 187
positivism, 500, 523, 596 projective identification, 56, 102, 367
post-structuralism, 470, 478 proliferation of therapeutic models, 10–12, 15
post-traumatic stress disorder (PTSD), 249, 306, 319, 395 psychiatry, 4
Potkar, K.A., 616 psychic determinism, 23
Power, M., 8, 440 psychic wholeness, 89
practice-based evidence, 581–2 psychoanalysis, 5, 10–12, 15, 21–2, 28–9, 38, 43–4, 64,
practice–research networks (PRNs), 583–4 101, 108–9, 245, 362, 521, 608
practice of therapy controversies about, 44
in behavioural activation, 337–46 criticisms of, 43–4
in cognitive analytic therapy, 367–76 Freud’s aims for, 28
in cognitive therapy, 250–60 origins and development of, 21–2
in compassion-focused therapy, 309–20 as a treatment for pathological behaviours other than
in the ‘contemporary Freudian’ approach, 28–38 neurosis, 29
in existential therapy, 162–70 underlying theory, 50
in gestalt therapy, 186–96 psychodynamic therapy, 21–46
in the ‘independent’ approach to psychodynamic assessment for, 32–4
therapy, 58–66 as distinct from psychoanalytic psychotherapy, 608
in integrative therapy, 530 efficacy of, 124
in interpersonal therapy, 422–32 practice of, 28–38
in Jungian and post-Jungian approaches, 81–91 research on, 44–6
in the Kleinian approach, 108–16 training in, 608–9
in mindfulness-based approaches, 452–7 underlying theory, 22–8, 556
in narrative therapy, 476–86 see also ‘contemporary Freudian’ approach;
in person-centred therapy, 136–45 ‘independent’ approach; Kleinian approach
in pluralistic therapy, 554–64 psycho-education, 223, 225
in rational emotive behaviour therapy, 278–88 psychoid archetypes, 76
in solution-focused therapy, 395–405 psychological disturbance
in transpersonal psychotherapy, 502–12 and behavioural activation, 333–6
preconscious mind, 23 and cognitive analytic therapy, 363–5
predisposing factors for psychological problems, 8 and cognitive therapy, 245–8
‘preferred futures’, 476 and compassion-focused therapy, 305–9
present moment awareness, 447–8, 463 ‘contemporary Freudian’ approach to, 23–7
pre-session change, 398, 401 definition of, 365
‘pretending experiments’, 400 and existential therapy, 159–61
‘primary self’ (Fordham), 80 and gestalt therapy, 182–4

INDEX 643
psychological disturbance cont. rackets (in transactional analysis), 216

and ‘Independent’ psychodynamic therapy, 53–6 Raitt, Al, 272
and interpersonal therapy, 418–21 randomised controlled trials (RCTs), 44, 123, 177, 267,
Jungian and post-Jungian approaches to, 77–9 330, 353–4, 383, 410–11, 415, 493, 578, 581–8,
Kleinian approach to, 103–6 604, 611
mindfulness-based approaches to, 449–51 Rank, Otto, 129, 179
and narrative therapy, 472–4 rational emotional dissociation, 301
and person-centred therapy, 131–4 rational emotive behaviour therapy (REBT), 4, 11–12,
and pluralistic therapy, 551–3 243–4, 271–98
and rational emotive behaviour therapy, 274–7 changes of name, 295
and solution-focused therapy, 392–4 controversies around, 295
and transactional analysis, 211–16 criticisms of, 295
and transpersonal psychotherapy, 499–501 Insight 1, Insight 2 and Insight 3 in, 276
psychological health limitations of, 293–4
and behavioural activation, 334 rationaliy in, 272–8
and cognitive analytic therapy, 365–7 research on, 295–7
and cognitive therapy, 246 specific and general, 285–6
and compassion-focused therapy, 307–8 rational emotive imagery (REI), 286
‘contemporary Freudian’ approach to, 24–5 Ratner, Harvey, 388
definition of, 365 Rayner, E., 50–5, 59, 64
and existential therapy, 160 reality
and gestalt therapy, 182–3 co-creation of, 193
and ‘Independent’ psychodynamic therapy, perceptions of, 103
53–4 reality-testing, 246, 252, 257
and interpersonal therapy, 420 reattribution of cause or effect, 257–8
Jungian and post-Jungian approaches to, 77–8 re-authoring conversations map, 482
Kleinian approach to, 104–6 reciprocal relating, 364
mindfulness-based approaches to, 449 reconstruction as a therapeutic technique, 36–7
and narrative therapy, 473 Red Book, 76–7, 97, 502
and person-centred therapy, 132–3 redecision therapy, 223, 226–8
and pluralistic therapy, 552 redefining process, 216
and rational emotive behaviour therapy, 275 re-evaluation co-counselling, 7
and transactional analysis, 214–15 referral of a patient to another therapist, 33, 504–5
and transpersonal psychotherapy, 499–500 reflective listening, 143
psychological mindedness, 29–30, 422 reflective therapists, 597
psychological problems reformulation by therapists, 371–2, 383
predisposing factors for, 8 registration of therapists, 603, 620–2
‘upstream’ and ‘downstream’ aspects of, 7 regression, 64–6
psychological therapies, roots of, 4–5 benign and malign, 64, 66
psychology, first use of term, 5 regulation of therapy see statutory regulation
psychometric assessments, 341 Reich, Wilhelm, 6, 69, 179
psychosis, 265 reinforcement, positive and negative, 332–9, 342–6,
psychosynthesis, 502 351–5
Psychotherapists and Counsellors for Social ‘reintegration’ (Fordham), 80
Responsibility, 6 relational approach to therapy, 455
psychotherapy, first use of term, 5 relationship affiliations, 417
Psychotherapy and Politics International (journal), 7 relativism, concept of, 548
purism, methodological, 519–20, 533, 596 religion, 3, 5–6, 13, 15, 88, 487, 510, 515, 535
re-membering practices and the re-membering
qualitative interview methods, 571 conversations map, 482–4
qualitative research, 596 reminders of negative experiences, 336
‘Quantum Society’ (Zohar and Marshall), 532 Renlund, C., 123

644 INDEX
repetition compulsion, 25–8 safety strategies, 316

repression, 24 Safran, J.D., 251, 534–5
repression resistance, 26 Sanders, P., 8
Rescher, Nicholas, 520 Sandler, J., 27, 36
research into individual therapy, 577–98 Sanford, Ruth, 133, 141
definition of, 151 Sartre, Jean Paul, 156
emerging culture of, 579–80 scaffolding conversations, 481
on factors relating to the therapist and client, 591–4 scaling technique, 399, 402–4
future challenges for, 594–5, 598 scepticism, 548, 593
phases in historical development of, 579–80 scheduling of activities, 258, 345
qualitative and quantitative, 516 schema change techniques, 259–60
reasons for undertaking, 577 schema therapy, 265–7
on therapeutic approaches, 589–91 schemata, 245–50
on the therapeutic relationship, 586–9 schizophrenia, 4, 79, 151, 473
undertaken by students, 622 Schmidt, L.A., 308
research awareness of practitioners, 580, 595 schoolism, 520
research–practice divide, 578, 595–6 Schopenhauer, Arthur, 76
resistance to therapy, 26, 144, 390 Scottish Intercollegiate Guidelines Network (SIGN), 416
retroflection, 187–8, 200 script (Berne) and the script system, 211–17, 221, 226–7
Richardson, P., 123 secondary gains, 27, 307, 382
rigid beliefs causing psychological disturbance, 274–5 secure base (SB) phenomenon, 418, 420, 422, 429
Rilke, Rainer Maria, 534 Segal, Hanna, 119
risk assessment, 254 Segal, Julia, 121, 123
Ritalin, 16 Segal, Z., 251, 447, 457, 462
Ritzer, G., 7 self
Robertson, M., 417, 425 as distinct from organism, 130
Rodgers, B.J., 152 as process, 180, 184, 201
Rogers, Carl, 9, 12, 129–53, 500, 531, 579 sense of, 5, 53, 58–9, 65, 70, 302, 448–9, 454,
role disputes, 419, 431 466, 509
role-play, 430–1, 506 Western concept of, 148
‘role responsivness’ (Sandler), 36 self-awareness, 190
role transitions, 419, 431 self-concept, 133
roles in CAT, 364–6, 382 self-disclosure by therapists, 32, 140, 193, 287, 370,
idealising and denigrating, 375 588–9
Rønnestad, M.H., 531 self-fulfilling prophecies, 277
Roosevelt, Franklin D., 130 self-involvement on the part of therapists, 140
root causes of clients’ problems, 392 self-observation by therapists, 60
Rose, N., 5 self-reflection by clients, 367
Rosenfeld, Herbert, 116, 119 self-reward and self-penalisation by clients, 287
Rosenzweig, Saul, 590–1 self-roles, 364–5
Roth, A., 585, 590 self-stories, 469-76, 484
Rowan, John, 15, 508 sensitivity to suffering and distress, 310–13
Royal College of Psychiatrists, 498 sequential diagrammatic reformulation (SDR), 371–2
rumination, 333, 336, 345–6, 457, 469 session frameworks, 480
‘rupture and repair’ cycle, 195 session goals, 279
Russell, R.L., 579 sessions
Ryan, J., 51, 69–71 activity between, 400
Ryan, V.L., 588 length of, 399
Ryle, Anthony, 361, 380, 382, 525 recording of, 483
‘unscheduled events’ in the course of, 526
‘safe-emergencies’, 194 Sevig, T.D., 514
safety-seeking behaviour, 248–9 sexual aspect of human development, 24–5, 71

INDEX 645
sexual contact with clients, 11 Society for Psychotherapy Integration, 522, 610
sexual gratification, 56 sociocultural contexts of therapy, 5–10
sexual orientation, 51, 592; see also homosexuality Socratic questioning, 168–9, 253, 257
shamanism, 515 Solms, Mark, 43–4
shame, experience of, 324 solution-focused therapy (SFT), 11–12, 387–412,
shame-attacking exercises, 287 476, 492
shaming and blaming, 303 controversies around, 410
Shedler, Jonathan, 124 criticisms of, 410
Shohet, R., 617–19 limitations of, 409
Shore, Allan, 96 research on, 410–12
‘sick role’, 427 Somers, B., 505
Siegel, D., 449–50, 454–7 soothing-affiliative system, 305, 307, 311, 319
Siegel, R., 450, 453, 462 Speedy, Jane, 490
Sills, C., 211, 227, 237–8 Speierer, G.-W., 144–5
skill-training methods, 287, 345 Spillius, E., 104
Skills for Health, 604 spirituality, 15, 76, 158–9, 236, 497–9, 510–11,
skills of therapists 514–15, 535
in behavioural activation, 340 splitting, 55–6, 59–60, 104, 187
in cognitive analytic therapy, 368–9 stages of change, 405
in cognitive therapy, 252 statement of position map, 482
in compassion-focused therapy, 314 statutory regulation of therapy, 9, 13–14
in the ‘contemporary Freudian’ approach 30 ‘stay in there’ activities, 287
in existential therapy, 165 Steiner, C., 213
in gestalt therapy, 190 Steiner, John, 119
in the ‘Independent’ approach to psychodynamic Stern, Daniel, 201
therapy, 60–1 Stiles, W.B., 152
in interpersonal therapy, 425 Stiles, W.M., 584
in Jungian and post-Jungian approaches, 84 Stockholm Outcome of Psychotherapy and
in the Kleinian approach, 111 Psychoanalysis project, 72
in mindfulness-based approaches, 454–5 Stoic philosophy, 4, 271
in narrative therapy, 478 storying, 475
in person-centred therapy, 139 Strachey, J., 36–7
in pluralistic therapy, 559 Stratford, C.D., 189
in rational emotive behaviour therapy, 282 stress reduction programmes, 445, 461
in solution-focused therapy, 396–7 Stuart, Scott, 416–17, 425, 436, 438
in transactional analysis, 225 ‘stuckness’, 185, 562
in transpersonal psychotherapy, 504 students of psychotherapy, selection of, 604–8
Skinner, B.F., 136, 329 Stumpfel, U., 203
Slade, A., 424 Subject Benchmark Statement for Counselling and
Smail, D., 7 Psychotherapy (2013), 612
Smith, J., 123 submissive strategies, 306
Smith, M.L., 296–7, 585 subtle self, 499, 502–10, 514–16
Smuts, Jan, 179 success rates for different therapies, 409–12, 494, 584;
snags (in CAT), 362, 366 see also ‘dodo bird verdict’
social anxiety, 308 successes in therapy, amplification of, 403
social constructionism, 390–1 suicide, 188
social context, 309 suitability of therapies for particular patients
social dimension of human existence, 158 behavioural activation, 339
social networks, 417–18, 427–8 cognitive analytic therapy, 368
social problems, 7 cognitive therapy, 250–1
social therapy, 7 compassion-focused therapy, 312–13
socialisation, 275, 483 ‘contemporary Freudian’ approach, 29–30

646 INDEX
suitability of therapies for particular patients cont. theoretical assumptions of therapy cont.
existential therapy, 163–4 interpersonal therapy, 416–22
gestalt therapy, 189–90 Jungian and post-Jungian approaches, 76–81
‘independent’ approach to psychodynamic therapy, Kleinian approach, 102–8
58–9 mindfulness-based approaches, 447–52
interpersonal therapy, 423–4 narrative therapy, 471–6
Jungian and post-Jungian approaches, 82–3 person-centred therapy, 130–6
Kleinian approach, 109=10 pluralistic therapy, 549–54
mindfulness-based approaches, 453–4 rational emotive behaviour therapy, 272–8
narrative therapy, 477 solution-focused therapy, 389–95
person-centred therapy, 137–8 transpersonal psychotherapy, 498–502
pluralistic therapy, 557 theory, nature of, 136, 138, 151; see also therapy:
rational emotive behaviour therapy, 280–1 theories of
solution-focused therapy, 395–6 therapeutic alliance, 59, 250–1, 260, 279, 293, 370–2,
transactional analysis, 224 397, 422, 560, 564, 587
transpersonal psychotherapy, 503 definition of, 586
Sullivan, Harry Stack, 416–17 therapeutic contract, 207, 586
summarisation after a session, 253 therapeutic operations (in transactional analysis), 227
superconscious, the, 497, 502 therapeutic relationship, 30–2, 45, 369, 586–7
superego, 23–5, 28 in behavioural activation, 340
superego resistance, 26 in cognitive analytic therapy, 369
supervision of clinical practice, 464, 538, 609, 615–19 in cognitive therapy, 252–3
Supervision Practitioner Research Network, 619 in compassion-focused therapy, 314
‘surrendered self’, 507 in the ‘contemporary Freudian’ approach 30–2
‘symbolic objects’, 504 in existential therapy, 165–6
synchronicity, 76 in gestalt therapy, 190–2
systematic existential analysis (SEA), 168 in humanistic therapy, 609
Szasz, Thomas, 550 in the ‘independent’ approach to psychodynamic
Szentagotai, A., 296 therapy, 60
in integrative therapy, 535–8
tact, professional, 60 in interpersonal therapy, 425–6
Taft, Jessie, 129–30, 138–9, 148 in Jungian and post-Jungian approaches, 85
‘taking-back practices’, 479 in the Kleinian approach, 111
Target, Mary, 43 in mindfulness-based approaches, 455
target problems (TPs), 371 in narrative therapy, 478–9
tasks set for therapist and client, 259, 279, 293 in person-centred therapy, 139–40
Tavistock Clinic, 6 in pluralistic therapy, 559–60
Tavistock Institute, 50 in rational emotive behaviour therapy, 283
Teasdale, J., 457, 462 in solution-focused therapy, 397
teleology, 76, 81 in transpersonal psychotherapy, 504
Teresa of Avila, St, 511 therapeutic strategies
theoretical assumptions of therapy in behavioural activation, 342–4
behavioural activation, 330–7 in cognitive analytic therapy, 370–1
cognitive analytic therapy, 362–7 in cognitive therapy, 256–8
cognitive therapy, 244–9 in compassion-focused therapy, 316,
compassion-focused therapy, 302–9 in the ’contemporary Freudian’ approach, 35
‘contemporary Freudian’ approach, 22–8 in existential therapy, 167–8
existential therapy, 157–62 in gestalt therapy, 194
gestalt therapy, 180–6 in the ‘independent’ approach to psychodynamic
‘independent’ approach to psychodynamic therapy, therapy, 62
51–8 in integrative therapy, 537–8
integrative therapy, 522–4 in interpersonal therapy, 429

INDEX 647
therapeutic strategies cont. therapeutic techniques cont.

in Jungian and post-Jungian approaches, 88–9 in rational emotive behaviour therapy, 286–7
in the Kleinian approach, 113–14 in solution-focused therapy, 401–4
at macro and at micro level, 194 in transactional analysis, 227–8
in mindfulness-based approaches, 456 in transpersonal psychotherapy, 505–8
in narrative therapy, 480 therapy
in person-centred therapy, 142 choice between different forms of, 280
in pluralistic therapy, 562 criticisms of, 13–14
in rational emotive behaviour therapy, 285–6 theories of, 2, 552
in solution-focused therapy, 398–404 therapy for therapists, 30, 190, 464, 608–9
in transactional analysis, 227 ‘therapy wars’, 10–11
in transpersonal psychotherapy, 505 Thorne, B., 143, 151
therapeutic style, 32 threat and self-protection system, 304–6
in behavioural activation, 341 Tillich, Paul, 157, 179
in cognitive analytic therapy, 369–70 The Time Line, 427
in cognitive therapy, 253 Timulak, L., 577
in compassion-focused therapy, 315 ‘top dog/under dog’ dichotomy, 184
in the ‘contemporary Freudian’ approach 32 touching in the course of therapy, 201–2
in existential therapy, 166 Towergate (insurance brokers), 124
in gestalt therapy, 192–3 TRAC acronym, 345
in the ‘independent’ approach to psychodynamic training of therapists, 603–4, 608–15
therapy, 60–1 in cognitive-behavioural techniques, 265
in integrative therapy, 535–7 in gestalt techniques, 190
in interpersonal therapy, 426 in integrative techniques, 522, 543–4
in Jungian and post-Jungian approaches, 85–7 in interpersonal techniques, 416
in the Kleinian approach, 111–12 models of, 608–12
in mindfulness-based approaches, 455 in the power of attention, 316–17
in narrative therapy, 479 trances, 506
in person-centred therapy, 140 transactional analysis (TA), 207–38
in pluralistic therapy, 560 associations concerned with, 208
in rational emotive behaviour therapy, 283–4 controversies around, 237
in solution-focused therapy, 397 criticisms of, 236–7
in transactional analysis, 226 limitations of, 235–6
in transpersonal psychotherapy, 504 relational, 223, 226–7, 234, 237–8
therapeutic techniques research on, 237–8
in behavioural activation, 344–6 terminology of, 236
in cognitive analytic therapy, 371–6 transference, 30–2, 36–8, 42–6, 63–5, 89, 122–3, 187,
in cognitive therapy, 258–60 252, 367, 425, 536, 588
in compassion-focused therapy, 316–19 classical view of, 31
in the ‘contemporary Freudian’ approach, 35–7 identifying and reciprocating (in CAT), 373
in existential therapy, 168–9 positive and negative, 31, 114
in gestalt therapy, 194–5 transference neurosis, 31
in the ‘independent’ approach to psychodynamic transitional objects, 54, 363
therapy, 62–4 transpersonal psychotherapy, 15, 497–517
in integrative therapy, 537–8 controversies around, 515–16
in interpersonal therapy, 430–1 criticisms of, 515
in Jungian and post-Jungian approaches, 89 limitations of, 515
in the Kleinian approach, 114–15 research on, 516–17
in mindfulness-based approaches, 456–7 TRAP acronym, 345
in narrative therapy, 480–5 traps (in CAT), 362, 366
in person-centred therapy, 142–3 trauma and trauma therapy, 80, 235–6, 319
in pluralistic therapy, 562–3 Treasure, J., 383

648 INDEX
treatment manuals, 582–3, 591, 598 Watzlawick, P., 390–1

trial interpretations, 34 Weissman, M., 437–9
triangulation, 596 Wenger, E., 612
Trowell, J., 123 Wertheimer, Max, 179
Trower, Peter, 272 West, W., 4, 15
Tuckett, David, 123 Westen, D., 38
Tudor, K., 236–8 ‘What if?’ technique, 258
two-chair technique see ‘chair work’ White, Michael, 390, 469–74, 478–81, 485,
489–94, 613
Uban, Elizabeth, 82–3 Wilber, Ken, 498, 501, 507–11, 514, 516
ulterior transactions, 218 Wilkins, P., 140
ultimate outcome goals, 279 Wilkinson, M., 617
unconditional positive regard, 135–6, 139–43, 150 Williams, J., 457, 462
unconscious mind, 23, 36 window shopper clients, 404
Understanding the Person in the Context of his or her Winnicott, D.W., 50, 53–7, 69–73, 83, 96, 363, 505
Problems (UPCP), 284–5 Winslade, J., 490
‘unfinished business’, 185 Wittgenstein, Ludwig, 410
unintended consequences, 316 Wollants, G., 201
‘unique outcomes’ from narrative therapy, 490 word-association test, 79, 98
United Kingdom Association for Solution Focused World Health Organisation (WHO), 351
Practice (UKASFP), 388–9 ‘world views’, 520
United Kingdom Council for Psychotherapy (UKCP), 9, Worrell, M., 352
612, 620–2, 180 ‘worried well’, 4
utilisation, principle of, 391 ‘wounded healer’ model, 462
Wundt, Wilhelm, 76
valued life goals, 345
values and valued ways of behaving, 332–3, 338, 341, Yalom, I.D., 534–5
344–6 Yeager, R.J., 515
van Deurzen, Emmy, 507 Yoga, 514
verbal disputing methods, 286 Yong-Wook Shin, 98
Visser, Coert, 409 Yontef, G., 202
Vygotsky, Lev, 369, 380, 481, 490 Young, J.E., 267
Wachtel, Paul, 522, 536 Zeigarnik, Bluma (and Zeigarnik effect), 185
Wagner, Richard, 78 Zeitler, D.M., 501
Wampold, B.E., 526–7, 585, 588–9, 596, 598, 611 Zohar, D., 532
Ward, A., 383 Zoja, Luigi, 83
Ward, C.C., 617 zone of proximal development, 369


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‘[This] is essential reading for all who aspire to professional practice to ensure that knowledge and

skills are up to date in order to best serve their clients.’

DRYDEN AND REEVES

New chapters include Compassion-Focused Therapy, Interpersonal Therapy, Mindfulness in Individual

Cover image © iStockPhoto | Cover deisgn by Lisa Harper-Wells

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Find out more at: www.sagepublications.com

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First edition published 1984 as Individual Therapy in Britain

Library of Congress Control Number: 2013937639

British Library Cataloguing in Publication data

A catalogue record for this book is available from

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Andrew: For Diane, Adam, Katie and Emily

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1 The Cultural Context of British Psychotherapy 1

Part I The Psychodynamic Tradition 19

2 Psychodynamic Therapy: Contemporary Freudian Approach 21

3 Psychodynamic Therapy: The Independent Approach 49

4 Psychodynamic Therapy: Jungian and Post-Jungian Approaches 75

5 Psychodynamic Therapy: The Kleinian Approach 101

Part II The Humanistic-Existential Tradition 127

6 Person-Centred Therapy 129

7 Existential Therapy 155

8 Gestalt Therapy 179

9 Transactional Analysis 207

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Part III The Cognitive-Behavioural Tradition 241

10 Cognitive Therapy 243

11 Rational Emotive Behaviour Therapy 271

12 Compassion-Focused Therapy 301

13 Behavioural Activation 329

Part IV Other Specific Approaches 359

14 Cognitive Analytic Therapy 361

15 Solution-Focused Therapy 387

16 Interpersonal Therapy 415

Part V Broader Developments in Individual Therapy 443

17 Mindfulness in Individual Therapy 445

18 Narrative Therapy 469

19 The Transpersonal in Individual Therapy 497

20 Integrative Therapy 519

21 Pluralistic Therapy 547

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Part VI Professional Issues 575

22 Research in Individual Therapy 577

23 The Training and Supervision of Individual Therapists 603

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Figure 8.1 Continuums of contact and withdrawal 188

Figure 9.1 Ego states 210

Figure 10.1 Perpetuation of panic disorder 248

Figure 12.1 Three types of affect regulation system 304

Figure 13.1 General BA formulation for depression 335

Figure 14.1 SDR: Franko 379

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Table 10.1 Cognitive distortions 246

Table 11.1 Irrational and rational beliefs in REBT theory 274

Table 12.1 David’s threat-based CFT formulation 322

Table 22.1 Summary of findings 586

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Windy Dryden is Professor of Psychotherapeutic Studies at Goldsmiths University of

Mick Cooper is Professor of Counselling at the University of Roehampton and a Chartered

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