| Original Full Text | University of RoehamptonPSYCHDGoal-setting theory in psychotherapyA theory-building case study Heien, SofieAward date:2024Awarding institution:University of RoehamptonGeneral rightsCopyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright ownersand it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights. • Users may download and print one copy of any publication from the public portal for the purpose of private study or research. • You may not further distribute the material or use it for any profit-making activity or commercial gain • You may freely distribute the URL identifying the publication in the public portal ?Take down policyIf you believe that this document breaches copyright please contact us providing details, and we will remove access to the work immediatelyand investigate your claim.Download date: 08. May. 2024 Doctoral Portfolio Sofie Heien BSc (Hons) PsychD in Counselling Psychology Department of Psychology University of Roehampton 2023 1 Table of Contents • Introduction: Portfolio overview page 2 • Part 1: Research work page 6 • Part 2: Practice and development work page 178 ▪ Year 2 case study page 179 ▪ Year 3 case study page 206 ▪ Reflexive integration essay page 231 ▪ Appendices ‘Learning and development record’ page 251 o Appendix 1: Practice placements: cumulative training record page 252 o Appendix 2: Practice placements: Year 1, 2, and 3 supervisor evaluations page 262 Appendix 3 Reflective learning statements: Year 1 and 2 page 334 2 Introduction: Portfolio Overview This doctoral portfolio is submitted in partial fulfilment of the requirements of the PsychD in Counselling Psychology programme at the University of Roehampton. It is made up to two main parts: research work and practice and development work. The portfolio exemplifies the identity of a counselling psychologist as reflexive scientist practitioner. I was drawn to counselling psychology for its humanistic value base and the focus on individual experiences. This focus is a thread that runs through the work in this portfolio. I believe in the evidence informed stance (Hanley, et al., 2011) and will aim to stay informed of new research developments throughout my career as a counselling psychologist. However, my clinical work is shaped by a myriad of factors including, the individual circumstances, goals, and preferences of the client, my own experience of successful interventions, as well as psychotherapeutic research. Throughout the training programme, the learning that has penetrated my heart has been from single clients, building relationships, picking up on how they respond to interventions, hearing their rich experiences, and witnessing the bravery in their vulnerability. My case studies offer examples of the depth of learning I experienced from working with clients. My research work is based on a single case and aims to build on a theory. I argue that one case can offer the richness and depth of data that is needed when investigating complex phenomena such as psychological theories. The theme that draws together the different parts of the portfolio is theory application and moreover that theories rarely cover all aspects of clients’ difficulties and strengths. The research work is aimed at theory extension based on detailed observations from a single case. Both case studies are examples where theory does not cover the entirety or complexities of the client and therefore, different theories are integrated in order to account for more aspects of the client’s experience. This raises a question of where theory is helpful and whether theories are sufficient tools for explaining challenges brought by clients to therapy. This portfolio argues that theories are needed in order to have consistent explanations for why interventions are helpful. However, 3 theories are to be utilised as ‘works in progress’ constantly integrating empirical observations, new areas of application, extensions, and limitation where appropriate. What this portfolio argues is that client factors, as well as the relationship with the therapist, will always be more important than any application of theory and theory should not be seen as a finished product to be ‘applied’ to clients, but as a potentially helpful tool which’s usefulness needs to be carefully considered in the individual client circumstance. The research work reported herein investigates goal-oriented practice in psychotherapy. A topic that I am passionate about due to its focus on client agency and empowerment. In the current climate of mental health work with commissioning based on targets, goals work can offer a more individualised way of measuring outcomes which focuses on what clients identify as meaningful rather than or in addition to using standardised tools. My research project aims to test whether a theory on goal-processes borrowed from organisational psychology – namely goal setting theory – is applicable to psychotherapy. The theory is often referenced as evidence for goal-oriented practice despite lacking evidence of applicability to psychotherapy. Therefore, I start by critically evaluating the evidence base for the theoretical propositions outlined by goal setting theory, both in terms of the evidence base underlying the proposition, but also, crucially, the evidence of applicability to psychotherapy. I then outline the theory building case study methodology adapted in the project. This form of research aims to build on a theory, such as apply it to a new area of enquiry – in this case psychotherapy. During my training, I set up a group of researchers who adopted theory building case study research methodology, together we reflected on methodological issues and conducted a systematic literature review of papers using this methodology focusing on analytic strategies adopted. The article is included as appendix E in the thesis appendices. It is currently under review for publication. 4 The next section of the thesis positions the study within a critical realist research paradigm where I critically reflect on the assumptions made within the study and how it positions itself towards knowledge, knowledge production, and the nature of reality. I then outline the results, discussion, and conclusion for the project. Throughout most of this research project, I have engaged monthly in a global ‘goals in therapy special interest research group’ with renowned researchers within the field. Within this group I have presented my research project twice, once focusing on the methodology and once focusing on findings. This provided me with valuable feedback on the project. This group has also allowed me to stay current on the most cutting-edge research within goals in therapy. Part two of the portfolio demonstrates my clinical development and ability to effectively, safe, and ethically engage with clinical work using a range of theoretical frameworks. Both case studies are grounded in a detailed formulation of client difficulties and demonstrate how I approach my work reflexively and empathically. The year two case study is grounded in a psychodynamic framework, integrating Kohut’s self-psychology theory, which offered a rich foundation for engaging with the complex challenges experienced by a client suffering from gambling addiction. The year three case study used assimilative integration grounded in a psychodynamic framework, integrating exposure and response prevention techniques. As counselling psychology focuses on having sensitivity to and celebrating clients’ individual religious views, I used this case study to explore the ethical and clinical implications for working with religious intrusive thoughts. Both cases aim to demonstrate my skills in doing effective and ethical interventions based on detailed formulations as well as my ability to practice reflexively whilst integrating different theoretical frameworks. The reflexive essay is a meditation on my journey through the doctoral training. It reflects on my experience of learning and implementing different theoretical frameworks and implementation of these in clinical practice, engaging in practice placements, supervision, the 5 experiential group, personal therapy, and my journey towards becoming a researcher. It also positions me as a counselling psychologist emphasising my stance within the humanistic value base and my focus on social justice issues. The appendices include my learning and development record. My cumulative training record demonstrates my desire to accumulate diverse placements and reflects how I have had the opportunity to work with different populations and within different service settings. It also includes my supervisor evaluations and reflective learning statements. Please note that during my training I studied full-time for academic year one and three and part-time for year two. This means that there are four terms of supervisory reports for year two, please also note that I worked in two clinical placements in year 2a. This portfolio demonstrates the experience, clinical, and research skills needed to meet the requirements to be awarded a doctorate in counselling psychology. References Hanley, T., Cutts, L., Gordon, R. & Scott, A. (2011). A research-informed approach to counselling psychology. In G.C. Davey (Ed.), Applied psychology (pp. 1-23). Blackwell Publishing. 6 Part 1: Research Work 7 Goal-Setting Theory in Psychotherapy: A Theory-Building Case Study by Sofie Heien, BSc (Hons) A thesis submitted in partial fulfilment of the requirements for the degree of PsychD Department of Psychology University of Roehampton 2024 8 Abstract Objective: A number of psychotherapy modalities advocate for setting goals with clients, however, much of the research and theories on goal processes used to underpin these practices is interdisciplinary and does not focus on goals work in psychotherapy per se. The aim of the current study was to test one such theory, namely goal setting theory, which is rooted in organisational psychology, on a goal-oriented psychotherapy case. This is the first systematic case study investigating goal processes in psychotherapy. Method: The relevant theoretical propositions were extracted from the theory to be tested in the study. A psychotherapy case utilising goal-oriented practice was then selected. A theory-building methodology and analytic strategy was employed, where transcripts of the therapy sessions and interviews with the client were coded using the theoretical propositions. Findings: The main theoretical propositions stated in goal-setting theory, namely that setting high (difficult) and specific goals will increase motivation and aid goal progress were not found in the current case. However, other theoretical propositions were supported: goal meaningfulness was found to moderate the relationship between goal progression/achievement and affect, and situational constraints were found to hinder goal progression/achievement. Conclusion: The current study is the first to investigate in-depth goal processes in psychotherapy using a case study methodology and more specifically, to investigate goal-setting theory in a psychotherapy setting. The propositions outlined by goal-setting theory might add to the evidence base for goal-oriented psychotherapy, however, as goal-setting theory was not developed with the psychotherapy context in mind, it is important not to assume that all theoretical propositions are applicable to psychotherapy. Clinical suggestions based on the findings include: setting goals later in therapy, engage in specific goal-based discussions with clients, psychotherapy goals can be non-specific, and having a flexible structure when working with goals. 9 Acknowledgements First, I would like to thank my esteemed Director of Studies Mick Cooper who has been with this project since its infancy. More than brilliant guidance and advice, he has provided consistent encouragement and support throughout the journey towards my goal of completing this thesis, thank you. Thank you also to my brilliant co-supervisors, Jasmine Childs-Fegredo and Monique Proudlove for their input and feedback. I would also like to thank the participants for their cooperation. As well as the goals in therapy special interest research group and the renowned researchers there for sharing their thoughts on the project. Thank you to the theory-building case study research group and John McLeod and Bill Stiles for methodological discussions and input. Personally, I wish to thank my husband who has made many sacrifices during this training and my family and friends for their support. Finally, I would like to dedicate this work to two little people who arrived at the final stages of this training. Being your mother will always be my greatest achievement. 10 Glossary Goal The object or aim of an action (Locke & Latham, 2013a). Explicit psychotherapy goal The desired state a client hopes to achieve through the course of therapy as recorded on the Goals Form (Cooper, 2015; Di Malta et al., 2019; Michalak & Holtforth, 2006). High goal Goals that are hard or difficult to achieve (Locke & Latham, 2006). Goal-setting theory A motivational theory developed by Edwin A. Locke and Gary P. Latham (Locke & Latham, 1990, 2002, 2006, 2013a, 2019). Goal-oriented practice Psychotherapy that focus on specific goal related activities such as goal setting, goal monitoring, and goal discussion (Cooper, 2019). Goal setting Discussion where goals are agreed and recorded on the Goals Form (Cooper, 2015). Goal tracking Weekly scoring of progress on Goals Form and discussion of goal progress. Goal discussion Explicit discussion of goals recorded on the Goals Form. Case The client, therapist, and the therapeutic process (McLeod, 2010). 11 Theory-building case study A scientific research methodology - a system of techniques that are employed to systematically describe and examine a case(s) to build on a theory that has accumulated within the field (Breiner, et al. 2023). 12 Table of Content ABSTRACT _____________________________________________________________ 8 ACKNOWLEDGEMENTS _____________________________________________________ 9 GLOSSARY ____________________________________________________________ 10 TABLE OF CONTENT _______________________________________________________ 12 1 INTRODUCTION _______________________________________________________ 17 1.1.1 Increasing Use of Goal-Oriented Practice and Goal- Based Tools ................................ 17 2 LITERATURE REVIEW _________________________________________________ 29 1.1 Goal-Oriented Practice in Psychotherapy____________________________ 17 1.2 The Limited Evidence Base for Goal-Oriented Practices _______________ 18 1.3 What the Current Study Will Add to the Literature ____________________ 20 1.4 The Lacking Theoretical Framework for Goal-Oriented Psychotherapy ____ 20 1.5 Goal-Setting Theory and Psychotherapy ____________________________ 22 1.6 Aim _________________________________________________________ 24 1.7 Objectives ____________________________________________________ 24 1.8 Research question ______________________________________________ 25 1.9 Personal rationale ______________________________________________ 25 1.10 Outline of dissertation __________________________________________ 28 13 3 METHODOLOGY ______________________________________________________ 43 3.2.1 Critical Realism and Theory-Building Case Studies ...................................................... 46 3.2.2 Critical Realism and Social Justice................................................................................. 47 3.5.1 Selection of Case ............................................................................................................ 50 3.5.2 The Client ....................................................................................................................... 52 3.5.3 The Therapist .................................................................................................................. 53 3.5.4 Therapy Summary .......................................................................................................... 53 3.6.1 Audio Recordings of Therapy Sessions .......................................................................... 54 3.6.2 Interviews ....................................................................................................................... 54 3.6.3 Goals Form ..................................................................................................................... 54 3.6.4 Patient Health Questionnaire (PHQ-9) ........................................................................... 54 2.1 Extracting Theoretical Propositions to Be Tested _____________________ 30 2.2 Search strategy ________________________________________________ 32 2.3 Theoretical Proposition 1: Setting High Goals Will Increase Goal Motivation and Improve Goal Progress/Performance ____________________________ 33 2.4 Theoretical Proposition 2: Setting Specific Goals Will Increase Goal Motivation and Goal Progress/Performance ___________________________________ 34 2.5 Theoretical Proposition 3: Monitoring Progress Will Improve Goal Performance ____________________________________________________________ 35 2.6 Theoretical proposition 4: Goal Commitment Will Improve Goal Motivation and Performance __________________________________________________ 37 2.7 Theoretical Proposition 5. Goal Meaningfulness Moderates the Relationship Between Goal Progression/Achievement and Affect ___________________ 39 2.8 Theoretical proposition 6: Situational Constraints Could Hinder the Client from Reaching Their Goals ___________________________________________ 40 2.9 Summary _____________________________________________________ 42 3.1 Qualitative Research ____________________________________________ 43 3.2 Critical Realism _______________________________________________ 44 3.3 Consideration and Rejection of Alternative Research Paradigms _________ 48 3.4 Theory-Building Case Studies ____________________________________ 49 3.5 Case ________________________________________________________ 50 3.6 Data _________________________________________________________ 53 14 3.6.5 Other Measures ............................................................................................................... 54 3.8.1 Immersion in the Case .................................................................................................... 56 3.8.2 Choosing the Analytic Strategy ...................................................................................... 57 3.8.3 Applying the Theory to the Case/Triangulate ................................................................ 57 3.9.1 Confidentiality ................................................................................................................ 60 3.9.2 Consent ........................................................................................................................... 60 3.9.3 Data Storage.................................................................................................................... 60 4 FINDINGS 63 4.1.1 Goal 1 Loss: Addressing Loss of Grandmother, Including Unresolved Grief. Looking at the Role of Other Losses in Life Including Mother, Stepmother ................................... 63 4.1.2 Goal 2 Future Worries: Addressing Anxiety About Own Future Including Work and Relationships. Looking at the Role of Anxiety About his Father and Grandmother ..... 68 4.1.3 Goal 3 Motivation: Thinking About Why Motivation for Everything in Life has been Decreasing Recently ....................................................................................................... 74 4.3.1 Theoretical Proposition 1. Setting High Goals Will Increase Goal Motivation and Improve Goal Progress ................................................................................................... 79 4.3.2 Theoretical Proposition 2. Setting Specific Goals Will Increase Goal Motivation and Aid Goal Progress ........................................................................................................... 81 4.3.3 Theoretical Proposition 3. Monitoring Goal Progress Will Improve Goal Performance 82 4.3.4 Theoretical Proposition 4. Goal Commitment Will Improve Goal Motivation and Performance .................................................................................................................... 85 4.3.5 Theoretical Proposition 5: Goal Meaningfulness Moderates the Relationship Between Goal Progression/Achievement and Affect .................................................................... 85 3.7 Theory-Building Case Study Research Group ________________________ 55 3.8 Analysis _____________________________________________________ 56 3.9 Ethical Considerations __________________________________________ 59 3.10 Reflexive Statement ____________________________________________ 61 4.1 Descriptive Account of Goals Work and Categorising Goals Using the Theoretical Propositions _________________________________________ 63 4.2 Summary _____________________________________________________ 78 4.3 Findings for Theoretical Propositions ______________________________ 78 15 4.3.6 Theoretical proposition 6. Situational Constraints Might Hinder Goal Progression/Achievement ............................................................................................... 88 5 DISCUSSION __________________________________________________________ 88 5.7.1 Directional Arc ............................................................................................................... 93 5.7.2 Goal-Focused Positive Psychotherapy ........................................................................... 94 5.9.1 Set Goals Later in Therapy ............................................................................................. 97 5.9.2 Engage in Specific Discussions About Goals ................................................................. 97 5.9.3 Therapy Goals Can Be Non-Specific ............................................................................. 98 5.9.4 Goals are Most Helpful When They Reflect the General Direction of Therapy ............ 98 5.9.5 Have a Flexible Structure ............................................................................................... 98 5.9.6 Consider Situational Constraints .................................................................................... 98 5.9.7 Be Open to Not Working with Goals ............................................................................. 99 6 CONCLUSION ________________________________________________________ 103 5.1 Theoretical Proposition 1: Setting High Goals Will Increase Goal Motivation and Aid Goal Progress __________________________________________ 89 5.2 Theoretical Proposition 2: Setting Specific Goals Will Increase Goal Motivation and Aid Goal Progress __________________________________________ 89 5.3 Theoretical Proposition 3: Monitoring Goal Progress Will Improve Goal Performance __________________________________________________ 90 5.4 Theoretical Proposition 4: Goal Commitment Will Improve Goal Motivation and Performance __________________________________________________ 91 5.5 Theoretical Proposition 5: Goal Meaningfulness Moderates the Relationship Between Goal Progression/Achievement and Affect ___________________ 91 5.6 Theoretical Proposition 6: Situational Constraints Might Hinder Goal Progression/Achievement ________________________________________ 92 5.7 Alternative Theoretical Frameworks _______________________________ 93 5.8 Limitations ___________________________________________________ 95 5.9 Implications For Clinical Practice and What the Findings Add to Existing Guidelines ____________________________________________________ 96 5.10 Suggestions for Further Research __________________________________ 99 5.11 Implications for Counselling Psychology___________________________ 100 5.12 Reflexivity __________________________________________________ 101 16 7 REFERENCES ________________________________________________________ 104 8 APPENDICES _________________________________________________________ 122 A) Goals Form (Including Instructions) ______________________________ 122 B) Code Book from NVivo ________________________________________ 129 C) Interview Schedule ____________________________________________ 134 D) Cohen’s Kappa Calculation _____________________________________ 139 E) Consent Form from Research Clinic for Larger Clinical Trial __________ 142 F) Therapist Information Sheet from Larger Clinical Trial _______________ 144 G) Manuscript submitted for publication______________________________ 147 F) Context of the case and treatment manual __________________________ 169 17 1 Introduction The goal of this chapter is to provide the context and rationale for the current study and to clearly outline the aim, objectives, and research question. It will also provide a personal rationale for engaging with this topic and methodology. 1.1 Goal-Oriented Practice in Psychotherapy Client and therapist dyads work with goals in different ways. For some, goals might be explored as a more implicit process (Oddli et al., 2014), whereas for others, goals are explicitly discussed with clients and recorded as part of the assessment (Kennerley et al., 2017; McLeod, 2018). The literature on the process of working with goals after they are set is not clearly described in the psychotherapy literature, possibly because of differences in practice. At the time of writing a scoping review is being carried out that aims to address how goal-orientated psychotherapy is being defined and implemented (Jacobs, et. at. 2023). 1.1.1 Increasing Use of Goal-Oriented Practice and Goal- Based Tools In the cornerstone paper on the therapeutic alliance, Bordin (1979) named agreement on goals as one of the main features of the working alliance. Since then, working with explicit therapy goals have been integrated as standard practice in several therapeutic modalities, such as CBT (Kennerley et al., 2017), pluralistic therapy (Hanley et al., 2015), and interpersonal psychotherapy (Law, 2018). Edbrooke-Childs et al. (2023) wrote in their paper, ‘Our experience is that the principle of setting and tracking goals is fundamental at this moment in time’ (p.699). It has also been found that 60% of clients wish to set goals for therapy (Cooper & Norcross, 2015) and almost 90% of clinicians state that goal setting helps to structure and focus treatment (Pender et al., 2013). In the past two decades, there has been an increase in using idiographic measures, such as goal-based tools, when measuring outcomes in psychotherapy (Elliott et al., 2015; Sales et al., 18 2023). Goal-based outcome measures typically asks clients and therapists to formulate goals for treatment, and then tracks progress (Lloyd et al., 2019). Goal based tools are being integrated into therapy with young people (Jacob et al, 2023) , in CAMHS services (Edbrooke-Childs et al., 2015), and with adult populations (Lloyd et al., 2019) and are being piloted by NHS England to assess service level change in youth mental-health services (Jacob et al. 2023). Edbrooke-Childs et al. (2015) stated in their study of over eight thousand therapeutic dyads, that both service users and clinicians reported that idiographic measures such as goal-based tools better capture the change that is relevant to individuals than standardised outcome measures, however, there is little evidence of the effect of goal tracking in psychotherapy. Based on the above it appears that goal-oriented practice is being integrated into several therapeutic modalities as standard practice, and there is an increasing use of goals in the form of goal-based outcome tools. In addition, a majority of clients wish to set goals and clinicians report positive effects of goal-oriented practice. Despite this, there appears to be a limited evidence-base for this practice. 1.2 The Limited Evidence Base for Goal-Oriented Practices Much research on goal-oriented practice has focused on the collaborative element of goal agreement between client and therapist (Tryon, 2018). Research has consistently found that better outcomes can be expected when client and therapist agree on the goals for therapy (Tryon & Winograd, 2001, 2011). In a review of the literature, goal consensus between client and therapist was stated as a demonstrably effective part of the therapeutic relationship as it relates to outcome (Norcross & Lambert, 2019). However, there is less research into the mechanisms underlying this effect. Some researchers hypothesise that collaborative goal-setting engages the client to actively participate in the therapy which increases motivation for treatment (Tryon, 2018). Mackrill (2010), on the other hand, suggests an existential rationale for this effect, where goal-oriented psychotherapy implicitly gives a voice to the clients ‘directedness towards the future, sense of self- 19 worth, isolation, relatedness and freedom, agency and the changing nature of the client’s world’ (p. 96), however, these are untested hypotheses. It is important to note the potential difference in meaning when discussing collaboration in therapy. At times, collaboration is mistaken for the client conforming to the therapists demands or the treatment method adopted. The current study defines collaboration as a mutual and reciprocal affair. This means an active partnership between client and therapist where decisions are discussed in a mutual manner and the client is empowered to feel an ownership of the direction of therapy and the interventions used. This means, in part, that the client takes an active role not just in choosing goals, but in deciding whether to work with goals. Another branch of research into goal-oriented psychotherapy has been the categorisation of treatment goals. Most notably the Bern inventory of treatment goals which identified five main categories of treatment goals: coping with specific problems and symptoms, interpersonal goals, well-being and functioning, existential issues and personal growth (Grosse & Grawe, 2002) which has spurred on further research into this area. For example Berking et al. (2005), who found that goals in some of these categories, such as wellbeing related goals, were more often attained and therefore yielded a better goal-outcome relationships than other categories, such as existential goals. There is limited qualitative research investigating in-depth goal processes in psychotherapy. To date, one qualitative mixed methods study has been published which investigated goal-oriented psychotherapy. The authors found that working with goals helped clients move from intention to action through increased awareness and focus, however, this effect hinged on having a flexible structure (Di Malta et al., 2019). Two case studies have been published investigating goal processes; however, both are descriptive in nature, rather than systematic research inquiries (Hawley et al., 2020; Winter Plumb et al., 2020). 20 1.3 What the Current Study Will Add to the Literature The potential benefits of using goal-oriented practice are being reported with adults (Cooper & Law, 2018b) and young people (Law & Jacob, 2013) and it is therefore arguably important to understand goal-processes in psychotherapy in order to implement best clinical practice. As stated above, the research on goal-oriented practice appear to focus on goal-based outcome measures (Jacob et al., 2018; Jacob, Edbrooke‐Childs, et al., 2023; Jacob, Rae, et al., 2023; Lloyd et al., 2019), goal setting and collaboration (Tryon & Winograd, 2001, 2011) and the categorisation of treatment goals (Grosse & Grawe, 2002). There is a lack of qualitative systematic enquiry into the process and outcome of goal-oriented practice, the current study aims to address this gap. Using a case study method and rich naturalistic data allowed for investigating multiple aspects of goal process and outcome. The study followed the case from setting goals at the onset of treatment, through the course of therapy where goals were tracked at each session. In addition, the client was interviewed by a researcher about his experiences of working with goals, at two different timepoints. This is the first case study which investigates goal-processes in psychotherapy using a systematic methodology. 1.4 The Limited Theoretical Framework for Goal-Oriented Psychotherapy One potential limitation of goal-orientated psychotherapy is that it is not grounded in a psychological theoretical framework. Rather, goal-oriented practice is based in the ethics of shared decision making (Cooper & Law, 2018a). Goal-oriented practice has therefore been integrated as an ethical way of working within different psychotherapy frameworks such as CBT (Kennerley et al., 2017) or pluralistic therapy (Hanley et al., 2015). The limited psychological theory on goal-mechanisms in psychotherapy poses the potential challenge that there is no consistent explanation for why goals might be useful in the specific psychotherapy context that is grounded in a theory. Some psychotherapy theories have been suggested such as Cooper’s directional arc (Cooper, 2019) 21 which proposes that when moving towards a goal, a person goes through different phases: emergence, awareness, evaluation, intention, planning, action, feedback, and termination. Another attempt at theorising goal-oriented psychotherapy is the recently developed goal-focused positive psychotherapy framework (Conoley & Scheel, 2018) which use goals in an effort to increase wellbeing and life-satisfaction. These theories are still in their infancy and hence, the evidence base for implementation and effectiveness of use in psychotherapy is still limited. Psychotherapy is typically grounded in theoretical frameworks that make certain theoretical propositions, these are typically interlinked and do not contradict each other (Stiles, 2007). This is because basing psychotherapy on research alone without fitting it onto a theoretical framework could create a lack of consistency because research findings might not fit within the context or might be contradictory. If goals are being used in psychotherapy, there needs to be consistent explanation and understanding of why goals are useful and what mechanisms might underly goals work – a consistent theoretical framework. When describing goal-oriented psychotherapy, Di Malta et al. (2019) state: ‘to date, another major limitation of the field is a lack of any overarching theoretical framework by which to draw together findings and hypotheses regarding goal‐oriented practices in psychotherapy’ (p.4). It appears that there is a need for a robust evidence-based theoretical framework which draws together research on goal-based mechanisms to underpin goal-orientated practice. Stiles (2009) writes that ‘theories are descriptions of aspects of the world, such as how psychotherapy works… Scientific research provides quality control on theory by comparing these theoretical descriptions with observations’ (p. 10). If research findings are not explained by theory, the theory might need to be extended to account for the new findings or some parts of the theory might have to be discarded based on new research, to facilitate best practices. Therefore, the current study aimed to test the applicability of a theoretical framework with a robust evidence base on goal-mechanisms which could ground goal-oriented practice within a theory. 22 Based on this, a theory-building case study methodology was selected for the current study, which uses case material to test and extend a particular theory (Stiles, 2017). As there appears to be a lacking robust psychotherapy framework for goal-oriented practice, a wider search was carried out to identify a theoretical framework that explains goal mechanisms. Goal-setting theory stands out in the literature as the most robust and well-established theory on goal processes. Goal-setting theory is based on findings from over 400 studies (Locke & Latham, 2006) and has endured for over fifty years with new research being incorporated ongoingly (Locke & Latham, 2019). Goal-setting theory has been rated by an independent review as having high scientific validity, practical usefulness, and importance (Miner, 2003) and was therefore chosen to be tested in the current study. 1.5 Goal-Setting Theory and Psychotherapy Goal-setting theory originated in organisational psychology initially focusing on ways to motivate employees for task completion through goal setting (Locke & Latham, 2019). At its core, goal-setting theory is a motivational theory that aims to explain why some people perform better than others (Locke & Latham, 1990, 2006). The main theoretical propositions outlined by goal-setting theory is that setting difficult and specific goals will lead to better goal-motivation and performance than setting vague goals (such as ‘do your best’) or easy goals. This is because setting a specific and difficult goals orients the person’s attention and effort towards the goal and leads people to spend more time trying to achieve the goal (Locke & Latham, 2013a). There is evidence of applicability of goal-setting theory to other areas such as sport (Locke & Latham, 1985; Williams, 2013), education, leadership, creativity bargaining, entrepreneurship (Locke & Latham, 2019), and health behaviours (Shilts et al., 2013); and the founders of goal-setting theory, advocate for the use of goal setting in psychotherapy (Locke & Latham, 2013b, 2019). Generally, the research underpinning goal-setting theory has been undertaken in laboratory or organisational settings where goals are either assigned or set participatively with the participants/employees 23 (Locke & Latham, 2013b). The goals are often quantitative, such as a number of trips that drivers make to the mill (Latham & Saari, 1982), and made to increase productivity. This differs from psychotherapy goals that generally address a personal difficulty that the client wishes to address (Grosse & Grawe, 2002). Therapy goals are more likely to be personal (Grosse & Grawe, 2002) hence, phenomenologically, the process of working towards them might be more personal than working towards organisational goals. However, the theoretical propositions outlined by goal-setting theory are often referenced in psychotherapy literature to underpin goal-oriented practice. For example when suggesting that setting challenging psychotherapy goals might be useful for clients, Cooper (2019) grounds this argument in the proposition made by goal-setting theory. Goal-setting theory claims that monitoring goal progress will improve goal performance and this proposition has been used when arguing for the potential benefits of monitoring goal-progress in psychotherapy (such as when using goal-based outcome tools). These include boosting clients sense of achievement and accomplishment and engender hope (Cooper, 2019), and enhancing task performance (Lloyd et al., 2019). Goal-setting theory has also been utilised to underpin the use of goal-based outcome measures when claiming that goal setting increase motivation (Jacob, Edbrooke‐Childs, et al., 2023). Goal-setting theory has also been used to argue that setting goals in psychotherapy might energise clients towards goal-progress (Cooper, 2019). In addition to this, the latest book on goal-setting theory dedicate a chapter to the use of goals in psychotherapy (Locke & Latham, 2013b; Matre et al., 2013). Di Malta et al. (2019) argued that: ‘goal setting and monitoring can mobilize effort, support persistence, and motivate people to develop strategies for goal attainment. However, these processes have not been evidenced within a psychotherapeutic context’ (p. 2). And so, it appears that goal-setting theory is being utilised to underpin goal-oriented psychotherapy, however, the applicability of the theory is yet to be tested in a psychotherapeutic context. Goal 24 processes in psychotherapy might differ from those in organisational psychology where most of the research underpinning goal-setting theory has been conducted. Although goal-setting theory is used to underpin psychotherapy practices, there is a lack of evidence of experiential correspondence – the theory matching people’s experience (Stiles, 2009). Stiles (2009) writes that when building on a theory it is important that the meanings inferred in the theory (the words and symbols used to describe it) remain as constant as possible. Problems arise when theories are taken out of context and applied elsewhere where the meanings might differ. However, there is still a question of whether certain goal mechanisms might be universal. Is there a psychological effect of setting certain types of goals or certain goal mechanisms that goal-setting theory claims to have found, that could be relevant in most settings? Goal-setting theory is being referenced as potentially relevant to psychotherapy and used when arguing for the potential benefits of goal-oriented practice, despite limited evidence of applicability to psychotherapy. Therefore, it is important to formally test the applicability of goal-setting theory to psychotherapy which is what the current study aims to do. 1.6 Aim i. The aim of this study is to test the applicability of goal-setting theory to goal-oriented psychotherapy. 1.7 Objectives i. Extract the relevant theoretical propositions from goal-setting theory that can be meaningfully applied to a psychotherapy case. ii. Apply these theoretical propositions to a psychotherapy case. iii. Identify where the observations of the case are explained by the theory and where they are not. iv. Revision of goal-setting theory’s applicability to psychotherapy based on the findings. 25 v. Make clinical recommendations for best practice of goal-oriented psychotherapy based on the findings. 1.8 Research question 1. Are the theoretical propositions extracted from goal-setting theory listed below, applicable to psychotherapy? i. Setting high goals will increase goal motivation and improve goal progress/performance ii. Setting specific goals will increase goal motivation and goal progress/performance iii. Monitoring goal progress will improve goal performance iv. Goal commitment will improve goal motivation and performance v. Goal meaningfulness moderates the relationship between goal progression/achievement and affect vi. Situational constraints could hinder the client from reaching their goals 1.9 Personal rationale As a trainee counselling psychologist I am interested in directionality within the therapeutic context, how clients’ lives might change direction when coming to therapy and whether this was the change they expected. Goal-oriented psychotherapy became a point of interest because of the explicit focus on directionality, but also because of the value it places on client autonomy. It assumes that the clients know what they wish to change/achieve/gain from the therapy and places this in the centre. It also focuses on the collaboration between client and therapists to set goals together (Tryon et al., 2018). This therapeutic stance fits well with how I approach my practice. I want to embrace the uniqueness of each client and therapeutic journey. This does not mean to disregard the evidence base for clinical interventions in favour of the individual client, but rather, to adopt a research-informed rather than evidence-based stance to practice. This means that research will form part of a myriad of factors that influence decisions about clinical practice, also 26 including; ‘personal philosophy, model of the person, supervisory experience, the personal history of the therapist, the training the therapist has undertaken and what the client wants from the therapy’ (Hanley et al., 2011, p. 7). Due to the uniqueness of each client, therapist, and relationship, psychotherapy is not an exact science that can be solely based on empirical evidence. The research informed stance to practice offers an alternative way of engaging with research (and theory) as possibly useful tools that might or not account for all aspects of what the client brings to therapy. Case studies offers a way of conducting research which provides insights into the uniqueness of the case and context which is not based on averages from large scale samples, but rather, a rich case record which might illuminate details that can still be helpful when evaluating the effectiveness of theory, as is the aim of the current study. Originally, I was interested in the goal-oriented nature of people as directional beings (Cooper, 2019). Locke and Latham (2013a) argues that the consciousness to choose and pursue goals are what distinguish humans from other organisms. Personally, I am a ‘goal-oriented’ person in that I reflect on and work towards long and short-term goals. In my life this has helped me move towards my goals and accomplishments, however, at times, this focus on goals has also served as a hindrance from appreciating the present moment because of the future-orientated nature of my mind. I believe goal-striving is mainly helpful if it is tied in with personal values. As discussed in the literature, people who set goals that are grounded in intrinsic motivation are more likely to be committed to and take ownership over their goals (Cooper, 2019). I wanted the study to be of clinical relevance in psychotherapy which led me to investigate goal-oriented practice. I have found therapy a helpful place to explore values and therefore, perhaps also a suitable place to explore goals. For example, I have a humanistic value base and strongly believe that all humans are of equal value, this might impact my short and long-term goals. I might want to find a placement that emphasise providing psychological support to communities that are otherwise marginalised in the mental health care system. Long-term, I might want to engage in work that 27 promote social justice. Based on this, in order for goals to be helpful, it requires space to explore values, intrinsic motivation, and an awareness of where people want to get to. My experience of having goals as both positive and negative enabled me to mainly approach my findings with a curious and explorative stance. The robust evidence base for the theoretical propositions I tested, might have made me more likely to expect for these to be found in the data, however, this was contrasted with the limited evidence for applicability to psychotherapy of the propositions. In personal therapy my experience of goals was a ‘set and forget’ process where we discussed goals in the first session, but they were never re-visited, and the direction of therapy was rarely explicitly discussed. At times, I think this was necessary and I felt that any pressing issue could be discussed without having to remain on course towards some previously agreed destination. Other times, it felt like the therapy was aimless and I wondered if my therapist and I had the same destination in mind. I believe that more meta-communication about the goals for therapy would have been helpful, however, having mixed emotions around goals made it natural for me to be open to findings of goal helpfulness and unhelpfulness in the current study. I was also mindful that my director of studies Mick Cooper is a leading figure in goal-oriented practice and that this might impact my attitude towards findings that were in contrast with some of his and his colleagues’ findings that goal-oriented practices are overall helpful. Although this should not affect the findings, it was important to be aware of power-dynamics that might have made me hesitant to report such findings. When reporting preliminary findings, I was reassured that coming from a pluralistic perspective, my supervisory team were committed to a self-critical perspective and openness to findings that countered previously held assumptions. I was also mindful of goal-oriented practice being in line with my passions for client engagement and collaboration in therapy and how I perhaps wanted my research to add to a body of literature that 28 might promote such ways of working. It was important to bracket this off and let the voices of the participants address the research question. 1.10 Outline of dissertation Following this chapter, this dissertation will continue with a literature review which critically evaluates the literature underpinning the theoretical propositions that were investigated in this study and evidence of applicability to psychotherapy. This is followed by the methodology chapter which situates the study in a research paradigm and provides a rationale and outline of the methodology as well as a reflexive statement. It will then present the findings, firstly by a descriptive account of the goals work and then outline the findings for each theoretical proposition. Finally, a discussion of the findings and conclusion will be offered. 29 2 Literature Review The goal of this chapter is to first outline how the theoretical propositions to be tested were extracted from the theory, then present and critically evaluate the evidence base supporting each proposition, as well as any contradictory evidence. Finally, to critically evaluate the evidence of applicability to psychotherapy. 2.1 Structure and Process of the Literature Review Deciding on which literature to include and the structure of this literature review required careful consideration. Theory building case studies engage with literature in different ways (Breiner et al., 2023), where some use the pre-existing literature as a starting point, extracting theoretical propositions from different studies (Quinn et al., 2012), others, use pre-existing theory to extract the theoretical propositions to be tested on a case (Wilson et al., 2021). Initially, a systematic review was planned for the current study, where studies from goal setting theory and goal-oriented psychotherapy were to be included based on inclusion and exclusion criteria. However, as a named theory had already been selected to be tested in the current study, it was decided that three considerations of the previous literature underpinning the theoretical propositions to be tested in the current study was of higher importance and relevance. Namely: to critically evaluate the evidence base underlying the theoretical propositions, to evaluate whether there was evidence of applicability to psychotherapy, and finally, to consider whether the proposition was being referenced in psychotherapy. This allowed for evaluation of the relevant evidence base when applying the theoretical propositions to the case. This also means that the literature review is deductive in the sense that it will use goal-setting theory as a starting point. As this literature review aims to evaluate the evidence for each theoretical proposition, it will effectively be series of reviews – one for each proposition, as supposed to one general review. 30 2.2 Extracting Theoretical Propositions to Be Tested Theory-building case study research aims to test whether a theory can be applied meaningfully to a case (Stiles, 2007). In order to do this, it needs to be clear which theoretical propositions are being tested, so that these can be applied and compared to the observations in the case (Stiles, 2017). As the current review aimed to evaluate the evidence for each proposition, the first step consisted of extracting which theoretical propositions were to be tested. Certain criteria were applied when extracting the theoretical propositions in the current study: Inclusion criteria The propositions needed to be explicitly and clearly defined as a statement made by goal-setting theory, this ensured that the relevant propositions of goal-setting theory were being tested. One had to be able to meaningfully apply the propositions to a psychotherapy case. They also had to have been referenced in psychotherapy literature. This ensured the propositions tested were relevant and meaningful to test in this context. The theoretical propositions had to be stated in the most recent summaries and updates of goal-setting theory (Locke & Latham, 2013b, 2019). As goal-setting theory is formulated inductively and new evidence is constantly being integrated (Locke & Latham, 2019), it was important that the most recent literature was being utilised. Systematic readings of the most recent updates of goal-setting theory (Locke & Latham, 2013b, 2019) revealed the propositions that goal-setting theory claims are consistently found in empirical research. These propositions are claimed by goal-setting theory to have high validity and relevance and are stated as the consistent propositions outlined by the theory. Applying the inclusion criteria above, six appropriate theoretical propositions were identified to be tested in the current study. The main proposition offered by goal-setting theory states that ‘high’ (difficult) and specific goals lead people to be motivated towards goal achievement and perform better. This is stated as the ‘core findings’ for the theory by the authors based on findings from nearly 400 31 empirical studies (Locke & Latham, 2013a, 2013b, 2019). For the purpose of clarity, this proposition was divided into two propositions to be investigated in the current study. As there was a rich case record of session recordings and interviews about the client’s experience of working with goals, the current study aimed to identify goal difficulty level and goal specificity and whether the effects of these goal characteristics had the motivating effects in psychotherapy that goal-setting theory proposes. Goal-setting theory claims that feedback and goal monitoring motivates people to better goal performance: ‘Feedback is critical to goal effects because it enables people to track progress’ (Locke & Latham, 2019, p. 98). The current study focused on goal-setting theory’s claim of positive effects of goal tracking on goal performance. The fourth theoretical proposition made by goal-setting theory that was deemed appropriate was that goal commitment increase goal motivation and goal performance. Locke and Latham (2019) state: ‘A goal that one is not committed to attain will not affect that person’s actions’ (p. 98). As the client in the current study has been interviewed about his experiences of working with goals, the current study wanted to investigate whether goal commitment in psychotherapy would also affect motivation to achieve psychotherapy goals. Goal-setting theory argue that goal meaningfulness moderates the relationship between goal progression/achievement and affect (Locke & Latham, 2006). It states that progressing towards or achieving a goal that is meaningful creates positive affect, whereas lack of progress towards a meaningful goal creates negative affect. This proposition was relevant to test in the current study as psychotherapy literature often argues that psychotherapy goals should be important to the client (Cooper, 2019) which might overlap with goal meaningfulness. The data in the current case also entailed information about the client’s affect, both in the qualitative data (sessions and interviews), qualitative measures (PHQ-9 and GAD-7), and records of goal progress (Goals Form) and it was therefore deemed appropriate to test this proposition in the current study. 32 The final proposition states that situational constraints could hinder goal achievement which goal-setting theory states should be self-evident (Locke & Latham, 2013a). This proposition was included because there is a lack of focus on constraints to goal pursuit within psychotherapeutic literature, and the current study wanted to test whether there were situational constraints which might be relevant to consider in goal-oriented psychotherapy. There are several other theoretical propositions made by goal-setting theory that were deemed inappropriate to be tested in the current study. Most commonly propositions were excluded because the data in the current study would not have allowed for them to be meaningfully investigated and others were deemed irrelevant to psychotherapy. 2.3 Search strategy In an initial search, summary publications of goal-setting theory from the past 30 years were utilised (Locke & Latham, 1990, 2006, 2013b, 2019), identifying the evidence base as stated by the authors of goal-setting theory for each of the selected propositions. In addition to this, relevant literature was identified through searches on Web of Science and PsychInfo. Relevant search-terms for each proposition were brainstormed and selected. In addition, an extra search for each proposition was conducted which included key terms of the proposition adding search terms that would include literature from the psychotherapeutic field in the results: counsel* OR therap* OR psychotherap* OR psychological therap* OR treatment. Key texts for goal-orientated psychotherapy were also consulted (Cooper & Law, 2018b; Michalak & Holtforth, 2006). A snowball search from key texts for each proposition was added where appropriate. Results were screened, first by title, then by abstract and categorised using Ryyan software. The next section will outline the general evidence base for each theoretical proposition, then the evidence of applicability to psychotherapy and state whether the proposition is referenced in psychotherapy literature. 33 2.4 Theoretical Proposition 1: Setting High Goals Will Increase Goal Motivation and Improve Goal Progress/Performance The main claim made by goal-setting theory is that high goals increase task performance and motivation than easy or ‘do you best’ goals (Locke & Latham, 2013b). The theory states that there is a linear relationship between level of goal challenge and performance, which exists until the participants no longer have the abilities needed to reach the goal. If people set easy goals, they often achieve them, however, their motivation does not improve, and they do not exceed their goals (Kerr & LePelley, 2013). Whereas when people set high goals, they become more motivated towards achievement and performance and outcome improves (Locke & Latham, 2013b). The evidence base supporting this claim appears robust. The authors (Locke & Latham, 2006, 2013b, 2019) site several meta-reviews in evidence of this proposition, such as Mento et al. (1987) who found strong supportive evidence that high goals leads to better task performance across 70 studies using different tasks. Locke (1968) also provides a summary of the literature citing 12 papers, concluding that ‘the results are unequivocal: the harder the goal the higher the level of performance’ (p. 162). There is also more recent research supporting this proposition, amongst others a review paper which found that groups perform better when working towards high than easy goals (Kleingeld et al., 2011). In addition, a study by Silvia et al. (2010) found that participants used higher effort for difficult vs. easy tasks. However, these findings are not always replicated, some research in health psychology found that high goals do not predict goal progress for people with diabetes (Hricova, 2021). There is also some evidence across different studies that people feel a greater sense of satisfaction when pursuing high goals (Stamatogiannakis et al., 2018). Within psychotherapy there is limited evidence on the effects of difficult vs easy therapy goals on goal motivation or progress. This could be because psychotherapy goals are not as easily classified as ‘easy’ or ‘difficult’. Different clients might perceive the same goals as difficult or 34 easy depending on a myriad of factors, so unless explicitly asked about their perception of therapy goal difficulty level, this might not get recorded. Indeed, Berking et al. (2005) states that there are few studies that categorise and compare treatment goals in psychotherapy in terms difficulty level. Berking and colleagues found that certain types of goals such as wellbeing related goals were more likely to be attained than other categories of goals such as existential goals, however, they did not comment on whether degree of difficulty affects motivation or goal progress. Despite the lack of specific evidence on goal-difficulty level and goal progress within the psychotherapeutic literature, clinical guidelines suggest setting goals that are challenging (Cooper, 2018), but realistic (Kennerley et al., 2017), referencing goal-setting theory to support this claim. In conclusion, it appears that there is a strong evidence base for the effect of high goals on motivation and performance. Within psychotherapeutic literature, this study is the first that investigated the effects of goal difficulty level on motivation and goal progress. 2.5 Theoretical Proposition 2: Setting Specific Goals Will Increase Goal Motivation and Goal Progress/Performance Goal-setting theory states that specific goals lead to higher level of task performance and motivation than vague or abstract goals (Locke & Latham, 2013b). Within the wider psychology field, research has indicated that setting specific goals leads to better motivation (Wallace & Etkin, 2017) and that specific (vs non-specific) goals lead to better performance on tasks (Pretz & Zimmerman, 2009). However, the helpfulness of goal specificity hinge on the task being difficult. These findings echo two previous meta-reviews which found that setting specific goals leads to better task performance and higher output in different fields and within laboratory studies (Locke et al., 1981; Mento et al., 1987). The limitation with these findings was the lack of separation between goal difficulty level and specificity. The studies included in the meta-analyses mainly investigate the effects of difficult and specific goals on performance, hence one cannot confidently conclude that goal specificity alone effect motivation and performance. Both the meta-analyses 35 mentioned are from the wider motivational and organisational psychology fields and mainly include studies from organisational psychology. Within the psychotherapeutic literature, the evidence base for the helpfulness of goal specificity is limited. Some research has indicated that goal specificity has no effect on whether clients see their goals as attainable in psychotherapy (King & Voge, 1982) and that goal specificity does not affect outcome in couples therapy (Townes, 1997). On the other hand, there is some indication that goal specificity might enhance the general efficacy of CBT for specific populations such as chronic headaches (James et al., 1993). Overall, there appears to be a lack of recent evidence for the helpfulness of goal specificity in psychotherapy. Despite this, setting specific goals is advocated for by several key texts within goal setting in psychotherapy, such as Michalak and Holtforth (2006) and Cooper and Law (2018b) using goal-setting theory to support this claim. Certain therapeutic modalities such as CBT state the importance of setting specific goals as part of the SMART acronym (specific, measurable, achievable, realistic, timebound) which is integrated as standard practice (Kennerley et al., 2017). However, most of the research on the helpfulness of goal specificity is from the wider psychology field and there is limited evidence of the applicability of these studies to other fields, such as psychotherapy. In conclusion there appears to be quite a strong evidence base that goal specificity increase goal motivation and performance, however, there is not much evidence of this within psychotherapy. Despite this, setting specific goals is standard practice within some psychotherapeutic modalities. 2.6 Theoretical Proposition 3: Monitoring Progress Will Improve Goal Performance Goal-setting theory claims that monitoring/tracking goal progress helps people reach goals. As a part of the feedback loop, the authors argue that self-monitoring of goal progress results in 36 higher performance (Locke & Latham, 1991). The most comprehensive review of the literature on goal-monitoring and outcome was provided by Harkin et al. (2016). The authors reviewed 138 studies (N=19,951) that compared a monitoring goal progress vs control condition on goal attainment. They found that prompting goal monitoring had a small to medium sized effect on goal attainment and concluded: ‘These findings confirm the importance of progress monitoring as a key mechanism by which people strive for goals’ (p. 216). They also found that recording goals physically, positively effects goal attainment. Within organisational psychology, self-monitoring of goal progress has been a crucial part of self-management training programs and research on these programs have found increase in job performance across studies (Day & Unsworth, 2013; Frayne & Geringer, 2000; Uhl-Bien & Graen, 1998). However, goal-monitoring was one of several parts of the training programs and so it is not possible to say with certainty which factors are driving their effectiveness. Another review of 52 randomised control trials within health and mental health care also found that routine outcome monitoring improved physical and mental health outcomes (Carlier et al., 2012). However, this research did not look for individualised goals, but rather generalised outcome measures. Due to the apparent effectiveness of goal-tracking and monitoring within health psychology, some psychotherapeutic practices now use goal monitoring, and several goal-tracking and measuring tools have been developed for use in psychotherapy (Jacob et al., 2018). These tools are typically used to set goals and measure degree of goal attainment (Lloyd et al., 2019) and goal-setting theory has been referenced to underpin the potential positive effects of utilising goal based outcome tools (Jacob, Edbrooke‐Childs, et al., 2023). A systematic review of these self-report ideographic instruments of goals in psychotherapy concluded that these measures may be appropriate tools for supporting client progress and that they ‘can support the process and outcomes of therapeutic work’ (Lloyd et al., 2019, p. 12). However, the authors state that the 37 evidence thus far cannot substantiate the use of goal measures alone (as supposed to/in addition to standardised outcome measures). Overall, there appears to be a relatively robust evidence base from the wider psychology field that monitoring goals aid goal progress. This has been adapted within psychotherapy in the form of goal-based outcome measures and there is evidence that tracking psychotherapy goals can facilitate goal-progress, hence there is some evidence of applicability of this proposition. 2.7 Theoretical proposition 4: Goal Commitment Will Improve Goal Motivation and Performance Goal commitment has been defined as a person’s ‘attachment to or determination to attain the goal’ (Locke & Latham, 2013a, p. 7), however, it has been pointed out that there are definitional inconsistencies among researchers making goal commitment difficult to measure (Donovan & Radosevich, 1998; Klein et al., 2013). Locke and Latham (2019) argue for the importance of commitment to goal performance as one will not act towards achieving a goal one is not committed to. They claim that goal commitment is more important for high goals as these require more effort and persistence. Within organisational psychology, several meta-reviews on the effects of goal commitment on performance have been carried out, yielding different results. Donovan and Radosevich (1998) found that goal commitment only accounts for 3% of the variance on performance, indicating a small effect size. However, other meta-reviews have found that goal commitment significantly effect goal achievement (Klein et al., 1999; Wofford et al., 1992), but that this effect hinges on the goal being difficult, if the goal is easy, goal commitment does not affect the outcome (Klein et al., 1999). There is a large difference in the number of studies included in these reviews, where Klein et al. (1999) analysed the data from 83 samples, Wofford et al. (1992) 78 studies, and Donovan and Radosevich (1998) only included 11. The difference in findings appear to be due to the different sample size of papers. Since then, several studies have found a positive relationship 38 between goal commitment and goal performance (Latham et al., 2008; Piccolo & Colquitt, 2006; Schweitzer et al., 2004; Seijts & Latham, 2011), however, the effect size has not always been significant (Pedersen, 2016). Within psychotherapy literature, there is limited evidence on the relationship between commitment to psychotherapy goal and outcome/motivation/goal achievement. This could be due to definitional inconsistencies between the disciplines. There are some studies within addiction treatment that have found goal commitment among young people to consistently predict treatment outcome with cannabis (Kaminer et al., 2019) and alcohol abuse (Kaminer et al., 2018). Commitment has been named as a key factor to psychological therapy, for example acceptance and commitment therapy is partly formulated around the importance of clients’ committed-action to psychotherapy goals (McCracken, 2022). Clients’ committed action has been shown to have an effect on treatment outcome (McCracken et al., 2015; Scott et al., 2016), however, this is not quite the same as commitment to goals as discussed by goal-setting theory. Arguably, most clients come to therapy being motivated for change. Whether this translates to ‘committed action’ as discussed in the literature might vary between clients and might not always be measurable. Setting goals have been argued to increase motivation for treatment (Jacob et al., 2018), however, the evidence underpinning this argument is mainly based on research borrowed from organisational psychology and might not be applicable to working with goals in psychotherapy. Individual client factors need to be considered when discussing commitment to therapy and indeed whether it is appropriate to use this language when discussing psychotherapy goals. Commitment in therapy depends on client readiness for deep change and whether they have the support for this. Goal-setting theory has been used to argue for the importance of clients’ commitment to psychotherapy goals (Moore, 2019). 39 It appears that there is a robust evidence base within organisational psychology that goal commitment enhance performance if the goal is difficult. However, there is limited evidence that these findings can be applied to psychotherapy, this could be down to differences in language. 2.8 Theoretical Proposition 5. Goal Meaningfulness Moderates the Relationship Between Goal Progression/Achievement and Affect Goal-setting theory claim that if goals are meaningful to the person pursuing it, progression or achievement will create a positive affect such as feeling satisfaction. Whereas if the goal is meaningful, but one is not progressing, this will create negative affect (Locke & Latham, 2013a, 2019). Locke and Latham (2006) write: ‘feelings of success in the workplace occur to the extent that people see that they are able to grow… by pursuing and attaining goals that are important and meaningful’ (p. 265). There are some differences in language in the literature on goal meaningfulness. Some research discusses goals which are congruent with intrinsic motivations or values, and others discuss goal importance which could also indicate goal meaningfulness. There is some evidence to support of this theoretical proposition. For example, a review of several studies found that participants tended to show greater progress towards goals that were meaningful and that this progress translated into improved affect (Koestner et al., 2002). The authors wrote that ‘goal attainment will fail to be accompanied by enhanced wellbeing if people pursue goals that are incongruent with the intrinsic needs for competence, self-determination, and relatedness’ (p. 233) which might indicate goal meaningfulness. When goals are meaningful, people tend to make more progress towards them (Koestner et al., 2002) and goal progress has been found to be positively correlated with positive affect (Koestner et al., 2002; Sheldon & Kasser, 1998). One study found that the amount of wellbeing experienced when progressing towards a goal, hinged on goal meaningfulness (Sheldon & Kasser, 1998). Other research has indicated that simply having meaningful goals is in itself associated with increased life satisfaction (Emmons, 1986) and positive affect (Emmons & Diener, 1986). Goal importance has also been 40 positively associated with positive affect (Emmons, 1986; Zaleski, 1987) and the amount of time the participants spent on a task (Emmons & Diener, 1986). However, other moderators of the relationship between goal achievement and positive affect have been suggested, such as emotion reappraisal (Wang et al., 2017) implementation intentions (Koestner et al., 2002), goal commitment (Brunstein, 1993), and goal-difficulty level (Wiese & Freund, 2005), and so goal meaningfulness might be one of many factors in goal striving which impacts affect. Psychotherapy guidelines emphasise the importance of setting goals that are in line with a client’s values and driven by intrinsic motivation (Hanley et al., 2015). This means setting treatment goals that reflect the client’s inherent psychological needs, rather than goals that are formulated to elicit a response from someone else (Cooper, 2019) which might overlap with goal meaningfulness. Psychotherapy clients who set intrinsically motivated goals have been found to show lower levels of psychopathology (Wollburg & Braukhaus, 2010) and more positive session outcomes (Michalak et al., 2004). Achieving therapy goals that are important have been also associated with improved recovery (Oliver et al., 2017). When writing about the application of goal-setting theory in psychotherapy Matre et al. (2013) state that setting important goals generates positive images which positively influence emotions. Overall, there appears to be some evidence supporting this theoretical proposition from organisational psychology, however, the evidence base is not as robust as for other propositions. There is also some evidence of applicability to psychotherapy, however, there is some difference in language between the psychotherapeutic literature and goal-setting theory. 2.9 Theoretical proposition 6: Situational Constraints Could Hinder the Client from Reaching Their Goals Situational constraints refers to factors ‘which inhibits persons from using their abilities or expressing their motivation effectively’ (Peters et al., 1982, p. 9). Goal-setting theory claims that ‘it should be self-evident that situational constraints hamper goal attainment. Without the 41 necessary resources, a goal is unlikely to be attained’ (Locke & Latham, 2013a, p. 9). Within organisational psychology it has been argued that situational constraints have the potential to influence goal performance and should be considered in performance management and appraisals (Dobbins et al., 1993). This claim does seem to have some grounding in empirical evidence. Peters et al. (1982) found that situational constraints have a direct negative impact on goal performance and notes that these results underscore the importance of contextual factors in the goal-setting process. Even the perception of situational constraints has been found to negatively relate to goal commitment, which in turn is associated with lower performance (Borgogni & Russo, 2013; Klein & Kim, 1998). The same study found that situational constraints significantly negatively correlated with goal performance. Time constraints has also been found to negatively affect goal performance (Brown et al., 2005). In healthcare settings it has been reported that situational constraints negatively impact clinicians’ ability to reach their goals (Presseau et al., 2009). When working with goals in psychotherapy it is important to consider the context of the client (Law, 2018) as goal pursuit is not only dependent on the individual client, but the context being favourable for goal attainment. It might be considered intuitive that situational constraints hinder clients reaching their therapy goals and thus, this has been a less discussed and researched phenomena in the psychotherapeutic literature on goals. However, as situational constraints could be instrumental to clients’ goal progress, it merits some discussion. In fact, situational constraints have been noted as one of the main reasons for clients terminating therapy (Roe et al., 2006; Todd et al., 2003). Time constraints of working with goals in psychotherapy has been noted as a limitation to reaching therapy goals (Froberg & Slife, 1987) and having sufficient time has been noted by psychotherapy clients as important to be able to explore what they truly want to gain from the therapy (Di Malta et al., 2019). Although this proposition has not been referenced in psychotherapy literature per se, the study tested for this proposition because there is evidence of 42 its applicability to psychotherapy, however, there is a lack of focus on this issue in psychotherapeutic literature. It would appear that situational constraints do hinder goal progress/achievement in organisational settings and that there is some evidence of the same applying to psychotherapy goals. However, there is a lack of focus on situational constraints to psychotherapy in the literature. 2.10 Summary In summary, it appears that the theoretical propositions made by goal-setting theory have derived from a robust evidence base. As such, the theory is often referenced in other fields such as psychotherapy. However, there appears to be a lack of evidence of applicability to other fields and sensitivity to potential differences in goal processes in e.g. psychotherapy and organisational and lab settings. Therefore it is important to test whether the theory can be meaningfully applied in goal-oriented psychotherapy. 43 3 Methodology The goal of this chapter is to provide a rationale and outline of the methodology adopted in the current study. Firstly, I will offer a critical discussion of the research paradigm, I will then consider the practical procedure and design of this research project, ethical considerations, and finally offer a reflexive statement. 3.1 Qualitative Research Eighteen years ago, Ponterotto (2005) argued that research within counselling psychology was in the midst of a paradigm shift from reliance on quantitative research methods, situated in a positivist or post-positivist epistemology, towards relying on a combination of both qualitative and quantitative methodologies. Within counselling psychology, this shift has brought fourth an increased use of research which ‘focuses on understanding the individual as a unique, complex entity’(Ponterotto, 2005, p. 128) in a descriptive, detailed and context dependent way (Braun & Clarke, 2013). Using a myriad of qualitative methodologies with rich data when researching psychotherapy process and outcome provides access to in-depth processes that can illuminate the phenomena under investigation. In contrast to large sample quantitative studies which might over-simplify the therapeutic process (McLeod, 2010). A distinction has been made in in the literature between ‘big Q’ and ‘small q’ qualitative research (Kidder & Fine, 1987). Small q research refers to a way of doing research where data are of a qualitative nature, however, the analysis is conducted in a manner typically associated with quantitative research, such as scoring numbers of times a word was mentioned in a transcript (Willig, 2013). Big Q qualitative research, on the other hand, is exploratory in nature and concerned with theory-generation. Researchers advocating for big Q qualitative research might be critical of the current study. For example Ponterotto (2005) writes that a researcher who use established codes before data collection (as in the current study) and then code data into these 44 categories is ‘postpositivizing’ research that belong in a different research paradigm. Although the current study used pre-defined codes based on the theory it was testing, it was important to remain open to unexpected findings the theory does not account for (McLeod, 2010). 3.2 Critical Realism The current research aims to test whether goal-setting theory can be applied to psychotherapy. Within this aim lies assumptions about knowledge and knowledge production. It assumes that knowledge can be organised into theories such as goal-setting theory. It also assumes that there are regularities to the observations made by goal-setting theory and that these can be systematically and reliably found in empirical observations independently of the researcher and the researched. These assumptions marry well with a critical realist paradigm. It can be problematic to state the exact assumptions underlying critical realism as there are some debates within the field, however, this paradigm does have some characteristics that most critical realists agree on (Blaikie & Priest, 2017). Critical realism assumes a reality which exists independently of the researcher and researched. It also assumes that data can tell us something about this world, however, this requires interpretation in order to get closer to the underlying structures which generate the findings (Willig, 2013). There are different branches of critical realist perspectives and the current research aligned itself with the critical realist writer and philosopher Roy Bhaskar. Bhaskar argued that a reality does exist apart from our knowledge or experience of it (Collier, 1994). He states that the regularities which can be observed in the world (e.g. through research) are not direct representations of reality and that the underlying fundamental elements, causal structures and mechanisms in the world might not be directly observable. It is the task of research to try and identify correctly, the mechanisms which produce the observed regularity (Blaikie & Priest, 2017). Bhaskar (1975, 2016) describes reality as comprising of three layers. Firstly, the empirical level which consists of observable and experienced realm of reality. The second is the domain of 45 actual where human experience does not filter reality and events occur independent of being observed or experienced. The third domain is the real where the causal mechanisms exist. These causal mechanisms have the potential to cause changes in events. Although the real domain has been described as not always being accessible or observable, research within critical realism aims to represent the real domain as accurately as possible (Blaikie & Priest, 2017; Fletcher, 2017), considering that all phenomena occur within a context (Pawson, 1989). Critical realism has been described as an ontology, an epistemology, a meta-theoretical position, and a research paradigm (Archer et al., 2016; Blaikie & Priest, 2017; Fletcher, 2017; Willig, 2013, 2019). Some authors have argued that epistemology and ontology are interdependent, as the nature of reality affects the way that we can know reality as well as the extent to which reality can be known (Danemark et al., 2002). The current study aligns itself with the definition offered by Brown et al. (2002) which describes critical realism as a ‘full-blown’ philosophy of science. This means that it encompasses a wide range of topics including ontology, epistemology, nature of causality, and theory evaluation. The current research adopted the terminology ‘research paradigm’ when describing critical realism allowing for a wider description, entailing an ontological position, without excluding the epistemological implications (Blaikie & Priest, 2017; Fletcher, 2017). Ontologically, there are similarities between critical realism and positivism where both assumes a knowable reality. However, in contrast to positivism, critical realism claims that data does not reflect the full picture of reality, rather, critical realism emphasises the causal mechanisms underlying observed regularities which require interpretation and analysis to identify (Fletcher, 2017). Epistemologically, critical realism draws on interpretivism, in that it values the individual viewpoint of the participants, and that reality is understood through the realm of human knowledge, language, and experience. However, critical realism differs from interpretivism which offers multiplicities of socially constructed realities, and instead argues that there is one multi-layered reality (Fletcher, 2020). 46 3.2.1 Critical Realism and Theory-Building Case Studies The next section will outline how critical realist research aligns with theory-building case study research methodology and method. Theory is not represented as an absolute truth or reality in theory-building case study methodology or within the critical realism paradigm, but rather, as a possible explanation for an observed regularity which can be adjusted to be increasingly effective (Blaikie & Priest, 2017). Stiles (1981) writes that ‘a scientific theory is a system of statement about some aspects of reality’ and that ‘a good theory applies to a wide range of phenomena… and fits closely with empirical observation’ (p. 227). For the current study this means that as goal-setting theory claims to be a well-established, reliable theory, the theoretical propositions made by goal-setting theory should hold up when applied to new empirical observations. Fletcher (2020) argued that critical realist research aims to build explanations through systematic engagement and integration of existing theory. Therefore, researchers should aim to examine whether there is correspondence between empirical findings and existing theory. Both critical realist research and theory-building cases study methodology discuss the potential fallibility of existing theory claiming that research needs to map out where the theory corresponds to the findings, or where it may need refining, qualifying, modifying, elaborating, or be extended (Fletcher, 2020; Stiles, 2017). Critical realist research emphasise the use of intensive data such as deep idiographic information (Danemark et al., 2002; Fletcher, 2020). This means that rather than aiming to look for averages within a population, critical realist research might utilise in-depth data from a particular case emphasising the unique experiences of an individual to deepen the understanding of the phenomena under investigation. Triangulating different data sources such as transcripts of therapy sessions, interviews, outcome measures, and therapist notes allows to form a rich picture of what went on in one unique case. This makes it suitable for case study research which emphasise the in-depth study of rich case material (McLeod, 2010). When discussing method in critical realist 47 research, Fletcher (2017, 2020) used theory to inform her research questions and coded data based on theory, she also coded data that did not fall within the pre-conceived codes. Theory-building case study research includes a myriad of methods of analysis (Breiner et al., 2023). The current study will align itself with Fletcher’s method of coding data using theoretical propositions as well as coding data which does not fit within the theoretical propositions. The same method of coding has been used in theory-building case studies when developing and extending theory (Stiles, 2017). 3.2.2 Critical Realism and Social Justice Blaikie and Priest (2017) point out that scientific research has consequences for people, whether they are involved in the knowledge production or not. It is important for researchers to acknowledge the responsibility of putting forward a theory or phenomena as a truth. Therefore, the current study sees theory as flexible and amenable to change. This is important as contexts change and arguably research findings should not be reported as static representations of people’s lived reality. The current study argues that positioning the social sciences as objective observers and reporters of truth can have potentially aversive effects. The aim is to produce knowledge which can inform and improve clinical practice, whilst recognising that the findings from this study might not be generalisable to everyone as peoples’ experience of reality differ. The findings will be considered within their context and open to being extended on and changed based on future research. Bhaskar (1986) put forward the idea of a meta-critical dimension of discourse where the assumptions of scientific enquiry are ‘critically and self-reflexively scrutinised’ (p. 25). Bhaskar is arguing for a science that can play an active role in creating new language and that this consequently can create new perceptions and mental concepts and representations. Taking this argument further, Bhaskar argues that scientific enquiry can have an emancipatory quality in creating language which represents the reality or experience of the participants. This resonates 48 with the current study which aimed to give voices to individual participants and ultimately extend on a theory which might improve clinical practice. 3.3 Consideration and Rejection of Alternative Research Paradigms When considering alternative research paradigms, it was important to be mindful of the type of knowledge that this study aimed to produce as well as the method adopted for acquiring knowledge. Adopting a positivist stance would be problematic for the present study as this would arguably use the theoretical starting point as a hypothesis to be confirmed or rejected (Ponterotto, 2005). This could mean that the data would be approached with the existing theory in mind with the aim of confirming or denying the theory. Although this is part of theory-building, it would miss the important aim of extending the theory, finding aspects of the cases that are not explained by the theory, or offer alternative explanations to previous claims within the theory which are all vital parts of the analysis in theory-building case studies (Stiles, 2009). The current study aims to produce knowledge by means of theory extension/confirmation/modification. The findings themselves in a theory-building case study are not meant to be directly generalisable, however, the changes made to the theory can then be applied to other cases, in this way, the theory is how one generalises from this type of research (Stiles, 2017). This contradicts with the relativist paradigm which argues that there is no one reality, but rather, that reality is constructed and unique to each person (Ponterotto, 2005). 3.4 Consideration and Rejection of Alternative Methodologies When deciding on the methodology to be adopted in the current study it was important to consider the aim of the study which was to test the applicability of a theory on a psychotherapy case. Another qualitative design might have involved interviewing clients about goal processes in psychotherapy and conducting a thematic analysis comparing the emerging themes with the theoretical propositions outlined by goal setting theory. Thematic analyses could offer an exploration of clients’ experiences of goal-oriented practice and has indeed been adopted for this 49 purpose (Di Malta et al., 2019). This way of analysing data would have allowed for coding the data that fit with the propositions outlined as well as data which did not fit, making it appropriate for theory extension, it would also have included a larger number of participants. However, what this might have missed out is the naturalistic, in-depth data that case study research offers. A thematic analysis study conducted by a single researcher would not have been able to analyse recordings from therapy sessions over the full course of therapy, including interviews, with the number of participants needed for such an analysis. But rather would have focused on interviewing approximately ten participants missing the ‘real-life’ insights gained from investigating a full course of therapy and complexitites of a case. Therefore, a case study design was chosen for the current study. A number of different methodologies and methods exists for conducting case study research in psychotherapy(McLeod, 2010). Choosing a pragmatic case study methodology would have allowed for rich details of the context and nuances of the case to be investigated. Pragmatic case studies also pay close attention to the individual clients’ goals for the treatment making it partly suitable for the focus of the current study. However, adopting a pragmatic case study design would have had a more clinical focus and missed the important aspect of theory application and evaluation that was central to the current study. Therefore, a theory building case study methodology was chosen for the current study. 3.5 Theory-Building Case Studies The current research utilised a theory-building case study methodology drawing on a rich case record based in a critical realist research paradigm. Theory-building research aims to test, correct, elaborate, and extend a particular theory (Stiles, 2007). Case studies aiming for theory building make systematic observations within a case and evaluate how well these observations correlate to theoretical statements made within a theory (Stiles, 2017). Theory-building case studies start the inquiry with numerous statements from the theory. The statements are tested on a 50 single observation or few observations (case(s)). The idea is to have many ‘points of contact’ between the theory and the case(s). In addition to this, theory-building case studies aim to identify areas of the case that might not be explained by the theory; hence, the theory is being applied to the case and the case is being applied to the theory. 3.6 Case The next section will outline the selection procedure and overview of the case. The client and therapist are both referred to by first name synonyms: Martin (client) and Amber (therapist). 3.6.1 Selection of Case For reasons of confidentiality the context of the case and treatment protocol is described in Appendix H. Case study research does not typically aim for representative sampling (Stiles, 2017). This is because it would be difficult to make generalisable statements about a population based on one case, hence this type of research typically has different aims (such as theory building or making detailed and rich clinical observations and recommendations). However, it is important to be explicit about the reasoning behind the selection of a case for case study research (McLeod, 2010; Stiles, 2007). The selection process for the present study was based on inclusion and exclusion criteria. These criteria were aimed at identifying a case that was rich in data on goal-oriented practice. Inclusion criteria Client has participated in interviews about their experience of goal-oriented practice. Client has finished treatment. Case must have minimum ten sessions of goal-oriented practice that has been recorded. Client must have shown reliable change on the PHQ-9 (change in scores of minimum six points) (Gyani et al., 2013). Client must also have shown clinical improvement on PHQ-9, meaning 51 movement from a clinical score (above 14 indicating ‘moderately severe’) to a non-clinical score (below ten indicating ‘mild’ to ‘minimal’ depression). This ensured that the client had experienced change in symptoms, through goal-oriented psychotherapy. Exclusion criteria Goals not rated at assessment. Director of Studies acted as therapist. Figure 1 Cases including interviews: 22 Client finished treatment: 15 Ten sessions of goal-oriented psychotherapy: 15 Showing reliable and clinical change: 13 Goals not rated at assessment: 13 Number of cases available: 65 52 As shown in figure 1, ten cases matched the inclusion and exclusion criteria and the case with most improvement on the PHQ-9 outcome measure was selected. Arguably, the case demonstrating the most change might illuminate helpful aspects of goal-orientated practice and result in clinical recommendations based on the findings. Although the current study aimed to test a specific theory, it also extracted any helpful aspects of goal-orientated practice that arose in the analysis. The case selected also demonstrated goal dialogue within the sessions, and a rich case record of audio recordings of all therapy sessions and a large battery of outcome measures. 3.6.2 The Client Martin was referred by his GP, after presenting with low mood and anxiety. Martin identifies as gay and is a second-generation immigrant from Asia in his mid 20s. At assessment he met clinical criteria for moderately severe depression (score 15 on PHQ-9) and severe anxiety (score 17 on the GAD-7). The onset of his depression coincided with the loss of his grandmother. Martin was in his final year nurse-in-training; however, he had changed his mind and did not want a career in healthcare anymore. Martin was in a long-term relationship (5 years), but was unsure of the longevity of this relationship. His partner lived with him at his grandfather’s house and he described feeling stuck in a caring role for his grandfather. Martin had no history of psychiatric illness. He was from a single parent household having been raised by his father, after his mother left when he was one year old. Martin attempted to contact his mother before coming to therapy, but she did not express interest in having a relationship. Martin’s father married when he was 13, at the time of attending therapy, his father and stepmother were in the process of separating. Director of studies acted as therapist: 10 53 When Martin was eight years old, he was diagnosed with ADHD. He claimed not to remember much of his childhood, which he linked to being prescribed Ritalin. He described his father as ‘not an easy person to live with’ (Assessment, M1331) and there was an indication that he was a parentified child. 3.6.3 The Therapist The therapist was female and in her final year of training to become a psychologist. 3.6.4 Therapy Summary Martin presents with depression and anxiety, feeling low about the prospect of his future. It became apparent through the therapy that Martin did not want to be with his current partner and the most meaningful change he makes through therapy was leaving his relationship. The therapy had an open structure where Martin could bring anything to the sessions. They worked with imagery and metaphors which Martin found helpful. There was a noticeable difference in Martin through the course of the work. In the first sessions his speech was slow, and his tone of voice was lower. Towards the end of therapy he spoke faster and there was a brighter tone, and he described feeling more optimistic towards his future due to the therapy. This was reflected in the outcome measures where Martin improves from clinical levels to non-clinical levels of depression and anxiety. 3.7 Data This study used pre-collected naturalistic data from a wider research trial. In order to construct a rich case record (McLeod, 2010) the study used a number of different types of data enabling triangulation across the different data sources (Braun & Clarke, 2013). Typically in qualitative research, the researcher plays an intimate role in data collection (Etherington, 2013). This was not the case for the present study which might have minimised the influence of the 1 Quotes are referenced using the session number and the turn taking number in the dialogue, so M81 is the 81st time Martin speaks in the session. 54 researcher on the data, and at the same time, contributed to a disconnect between researcher and data. The impact of this was monitored throughout the research project through supervision and a reflexive journal. Below is a list of data investigated in the current study. 3.7.1 Audio Recordings of Therapy Sessions The study used audio recordings of 20 therapy sessions including the assessment session. 3.7.2 Interviews The client was interviewed after session four and at endpoint by a researcher about his experiences of working with goals (See Appendix C for the full interview schedule). 3.7.3 Goals Form The Goals Form (Appendix A) is a personalised tool where up to five goals can be set for therapy (Cooper, 2015; Cooper & Xu, 2023). Goals are typically set within the first three sessions and should be determined by clients in collaboration with their therapists. At the beginning of each session, clients are asked to rate their progress on each goal on a score from 1-7, the goals can be revised at any point in the therapy. 3.7.4 Patient Health Questionnaire (PHQ-9) As the treatment protocol focused on depression (see Appendix F), the PHQ-9 outcome measure was considered the most important of the standardised outcome measures used in the analysis. The PHQ-9 is a depression severity measure that was administered at every session (Kroenke et al., 2001). 3.7.5 Other Measures An extensive battery of measures was collected including: GAD-7 (Spitzer et al., 2006), authenticity scale (Wood et al., 2008), working alliance inventory (WAI-SR) (Hatcher & Gillaspy, 2006), relational depth frequency scale (Di Malta et al., 2020), and the alliance and negotiation scale (Doran et al., 2012). These measures were not the focus of this study, however, in order to 55 create a rich case record, these were part of creating the full picture of the client and the therapeutic journey. 3.8 Theory-Building Case Study Research Group In 2020, I formed a research group with four other doctoral students adopting theory-building case study methodologies. The group aimed to explore methodological issues as they arose in our different projects. Although guidelines for doing theory-building case studies do exists (McLeod, 2010; Stiles, 2007), we discovered that researchers attributed different meanings to method and analytic strategy when conducting theory-building case study research. We wanted to find examples of good process research that rigorously and reliably analysed case material and were particularly interested in the theory-building element. However, we discovered that examples of such papers were scarce and hence decided to conduct a systematic search of the literature for articles that explicitly stated theory-building case study as the methodology adopted. We found that majority of the papers we reviewed used a named analytic strategy (such as assimilation of problematic experiences scale (APES)) or IPA within an overarching theory-building case study methodology. Some studies (three out of twenty-five papers reviewed) used theory-building as their method of analysis. Twenty papers had a theory-driven analysis where an explicitly named theory was utilised to organise and analyse the data. The findings from the literature review were used to inform the analysis in the current study and better understand the analytic strategies adopted in theory-building case study research. The review paper has been submitted for publication, see Appendix E. For the current study, the group provided a sounding board when making decisions about this reseach project, such as choosing which analytic strategy to adopt. Prominent figures in theory building case study research such as Bill Stiles and John McLeod visited the group allowing for the group to ask questions about our individual projects which helped me decide on how to code the data for the current study. As this methodology is scarcely 56 chosen for doctoral research, the group provided an invaluable community and cooperation with other researchers. 3.9 Analysis The next section outlines the approach chosen for analysis in the current case. 3.9.1 Immersion in the Case The first step in the analysis consisted of immersion in the case. This involved bracketing preconceived ideas about the theory and approaching the case material with an open mind, which includes reflexivity about own assumptions about potential findings (Braun & Clarke, 2013; Breiner et al., 2023; McLeod, 2010). Initially, all session recordings and interviews were repeatedly listened to (McLeod, 2010) and a descriptive summary of the content was written out for each session. Stiles (2017) describes ‘selecting and focusing’ as a vital step in theory-building case studies where materials are selected ‘that are relevant to the focal theoretical topic or theme’ (p. 445). For this study, this involved selecting sessions based on the criterion that the session or interview entailed discussion around goal progress, goal-processes, goals, the theoretical propositions, or other aspects of goal-oriented practice. Ten therapy sessions were deemed most valuable for further analysis and selected for transcription. Transcription is often discussed as merely a technical task, however, in the present study the transcription process was considered part of the immersion in the data (Braun & Clarke, 2013). When transcribing, decisions were made on how to translate the speech into text. Paralinguistic features such as crying, laughing, pauses etc. were included where relevant. Parts of the recordings that were deemed irrelevant to the analysis were identified and omitted from the transcripts. Immediate reactions to the transcripts were recorded in a reflexive log. The transcripts were then read from Amber’s then Martin’s perspective, focusing on only their part of the dialogue. Reading the data from different perspectives became part of the initial emotional and imaginative engagement with the data (McLeod, 2010), an important step before employing a more systematic 57 analysis. It involved a more creative process of imagining the emotional responses and intentions behind the words and reading with a more therapeutic ear, noting thoughts on the process. Following this, transcripts were read from the perspective of each goal. This involved focusing on each goal on the Goals Form in turn, reading the transcripts and identifying where in the dialogue the goal had been discussed or omitted from discussion. Then, a descriptive goal narrative for each of the goals was written, including how the goals had been set, progression towards each goal, and what had happened to each goal through the therapy. 3.9.2 Choosing the Analytic Strategy For the current study, this step involved a lot of consideration. As stated above, some theory-building case studies use a named analytic strategy such as APES within a theory-building case study methodology (Breiner et al., 2023). One of the most prominent figures within theory-building case study research in psychotherapy, Bill Stiles, used this methodology to develop assimilation theory. In his research the parts of the theory that are already developed are used to analyse case material, (for examples of this type of analysis see: (Aro et al., 2021; Gray & Stiles, 2011; Kramer et al., 2016; Penttinen et al., 2017). As the theoretical propositions had been extracted from the theory, it made sense to employ a similar analytic strategy. Stiles (2017) suggests listing observations (such as quotes from a transcript) in one column and corresponding theoretical concepts in another, to best display how the theory relate to the data. For the current study, the selected transcripts were coded using the theoretical propositions extracted from the theory. This analytic strategy is similar to that employed in the assimilation studies and allows for applying the theoretical propositions which are already established within the theory on case material. 3.9.3 Applying the Theory to the Case/Triangulate In this part of the analysis, the theory which had been bracketed in the initial immersion in the data, was now brought to the forefront. Before applying the theory, it was important to clearly 58 state whether the goals fit into the categorisations of the propositions e.g. were the goals considered ‘high’ or ‘specific’. Each goal was therefore categorised using the theoretical propositions. This allowed for clarity when approaching the application of the theoretical propositions to the case material. Several authors within theory-building case study research have argued for the importance of comparing/contrasting theoretical observations to empirical evidence (Eisenhardt & Graebner, 2007; McLeod, 2010; Stiles, 2007, 2009). Following on from this, it was important to investigate how well the theoretical propositions fit with the case observations, if at all. Therefore, each theoretical proposition was categorised in terms of the level of evidence found. The propositions were categorised into one of five levels: ‘clear supportive evidence’, ‘limited supportive evidence’, ‘insufficient evidence’, ‘limited contradictory evidence’, and ‘clear contradictory evidence’. Were the dialogue directly addressed the proposition either in a contradictory or supportive manner this will be deemed as ‘clear contradictory/supportive evidence’. Where there were indications within the dialogue in support or contradiction a proposition, however, it had not been clearly or directly addressed, this was deemed as ‘limited contradictory/supportive evidence’. Propositions that were not discussed, or there was insufficient data to address were categorised as ‘insufficient evidence’. This is in line with previous single case study designs (Elliott, 2002). Data were coded using NVivo software. There were also codes for each explicit psychotherapy goal, and some additional codes which emerged during the analysis, for example, who initiated goal discussion, and how goals were initially agreed upon, see Appendix B for the code book. Triangulation often involves using two or more sources of data or two or more researchers to investigate a phenomenon. In this study, there was triangulation of different sources of data, and different researchers. Two other researchers were given an extract from the first session, along with the theoretical propositions and the goals and asked to code and make notes about the goal processes in the session. One researcher coded blind, and one was familiar with the case and 59 outcome. After looking at the other researchers’ codes and notes, differences and similarities to my initial codes were recorded. Their coding was used to aid discussions and served a developmental function to the analysis. For example, it was suggested to code the goals using sub-goals as the wording of some goals were broad. This enabled the analysis to better track each part of the goals. The codes were further developed in discussion with the other researchers and consequently discussed and agreed with supervisors. The new codes were then audited by another researcher. In order to ensure reliability of the findings, a researcher who was highly familiar with the case coded each theoretical proposition using the levels of evidence and an 84% agreement was found. A contingency table was created to compare the findings (see Appendix D for the full calculation of the Cohen’s kappa). Cohen's kappa coefficient for the inter-rater agreement was found to be 0.78 indicating a substantial agreement beyond chance (McHugh, 2012). 3.10 Ethical Considerations To ensure ethical considerations were made, a number of policies and regulations were adhered to including: • European Union´s General Data Protection Regulation (GDPR) • British Psychological Society Code of Human Research Ethics (2014) • Policies from the University of Roehampton: o Data Protection and Storage Guidance of Researchers o Data Protection Policy o Ethics Guidelines The research for this project was submitted for ethics consideration under the reference PSYC 20/360 in the Department of Psychology and was approved under the procedures of the University of Roehampton’s Ethics Committee on 30.06.20. 60 3.10.1 Confidentiality As highlighted by McLeod (2010), case study research is by nature interested in the particulars of a case and therefore require extra consideration of confidentiality. Considerable steps were taken to anonymise participants including changing demographics and place names and organisations whilst keeping relevant information. 3.10.2 Consent Participants had already consented to their data being used for further research as stated in the consent form administered by the research clinic: ‘I understand that data may be used for subsequent research projects and data analyses (by persons other than the present Chief Investigator) at the discretion of the Chief Investigator’ (see appendix E). However, there was still a risk that clients/therapists could find it exposing to have their data analysed in-depth. When discussing consent for case study research post-treatment, McLeod (2010) states: ‘the very act of contacting the client may cause harm, by restimulating memories of the therapy’ (p. 65). For the present study it was deemed that the risk of distress to the client outweighed the ethical advantages of contacting participants to re-give consent. The therapist had already been provided an information sheet stating that data collected by the research clinic ‘may be used for subsequent research projects and data analyses (by persons other than the present Chief Investigator)’, however, no ethical concern was identified for contacting the therapist, who gave informed consent for the data to be re-investigated for the purpose of this study. 3.10.3 Data Storage Audio recordings of therapy sessions and interviews were transferred to the researcher through an encrypted memory stick and stored in a locked cabinet. When transcribing data, any identifiable data e.g. names of people or places, where altered. Password protected access was provided to the secure server used by the research clinic to store outcome measures and therapist notes. 61 3.11 Reflexive Statement Personally, I believe in the importance of linking therapeutic practice and research and ideally for research findings to improve clinical practice. I wanted this research to add to a growing body of research into goal-oriented practice which celebrates client engagement and individuality. Therefore, it was important to bracket my own assumptions of goal-oriented practice as overall helpful. My choice to do a case study sprung from the depth of learning I experienced from individual clients and how this informed my clinical practice. Clients offer rich insights into their experiences, and I wanted to use this type of data to systematically explore my research interest. I also believe that individual experiences are valid of exploration in their own right and that they can provide psychotherapists with an understanding that can inform their practice. I was also interested in how theory inform practice and how counselling psychologists apply theory to cases. This led me to explore theory-building case study methodology for my research. When using theory in my clinical work, I discovered that, at times, the theories did not account for the full experience of the client and had to be extended or integrated with a different theoretical framework in order to be helpful. This is in essence, theory building from a case. I appreciate that theory-building case study methodology is closely linked with clinical practice and thus this type of research has much to add to counselling psychology. I strongly believe in interdisciplinary learning and was fascinated by the idea that different disciplines might offer insights into psychotherapy processes. Research such as the current study offer a wider inter-disciplinary-perspective, which is in-line with the inclusive ethos of counselling psychology (Orlans, 2013). I have experience of setting goals for therapy both as client and therapist, however, I have not engaged in the more formal goal tracking. Thus, I have experienced moving between the insider and outsider position in this research (Dwyer & Buckle, 2009). This involves recognising 62 that some of the clients and therapists’ experiences of goal-oriented practice in my own clinical practice and personal therapy, however, at the same time recognising that I am not, as such, a full member of either the therapist or participant population of my study. Throughout this research journey, I was mindful of my own biases and bracketed, as best possible, my preconceived ideas about the data, this was done through supervision, a reflexive research journal, and continuous reflexivity on the research paradigm, methodology, and topic. 63 4 Findings The goal of this chapter is to present a descriptive account of the process of working towards each goal, to categorise each goal based on the theoretical propositions: level of difficulty, specificity, monitoring of goal progress, goal commitment, goal meaningfulness, situational constraints to reaching the goal. Finally, to outline the findings for each theoretical proposition. 4.1 Descriptive Account of Goals Work and Categorising Goals Using the Theoretical Propositions Martin and Amber wrote down three goals for the therapy, below are the goals as recorded on the Goals Form: 4.1.1 Goal 1 Loss: Addressing Loss of Grandmother, Including Unresolved Grief. Looking at the Role of Other Losses in Life Including Mother, Stepmother In the assessment, Martin described losing his paternal grandmother a few years prior to entering therapy coinciding with the onset of his depression. Towards the end of the assessment, Amber asks Martin what he would like to focus on: Goal 1 Loss: Addressing loss of grandmother, including unresolved grief. Looking at the role of other losses in life including mother, stepmother. Goal 2: Future Worries: Addressing anxiety about own future including work and relationships. Looking at the role of anxiety about his father and grandfather. Goal 3 Motivation: Thinking about why motivation for everything in life has been decreasing recently. 64 Amber: So, I’m wondering, in the context of you know coming here, what do you think would be helpful for you to focus on to work on? Martin: I’m not sure, I’m really not sure I’m not very ambitious with my own goals I don’t think Amber: No, well that’s ok, ehm, let me tell you what come up for me then shall I? would that be useful? Martin: Yeah Amber: I’m thinking about, there’s been a lot of loss ehm, and they might not necessarily have happened close together but there has been a loss there was the loss of your mother initially which you might not have noticed but there’s a loss and then that fresh loss when regardless of that you’ve dealt with it in what seems like a very mature way, there’s a rejection which is a loss and there’s the very important loss of your grandmother and it feels like it might be useful to think about what those losses mean and how they have affected you (Assessment Session, A201) Amber then writes Goal 1 on the Goals Form and Martin stated that it is ‘spot on’. Although there were two other losses included in this goal, namely his mother and stepmother, they mainly addressed this goal in relation to Martin’s grandmother. With regards to his stepmother, Martin revealed in session 8 that his father and stepmother, who were about to separate, were staying together. Hence, his stepmother did not become a loss, as originally feared. Martin did not bring up his mother after the assessment. When Amber enquires about her, Martin claimed that he did not think about her, and she never became the focus of therapy. In session 1 and 2 they focused on the loss of his grandmother in relation to Martin’s guilt around not visiting her enough towards the end of her life when was diagnosed with dementia. She suffered violent outbursts and did not recognise Martin. After the assessment, majority of data 65 coded as Goal 1 involved Martin telling positive stories about his grandmother. There were no specific grief work or protocol and they kept an open structure. They sporadically focused on the loss of his grandmother up until session 11, after which there was not much discussion of this goal. In the endpoint interview, Martin reported that the goal had not felt relevant after this. Amber said in session nine about Goal 1 that she felt like they had ‘packaged it up and put it away’. On the Goals Form, Goal 1 plateaued on a score of 6 in session 11 (see figure 3). When asked why he scored 6 rather than 7 (completely achieved), it became apparent that Martin had not wanted to reach 7 because that would mean that he had forgotten his grandmother and was no longer upset that she died. In terms of qualitative progress towards this goal, Martin stated that therapy helped him remember his grandmother fondly without making him sad and he stopped ruminating about her. The next section will categorise the Goal 1 using the theoretical propositions. Figure 1: Goal Progression on the Goals Form for Goal 1 4.1.1.1 Was Goal 1 a High Goal? Firstly, it is important to note that there are different levels of ‘high’ goals and a goal is not necessarily either high or not, but exists on a scale of difficulty. Martin claimed on several occasions that the goals were either idealistic or hard to achieve. For example he says: ‘I mean I was talking about that with Tom (interviewer – name changed) as well, and I was saying like, a lot of goals are kind of idealistic you know’ (Session 10, M81). He says about Goal 1: ‘Because that’s 66 why I think like, it says “completely achieved” but I don’t think you can ever completely achieve a loss’ (Endpoint Interview, M61). Several times, he stated that his view of completely achieving Goal 1 (score of 7 of the Goals Form) meant never missing his grandmother. Therefore Martin’s perception of achieving Goal 1 could be argued to be more difficult or ‘high’ than what would be implied in the wording of the goal which is to address the loss. Based on the above, I argue that it is indicated that Martin considers Goal 1 to be ‘high’. 4.1.1.2 Was Goal 1 Specific? The first part of Goal 1 is addressing the loss of his grandmother. Although it was not immediately clear what ‘addressing’ entails in practice, the focus of this part of the goal is specific and entails addressing his grief of losing his grandmother. Adding the sub goals of other losses including mother and stepmother made this goal less specific as the focus became wider. However, when working on this goal, the focus remained on the loss of his grandmother. The weekly Goals Form filled out in the sessions reflect this, where this goal was often shortened to ‘loss’ or ‘loss of grandmother’. And so, the original wording of the goal reflects the width of issues they were hoping to address, however, the goal gets a narrower focus on his grandmother and leave out the loss of his stepmother and mother. The wording of the goal is not specific, however, in practice they work on this goal with a specific focus, namely addressing the loss of his grandmother. 4.1.1.3 Was Goal 1 Monitored through the therapy? Goal progress was monitored every session through the use of the Goals Form. This was the case for all three goals. 4.1.1.4 Was Martin Committed to Goal 1? In the first two sessions, Martin seemed committed to this goal as it remained the focus of the therapy, however, after this, the focus changed. When reflecting on the therapy at his endpoint interview, Martin states that Goal 1 was not the most important aspect of therapy for him, and he did not wish to achieve it completely. Based on the above the analysis concluded that although 67 there might have been some commitment to Goal 1 in the beginning, he was not overall committed to this goal. 4.1.1.5 Was Goal 1 Meaningful to Martin? Initially, Goal 1 appears meaningful in that it relates to Martin’s overall wellbeing. In session 1, Martin reported thinking less about his grandmother during the week, he reports that this improved his mood: Amber: But it looks as if you have, as if you’re mood has improved since last week… does that make sense to how you feel? Martin: Erm I think so in a little way yeah, I think my mood has been better this week erm yeah I would agree with that erm I think I still have obviously I still have some worries, I haven’t had so much kind of, in my mind I haven’t thought so much about my grandma or anything like that (Session 1, M7). When Martin is asked about his goals in the post session 4 review interview, he says: Martin: I think the goals are pretty accurate…because I do think that the loss of my grandmother, the first goal, is a big thing that is something that I’m concerned about or sad about still (Post Session 4 Review Interview, M2). In the latter quote, Goal 1 appears meaningful in that it was described as a big thing that he was concerned about. However, after session 11 there was little focus on Goal 1 and in the endpoint interview, Martin claimed that the goals were not his biggest issues. Based on the above, Goal 1 is seen as meaningful to Martin in the beginning, then as the work progressed, Goal 1 became less meaningful. 4.1.1.6 Were there Situational Constraints to Reaching Goal 1? The analysis did not reveal any situational constraints to reaching Goal 1. 68 4.1.2 Goal 2 Future Worries: Addressing Anxiety About Own Future Including Work and Relationships. Looking at the Role of Anxiety About his Father and Grandfather In the assessment session, Martin explained that he was worried about many aspects of his future. He described feeling stuck looking after his grandfather and that he would feel guilty moving out of his house. He claimed that he hated his university training: ‘I don’t want to do it so, a lot of my anxiety I think and stress was about the fact that I’m doing something that I hate’ (Assessment, M187). At the time of therapy, Martin was in his final year of a qualification that he did not wish to pursue a career in and he worried about his future: ‘I am very cynical about a lot of things so I’m worried about the future’ (Assessment, M208). Goal 2 emerged in a similar way to Goal 1, when asked about his goals Martin claimed that he did not know. Goal 2 was suggested by Amber towards the end of the assessment session after suggesting Goal 1, she says: Amber: Then the other thing that’s kind of coming up for me is slight, not a fear, a fear is too strong a word but a kind of an ambivalence about the future in a way in terms of your relationship, in terms of what might happen with your grandma in terms of your career, even they’re the things that spring up for me I don’t know has anything come up for you in the course of this conversation Martin: I think those two are both spot on really, I think that even with the fear side of things or the future rather, I mean I’m kind of worried now about my dad you know, he’s not getting any younger. (Assessment, M201). Goal 2 was then written by Amber on the Goals Form. Initially, Martin discussed anxiety for remaining the carer for his grandfather, however, towards the end of session 3 anxiety about his partner becomes the focus. His partner remained the focus in session 5,6,7,8, and 10. Anxieties about his future with his partner was not recorded as part of Goal 2, however, in the endpoint 69 interview, Martin identified feeling stuck with his partner as his main worry for the future. Another aspect of working on Goal 2 was untangling Martin’s worries, as discussed below: Amber: So it feels like you’re kind of separating out the things, rather than it just being a kind of a, a sort of a worry blob, it’s now becoming; these are actually things, these are the separate things going on Martin: Yeah (Session 9, M7). Martin mentioned several worries though the course of therapy including his father becoming single, not knowing how to leave his relationship, the state of the political world, career and job prospects, and personal finances. Although all these issues were discussed in therapy, when Goal 2 was explicitly discussed, the focus remains on his work and career. Martin finds practical ways of addressing his career anxiety such as applying for a graduate scheme. Although he did not land on a definite career-plan, the future did not appear as daunting after talking about it in therapy. In session 18, Martin plateaus on a score of six on the Goals Form for Goal 2 (see figure 4) and when asked about goal achievement he says the following: Martin: they’re all kind of near enough completed but I don’t think I’ll ever… when can you stop worrying about your future really in a sense… you know there’s always some worry (Endpoint Interview, M61). 70 Figure 2 Goal progression on the Goals Form for Goal 2 Although Martin did not achieve this goal completely, his perception of his future changed significantly through the course of therapy. At the beginning he described feeling stuck and towards the end there was excitement about his future as stated in session 17: Martin: Mhm, it’s really nice yeah like, it’s something like 15 months ago or 15 weeks ago rather I wouldn’t have thought that I could be where I am now or sitting here talking about what we’ve talked about or you know looking forward to what’s gonna happen with such kind of I don’t know a sense of relief, excitement, anticipation instead of dread (Session 17, M81). The next section will categorise Goal 2 using the theoretical propositions. 4.1.2.1 Was Goal 2 a ‘High’ Goal? When working towards Goal 2, Martin described the goal as difficult: ‘the future worries, I think is attainable but at the same time it’s very difficult to attain’ (Post Session 4 Review Interview, M32). The different parts of Goal 2: worries about future, work, relationships, father, and grandfather made this goal difficult to work towards as there was not always time to address them all in each session. In the endpoint interview, when Martin discussed his scores on the Goals Form, he implied that scoring Goal 2 as ‘completely achieved’ would indicate that he no longer 71 had any worries about his future. And because there ‘is always some worry’ he will not reach this score for this goal: Martin: So they’re all kind of interwoven in a way but they’re all kind of near enough completed but I don’t think I’ll ever… I mean whoever, when can you stop worrying about your future really in a sense like you might be married with kids and have everything you want but you might worry about next month paying the bills or something, you know there’s always some worry, is it reasonable worry or is it something that controllable (Endpoint Interview, M61). In the quote above Martin sees Goal 2 as a ‘high’ goal, although Amber never claimed that she shared this description of goal achievement. In conclusion it appears that Martin found Goal 2 to be a ‘high’ goal and described it as difficult when working on in therapy. 4.1.2.2 Was Goal 2 Specific? The main focus of Goal 2 is addressing Martin’s anxiety, which the wording of the goal specifically states. However, there were many sub-goals including his future, work, relationships, father, and grandfather. These made the goal quite broad and less specific. When working on this goal, they narrowed the focus to mainly addressing his anxieties relating to his career. This make this goal more specific in practice than is recoded on the Goals Form. The issue with specificity for Goal 2 was that it was not clear from the wording what achievement entailed. It was difficult to say with specificity when an issue had been ‘addressed’ or ‘looked at’? The wording of the goal was not specific, however, in practice, it did have a more specific focus, namely addressing anxieties about his career. 4.1.2.3 Was Martin Committed to Goal 2? Although there was progress on the Goals Form and qualitatively reported in the recordings, Martin claims at the endpoint interview that the goals were not his biggest issues. This goal did 72 not naturally remain the focus of the work, hence, the analysis concluded that Martin was not committed to achieving Goal 2. 4.1.2.4 Was Goal 2 Meaningful to Martin? In the review point interview, Martin described his goals as accurate and suitable and it appears that Goal 2 was relevant to his difficulties: Martin: I am still worried about where I’m heading, I don’t know what my direction is…. so think that they’re pretty accurate and I think that they’re suitable (Post Session 4 Review Interview, M2). Martin also linked a decrease in his anxiety and depressive symptoms to progress on Goal 2 in that saying that: ‘I don’t feel like I’ve maybe I don’t feel like I’m worried each week’ (session 17, M5). Addressing the worries about work helped Matin clarify what he loves to do and work from there in terms of finding a career, rather than feeling stuck. When Martin’s worries for the future decreased, he reported feeling better in himself overall. Although the frequency of this goal being the explicit focus of the therapy decreased as therapy progressed, he reported having less worries for the future correlating with an overall increase in wellbeing. In conclusion, Goal 2 was meaningful and relevant to Martin. 4.1.2.5 Were there Situational Constraints to Reaching Goal 2? There were external circumstances that influenced this goal, such as his father and stepmother deciding to stay together. He was also worried about a future where he feels stuck in a caring role for his grandfather, should he live another 25 years. However, it is his relationship to his partner that is explicitly named as a situational constraint to reaching Goal 2. Martin claims that his relationship kept him from addressing his worries for the future, by distracting him and draining his energy. In the following extract Martin and Amber have been discussing Martin’s relationship: Amber: I wonder what it’s making us not think about and not look at 73 Martin: Opportunities perhaps Amber: What’s it distracting from, yeah Martin: Working out what I’m gonna do next or how I’m gonna move forward …I think maybe it’s distracting me from figuring out what I want to do or where I want to be or who I want to be with or any of those because I’m too concerned about what I’m doing right at this moment Amber: Yeah it’s kind of handy in a way isn’t it, cos you can’t really worry about the future cos you’ve really got to worry about this in a sense Martin: Yeah (Session 13, M 44). Later in the work, he claims that if he was not worrying about his relationship, he would fix his other worries: Martin: if I’m not worrying about other things that are draining all my energy, like my relationship whatever then I could spend a lot of my energy not worrying about that and like worry about and work on fixing other worries which I feel would (Session 18, M22). When discussing Goal 2 in the endpoint interview, Martin names removing other issues to free up his energy as the most important aspect: Martin: Worrying about my future I think, was something that came with removing my other issues, so by removing the things that were occupying my energy and time, I could start to think about my future and not worry and plan for it (Endpoint Interview, M 53). In conclusion there were situational constraints to reaching Goal 2 and removing these was significant to goal progression. 74 4.1.3 Goal 3 Motivation: Thinking About Why Motivation for Everything in Life has been Decreasing Recently After recording Goal 1 and 2 on the Goals Form in the assessment, Martin and Amber went on to discuss how Martin felt that there had been a decline in his physical fitness, a disengagement from his social life, and a drop in his attendance at university. Amber then suggested writing down a motivation goal to which Martin says ‘yeah, probably, yeah’ (Assessment, M 233). When wording the goal, Martin suggested ‘complacency in life’ (Assessment, M 234), but Amber felt this would be too critical and suggests ‘motivation’ to which Martin says OK. Goal 3 is then recorded by Amber on the Goals Form. Goal 3 was rarely discussed in therapy with the exception of scoring the Goals Form. When discussed, it was mainly in the context of motivation towards university. In the endpoint interview Martin claimed that talking about motivation in therapy was not helpful: Martin: Motivation wise it was just more, my own… that was me, I needed to take that into my own control, talking about it wasn’t really helping anyway, it was just that was an issue that I need to take ownership of (Endpoint Interview, M53). In the final session, when discussing the possibility of entering therapy again in the future, Martin claimed that he would use therapy as a resource for motivation which might indicate that the therapy had been helpful in this area. As there was a lack of focus on this goal, they discussed removing Goal 3 from the Goals Form in session ten, but decided to keep it, as a reminder. As with the other goals, Martin ended on a score of 6 for Goal 3 on the Goals Form. See Figure 5. 75 Figure 3 Goal progression on the Goals Form for Goal 3 Again, the analysis revealed some inconsistencies in the perception of goal attainment for Goal 3 between Amber and Martin and the meaning of attainment was never explicitly outlined. On several occasions, Martin implied that he perceived achievement of Goal 3 as an overall increase in motivation towards tasks, which differs from the wording of the goal which involves thinking about why his motivation has decreased. Martin: If someone says to me now can you go do this, I’d probably be like ‘ah, do I have to?’ whereas if someone is always motivated they’d be like ‘yeah’ straight away and jump on it, that’s what I feel a number seven would be and I don’t think I’ll ever be like that’ (Session 17, M29). In session 17, Amber insinuates that she perceived Goal 3 to be ‘completely achieved’ whilst Martin scores 6 on the goals form: Amber: I mean, how much more motivated is it possible to be? Martin: (Blows air out) Amber: I’m just wondering why you haven’t gone for the seven on that?’ (on Goals Form) Martin ‘cause that means it’s ‘completely achieved’ and I say I think motivation is a scale isn’t it? I mean that’s like saying that you know, if you say ‘I wish I was 76 always excited where you ever excited?’ you know? If I’m always motivated, am I ever motivated? (Session 17, M28). Martin showed progress towards this goal on the Goals Form (see figure 3), the analysis also revealed qualitative progress in the dialogue where Martin spoke about positive changes in his motivation. When discussing helpful aspects of therapy Martin says: ‘I have motivation or I have the energy to be motivated to fix my worries that are more, small chunks before they become large problems (mhm) if you know what I mean’ (Session 18, M22). In session 17 he claims experiencing a rush of motivation and that he felt more focused than he has in a long time. There was also a change in Martin’s motivation, from initially being more extrinsic, e.g. seeking a career that his father would approve of, to more intrinsic, where he thought about what he really wanted from his career. The qualitative progress towards Goal 3 in terms of the wording on the Goals Form was minimal, as they rarely thought about why motivation for everything in life had been decreasing. Martin described Goal 3 as a biproduct of the other two goals and claimed that he would naturally progress towards Goal 3, if he progressed towards Goal 1 and 2: Martin: ‘I’m hoping by achieving the other two (goals) I will address number three’ (Post Session 4 Review Interview, M45). This fits with goal-setting theory which claims that if one progress towards one’s goals, one will become more motivated. The next section will categorise goal 3 using the theoretical propositions. 4.1.3.1 Is Goal 3 a ‘High’ Goal? Martin claimed that Goal 3 would be difficult to work on in therapy, instead he would need to address it outside of therapy: Martin: I’m not sure motivation is anything that I can talk myself into doing because I think motivation is just, it’s mind over matter and motivation doesn’t come to 77 you, it’s only when you sit down and work that you create your own motivation I think (Session 8, M3). Martin also stated that he would not score this goal as ‘completely achieved’ on the Goals Form because that would mean always being motivated towards every task, which inevitable would be very difficult. When discussing his goals, he claims that he finds it ‘very hard to be motivated’ (Session 18, M20). In conclusion, Martin considered Goal 3 to be a ‘high’ goal. 4.1.3.2 Is Goal 3 Specific? As discussed above, there was a difference in the wording of this goal on the Goals Form and Martin’s perception of achievement of the goal. In contrast to Goal 1 and 2, there were no sub-goals for Goal 3 and there was a clear focus – namely his motivation. When explicitly discussing Goal 3, they mainly considered whether Martin had completed his university assignments. And so in practice, the goal is even more specific in that it considers his motivation towards his university assignments. 4.1.3.3 Was Martin Committed to Goal 3? There was a lack of focus and attention given to Goal 3. It was mainly discussed in the context of filling out the Goals Form. They even discuss removing this goal and so, it was concluded that Martin was not committed to Goal 3. 4.1.3.4 Was Goal 3 Meaningful to Martin? There is some evidence in the beginning that Martin finds Goal 3 meaningful. Clinically, the drop in motivation was most likely related to the depression which brought him to therapy. There was a correlation between Martin feeling generally more motivated and his overall wellbeing improving. In session 17, when Martin describes experiencing a rush of motivation, he states: ‘I’m still going to the gym regularly and I’m still doing…I’m not kind of being lethargic and sitting around indoors… I’m kind of embracing it and going out and doing things (Session 17, M6) which are meaningful changes. In conclusion Goal 3 was meaningful to Martin. 78 4.1.3.5 Were there Situational Constraints to Reaching Goal 3? Progress towards Goal 3 was mainly discussed in the context of removing obstacles that drained his energy and therefore decreased his motivation, mainly his relationship. In session 13 Martin claimed that it was difficult to be motivated before he addressed the future of his relationship: Martin: ‘I feel I know that links to motivational issues the fact that maybe I’m not very motivated ‘cos I don’t know what I’m gonna do, and it’s hard to be motivated if you don’t know what you’re doing’ (Session 13, M44). Martin claimed that talking through his relationship issues and consequently leaving his partner, helped him progress towards Goal 3 as the relationship had been draining his motivation. In conclusion, there were situational constraints towards reaching Goal 3 and removing these were significant to goal progression. 4.2 Summary In summary, the goals were the natural focus of the first sessions, then the therapy changed focus to Martin’s relationship, which was not part of the explicit therapy goals. Categorising the goals using the theoretical propositions made clear what the analysis can ascertain about the theoretical propositions based on the data available in this case. 4.3 Findings for Theoretical Propositions The next section of this chapter will outline the findings for each theoretical proposition investigated in this study summarised in Table 1‘Findings for Theoretical Propositions’. Table 1 Findings for Theoretical Propositions Theoretical proposition Finding 1. Setting high goals will increase goal motivation and aid goal progress. Limited contradictory evidence 2. Setting specific goals will increase goal motivation and aid goal progress. Clear contradictory evidence 79 3. Monitoring goal progress will improve goal performance. Insufficient evidence 4. Goal commitment will improve goal motivation and performance Insufficient evidence 5. Goal meaningfulness moderates the relationship between goal progression/achievement and affect Limited supportive evidence 6. Situational constraints might hinder goal progression/achievement Clear supportive evidence 4.3.1 Theoretical Proposition 1. Setting High Goals Will Increase Goal Motivation and Improve Goal Progress The analysis did not reveal level of difficulty of goals as a motivating factor or as aiding goal progress. As stated above, Martin considered his goals to be ‘high’ goals, however, this did not motivate him towards goal achievement. For example, when discussing achievement of Goal 1, Martin stated that in order for him to completely achieve this goal he would have to be ‘ok’ with his grandmother passing. This would arguably be a harder goal than ‘addressing’ as indicated by the goal on the Goals Form, however, this does not motivate him towards achievement: Amber: Mhm, and I mean, based on what you’re saying about your goal with your grandma it sounds as if you don’t get to seven (on the Goals Form) on all of these it’s not the end of the world for you? Martin; I mean I think it would be kind of more the end of the world if I did get to seven on all of them… And if I was suddenly like ‘oh it’s ok my grandma is gone’ and then the next person goes in my life ‘oh it’s ok they’ve gone’ you know? Like I’ve become kind of hollow I think, in a way. 80 Amber: So you’d be really suspicious of yourself if you hit sevens then almost? Martin: Yeah (Session 10, M92). Martin’s perception of goal achievement for Goal 1 is more difficult than the wording of the goal indicates, however, this makes him less motivated to completely achieve the goal, contradicting this theoretical proposition. When asked about helpful aspects of the therapy, Martin states that he found it helpful not to have any pressure and having a flexible structure, where he could take time to figure out what he wants. Martin: Yeah, but I think, I mean I don’t know, I enjoy that we just kind of talk about whatever is kind of pressing or whatever is going on I do enjoy that ‘cause it means that I can just chat shit… or not chat shit but just talk about whatever and you can say whatever and wherever it goes (Session 8, M5). The analysis found that it was Martin’s relationship to the goals, rather than goal achievement, that was meaningful. In practice, the high goals (Goal 1,2, and 3) functioned as focal points for the therapy rather than an end destination. Goal achievement was not the most important part of the therapeutic work for Martin. When Martin is asked about the helpful aspects of therapy he says: ‘which was incredibly helpful because I didn’t feel like I had any pressure, I didn’t feel like I had to do anything’ (Endpoint Interview, M39). The two quotes above could indicate that goals work is most helpful if the client does not feel pressure to achieve the goals and there is a flexible structure. The data in this case indicates that level of difficulty or ‘high’ goal did not create goal motivation or aid goal progress. Rather, goals were useful as a focal point where there was little or no pressure to achieve the goals. Conclusion: limited contradictory evidence. 81 4.3.2 Theoretical Proposition 2. Setting Specific Goals Will Increase Goal Motivation and Aid Goal Progress As stated in the goal categorisations, Goal 3 was considered specific, whereas it is unclear whether Goal 1 and 2 were specific. Regardless, it was possible to identify some aspects of the usefulness of goal specificity based on the meta-communication related to the goals work, as well as the interviews about goals work. Surprisingly, the analysis mainly found evidence contradicting this proposition. It seemed that Martin found it helpful that the goals were worded ‘ambiguously’ which allowed space to explore: Martin: I don’t really don’t really know why I am in a low mood or like why I got or why I have the anxiety at all and I’m trying to work out what that is, but I think that the goals are ambiguous enough for me to work that out (Post Session 4 Review Interview, M2). Martin did not come to therapy with a specific issue, as he states in the quote above, he did not know the cause of his low mood and anxiety. It appeared that it was helpful that the goals were ‘ambiguous’ as this allowed him space to explore what brought him to therapy. It also became clear that the explicitly stated goals did not capture the biggest issues and as the therapy progressed, they uncovered other more important issues to focus on: Martin: Even though my goals were three clear things, I feel like they weren’t necessarily the only reason that I was down, but they were something to aim for, and by following those, we kind of uncovered a few other things that actually I could resolve. And talking through them with Amber was one way of, that just helped me kind of clear… get some clarity in my head (Endpoint Interview, M1). Martin names ‘get some clarity’ about what he wanted to change as a helpful aspect of therapy. Therefore, it could be argued that setting specific goals might be a helpful therapeutic 82 process in itself that requires time and thought. Because Martin did not come to therapy for a specific issue, it was not helpful for him to set specific goals before they had spent time exploring the underlying causes to his low mood and depression. In the endpoint interview when asked how therapy had impacted what he wants to gain in his life, Martin stated that it has helped him gain a sense of clarity: Interviewer: …How do you think maybe, the process of therapy, do you think it has impacted on these wants? Martin: I feel like it’s helped me erm…maybe give me a sense of, a goal, of what I need to aim for or how to remove things that were hindering me from going about getting what I wanted. Interviewer: So it’s made clear what you wanted, is that what you’re saying? Martin: Yeah sense of clarity, definitely (Endpoint Interview, M84). If, as Martin claims in the quote above, gaining clarity of what his goals were, was a helpful part of the therapy, it might indicate that unless there is a specific focus of the therapy from the onset, setting specific goals is not a helpful intervention in the assessment session. Goal-setting theory claims that setting specific goals aids a process of increasing motivation for goal achievement. This is not found in this case, rather, it was found that setting specific goals did not make the client more motivated towards goal achievement. In fact, having ambiguity in the wording of goals was helpful as it allowed space to explore. Conclusion: clear contradictory evidence. 4.3.3 Theoretical Proposition 3. Monitoring Goal Progress Will Improve Goal Performance When discussing goal progress it appears that in this case there was a lack of clarity in what goal achievement entailed. This put the validity of goal monitoring in question. How can one monitor progress towards goals unless there is clarity on goal achievement? There are points in 83 the therapy where Martin and Amber disagreed on Martin’s scores on the Goals Form, and it became clear that Martin did not find his goals easily measurable. Martin: I think the goals are a good way to start but I don’t think you should preoccupy yourself by having them, unless the goal is something like, something definitive like I want to learn how to juggle, which you can easily measure. You know, number seven, I now know how to juggle…I feel like it depends on what your goal is and very much depends on how you can measure it (Endpoint Interview, M53). In this quote Martin indicates that unless goals are measurable, one might not need to have them and that he did not find his goals easy to measure. An unexpected finding of this study was that Martin’s scores on the Goals Form continued to improve regardless of whether the goals were the explicit focus of the work or not. One possible explanation for this was uncovered in the endpoint interview, when Martin was asked about monitoring his goals: Interviewer: So that was helpful in that sense, how about rating these three goals every week, do you think that’s… what did that do? Martin: I think it was helpful just to see the progress made about the goals, maybe what the other issues are causing me to make progress, how they, how they’re affecting by association the other goals, so me working on this issue that isn’t written down as a goal, in the last week, how has that impacted my, subconsciously how has that made me feel better about the other three things perhaps, so maybe it was a good way to see, measure that (Endpoint Interview, M55). In the extract above it appears that what the Goals Form was actually measuring was how other issues discussed in the therapy subconsciously affected the explicitly stated goals. It appears that there was a direction of the therapy, not related to the goals work, and there is synergy between 84 this direction and the explicitly recorded goals. Meaning that progressing towards his more implicit goals that were interwoven into the organic direction of therapy, also made him progress towards the explicitly stated therapy goals. In the quote above Martin was stating that the Goals Form scores are picking up something about the interaction between the goal progression and the other issues that come up in the work. This finding differs from goal-setting theory’s claim about monitoring progress towards goals helping clients reach goals. It appears that in psychotherapy, this process might be more complex. The goals might not be the most important part of the work, however, there could be an interaction, as in this case, between an implicit direction of therapy and the explicit goals. Therefore, measuring goal progress might pick up something about the interaction between implicit direction and explicit goals, rather than be a direct reflection of goal progress. This might be a similar process to how weekly standardised measures of anxiety and depression might pick up how progress on the issues discussed in therapy, affect the level of depression/anxiety. However in this case, it was a measure of how progress towards the issues discussed in therapy might affect progress towards the explicitly recorded goals. In this way, the Goals Form might offer something slightly different than originally intended. It might offer a way of tracking more general goals that the client set, and how the more specific issues worked on in therapy might affect these goals. As stated above, Martin reports that goal achievement was not his main concern with his goals, in fact, he did not wish to completely achieve his goals, for this reason, monitoring goal progress was unlikely to improve performance. This makes the effects of goal tracking difficult to assess. It was meaningful to work on the explicitly stated goals, but rather than working towards them in a linear way where there was an endpoint, they were treated as focus points to explore. The data showed that because there were implicit directions of the therapy and ambiguity in what goal achievement would entail, the process of goal tracking in psychotherapy might be more complex than in business psychology. In business psychology goals are more likely to be 85 quantifiable, making them easier to track. Not being clear on what goal achievement would entail puts into question the validity of goal tracking. Conclusion: insufficient evidence 4.3.4 Theoretical Proposition 4. Goal Commitment Will Improve Goal Motivation and Performance Goal-setting theory states that goal commitment is a key factor in motivation towards goal achievement. In this case, the analysis found some evidence that Martin’s commitment to his therapy goals decreased as therapy progressed because the focus on the goals continually decreased. The analysis also revealed that it was Amber, rather than Martin, who most frequently initiated goal discussion in the therapy. Martin stated that he did not see the explicitly stated goals as his priority, the following extract is taken from the endpoint interview when Martin is asked about his goals: Interviewer: ‘So they kind of became side tracked?’ Martin: ‘Yeah, they were just things on the side to kind of remember to keep them in your mind, but don’t make them priority unless they became priority again’ (Endpoint Interview, M60). Although Martin did not see his goals as the main priority for the therapeutic work, he did progress towards them, however, he did not achieve them completely (he never scores seven ‘completely achieved’ on the Goals Form). There was insufficient data to establish whether his progress was due to his commitment, or his lack of achievement was due to lack of commitment. Conclusion: insufficient evidence. 4.3.5 Theoretical Proposition 5: Goal Meaningfulness Moderates the Relationship Between Goal Progression/Achievement and Affect Progressing towards the meaningful goals appear to bring about different feelings and change within Martin. In the first session, when asked about his overall mood, Martin linked an improvement in his mood to thinking less about his grandmother, after having had the space to 86 discuss her in the assessment session. And so, it appears that very early in the work, when Martin considered Goal 1 as meaningful, goal progress was correlated with positive affect as suggested by this theoretical proposition. In terms of goal 2, when he arrived for therapy his outlook on the future was quite depressive, and through the course of therapy his anxieties about the future lessen, and he reported feeling excitement for his future, rather than ‘dread’. As Goal 2 was considered meaningful, these findings support this proposition. In terms of Goal 3, Martin and Amber did not explicitly think about why motivation has been decreasing as outlined by this goal, however, they do pick up on his motivation increasing, both for his university work, applying for internships, and going to the gym: Martin: … pretty much in a long time I’ve finished all but one of my essays. Amber: Fantastic! Martin: Yeah, and you know, ehm I’m still going to the gym regularly and I’m still doing… I’m not kind of being lethargic and sitting around indoors and kind of going, I’m kind of embracing it and going out and doing things (Session 17, M6). Although this goal was rarely the explicit focus of the therapy, there appear to be progression towards it and this progression does appear to correlate with an overall improvement in his mood. There was a quantitative correlation between progression towards the goals on the Goals Form and general outcome measures improving which might give an indication of affect. If the goals were considered meaningful in the beginning of the work, then progression towards them did correlate with an overall decrease in depressive and anxiety symptoms. However, this correlation does not mean causation. Martin claimed that the goals served a purpose at the beginning of the work, however, as therapy progressed the goals did not reflect the most meaningful parts of the therapeutic work: 87 Martin: I feel like they’re good to kind of have as a outlier, and aim for something at the beginning but I don’t think you should have your heart set on them, I think that’s something to maybe just to get the ball rolling and to get you talking to whoever your therapist is, just so you can unwind things, because actually that what… the three goals there weren’t my biggest issue, they were just things that I felt were my issue, because my biggest issue was my relationship at the time and just my overall unhappiness, erm and related to that, and my degree which my three goals were not related to (Endpoint Interview, M52). As the scores plateaued on the Goals Form (around session 17), his scores on the PHQ-9 and GAD-9 continue to improve. If the goals are not meaningful at this point, then increase in wellbeing and lack of goal progression does not contradict this proposition. Decrease on his scores on the outcome measures might be a direct indication of affect, but could give an indication of how he might have been feeling in terms of his depression and anxiety symptoms. It is difficult to say with absolute certainty whether it was the progression towards his goals that lead to Martin’s improved affect and whether goal meaningfulness moderated this. The analysis revealed that a lot of the therapeutic change Martin demonstrated, could be linked to his goals in some way and there is a sense of wellbeing and satisfaction as he progressed towards his goals. It could be argued, based on the data, that this proposition has the potential to be even more true in psychotherapy than in business psychology because the goals are more emotive. The data indicates it might be difficult to capture the feeling that progressing towards his goals bring up for Martin as they were complex. However, there was some indication that goal meaningfulness did moderate the relationship between goal progress and affect. Conclusion: limited supportive evidence. 88 4.3.6 Theoretical proposition 6. Situational Constraints Might Hinder Goal Progression/Achievement In goal orientated psychotherapy it is important to be aware of the external factors that might impact the goals work (Law, 2018). Situations outside of therapy might affect a client’s relationship with or ability to work towards the goals that have been set. There were significant situational constraints to reaching Goal 2 and 3, most notably Martin’s relationship to his partner which he felt was draining all his energy from pursuing other goals. When asked about his goals in session 17, Martin says: Martin: I feel like the biggest kind of thing that would have been the issue that made it or the biggest kind of thing that was preventing me from just kind of pursuing my own interest or doing anything was when I was with James (partner, name changed). It would appear that clearing the way for goal pursuits might have been a therapeutic intervention in itself. This is relevant to clinical practice where goals are set because it might be helpful to consider and discuss within the therapy the constraints to goal pursuit. Conclusion: clear supportive evidence. 5 Discussion The goal of this chapter is to discuss the findings and how they relate to previous literature, starting with a discussion of the findings from each theoretical proposition in turn, followed by a discussion of alternative theoretical frameworks that might explain the findings. It will then discuss the limitations of the study and outline the potential implications for clinical practice based on the findings. Finally it will make suggestions for future research, situate the findings in a counselling psychology context and offer a reflexive statement, followed by a conclusion. 89 5.1 Theoretical Proposition 1: Setting High Goals Will Increase Goal Motivation and Aid Goal Progress Although there was limited evidence of applicability from previous literature of this theoretical proposition to psychotherapy, there is a robust evidence base for difficult goals having a motivating effect in organisational settings. It was therefore surprising to find contradictory evidence for this theoretical proposition. This is the first study that specifically investigated the effects of goal difficulty level in psychotherapy. Previous research has found that psychotherapy clients preferred to break down hard goals into manageable tasks that were easier to achieve. This was motivating because the goal did not feel overwhelming (Di Malta et al., 2019). What the current study adds to these findings is that psychotherapy goals might be more helpful if they are formulated from the outset as easy goals that still feel important to the client. The data also revealed that it was helpful to not feel pressure to achieve goals. High goals might create a feeling of having to achieve something difficult, which studies in organisational psychology have consistently found to be motivating. However, findings from the current study indicates that this effect might not occur in psychotherapy because some psychotherapy clients might value having time to explore their goals and what they mean to them, rather than feeling pressure to achieve them. 5.2 Theoretical Proposition 2: Setting Specific Goals Will Increase Goal Motivation and Aid Goal Progress Several key psychotherapy texts advocate for the potential benefits of setting specific goals (Cooper & Law, 2018b; Kennerley et al., 2017; Law & Jacob, 2013), and so it was surprising to find that the data in this case indicated the opposite: that goals being un-specific helped the client figure out what he wanted. An interesting finding in the coding of this theoretical proposition was that setting specific goals might be a therapeutic intervention in itself. Previous research has also indicated that goal-oriented practice can help clients clarify what they want to achieve (Di Malta et al., 2019). The current study compliments these findings, adding that this process might take 90 several sessions. This finding is consistent with other case study reports of goal-oriented practice where clients have reported that explicit psychotherapy goals have grown more specific over time as the clients have explored what really matters to them (Hawley et al., 2020). It appears that the motivating effect of specific hard goals does not apply if this specificity is embedded in the goals set at assessment. Goal specificity might be a helpful aim over the trajectory of a number of sessions as some clients might value having time to explore what their goals are. 5.3 Theoretical Proposition 3: Monitoring Goal Progress Will Improve Goal Performance The findings of the effects of goal monitoring were complex. There is a robust evidence base for goal-setting theory’s proposition that monitoring goals will help people reach their goals. In business psychology, goals are more likely to be numerical, making the tracking process clearer. Whereas this case indicated that, in psychotherapy, definition and agreement on goal achievement requires more consideration. Martin’s relationship with his goals were complex and at times he did not want to achieve them, so tracking progress was unlikely to be a motivating factor. Progression on the Goals Form did, at times, reflect an interaction between the issues worked on in therapy (not the explicitly stated goals) and how this affected the explicitly stated goals. Goal-setting theory claims that goals can be in the ‘periphery of consciousness’ that guide and give meaning to the person’s actions (Locke & Latham, 2006). However, this is discussed in the context in goals that have been consciously set and then forgotten, or goals that are primed (such as showing participants an image) (Itzchakov & Latham, 2020; Stajkovic et al., 2006). In the current study, there were goals that were neither primed nor forgotten, but rather at the edge of awareness (such as leaving his relationship) that might affect a person’s motivation and goal progress depending on synergies between the direction and the explicitly stated goals. This means that as Martin worked through his feelings towards his relationship, this also made him progress towards his explicit therapy goals. In terms of goal progress monitoring, this meant that the goal-based 91 outcome tool might have measured something different than a clear reflection of goal progress. If there is synergy between the direction of the therapy and the explicitly stated goals, the goals might not have to be in focus in order for the scores on the goal-based tools to improve. Based on this, it might be useful to consider the way in which goal-based tools are used in therapy and what the scores might mean. For example, it might be more helpful for the explicitly stated therapy goals to reflect a general direction that the client wishes the therapy to take. This would mean that the form would measure how the different issues worked on in therapy might impact the desired general direction of therapy. 5.4 Theoretical Proposition 4: Goal Commitment Will Improve Goal Motivation and Performance As there was no explicit dialogue or measure of goal commitment it was difficult draw any certain conclusions about this proposition. Previous literature claims that being committed to one’s goals is associated with greater positive affect (Emmons, 1986), however, this was not found in this case. In fact, it appears that the scores on the generalised outcome measures continue improving, even as goal commitment appears low. Perhaps this could be explained by the fact that Martin was progressing overall, however, the progress was not necessarily always linked to the explicit psychotherapy goals. This begs the question of whether goals are useful in therapy if there is a lack of commitment to that goal? There was not enough evidence in this case to distinguish whether this proposition was applicable to psychotherapy. 5.5 Theoretical Proposition 5: Goal Meaningfulness Moderates the Relationship Between Goal Progression/Achievement and Affect Psychotherapy goals are likely to be more personal than organisational goals and thus more emotive. Goal-setting theory discusses goal progression/achievement as likely to trigger positive feelings, such as satisfaction. It appears from the findings in the current case that the emotive 92 change when progression towards goals might be more prominent in psychotherapy, however, this includes a wider range of emotions than discussed by goal-setting theory. For example, progression towards Goal 2 meant that Martin had a different outlook on his future: ‘excitement instead of dread’. This differs from the literature on emotions in goal pursuit as discussed by goal-setting theory which mostly describe a feeling of satisfaction when progressing towards a goal. Goal-setting theory appears too simplistic for the complex emotions and processes that might occur in goal-progression in psychotherapy. Martin wanted to progress towards his goals in the beginning, however, as the therapy progressed it became apparent that he did not want to completely reach his goals. This was especially in the case of Goal 1, as his perception of goal achievement meant not missing his grandmother. Progressing towards such a goal, although meaningful, might not just bring about a ‘feeling of satisfaction’, as discussed by goal-setting theory, but rather, a hesitation or internal conflict. Previous literature suggests that goals should be intrinsically motivated and important to the client in order for progression/achievement to lead to improved wellbeing (Cooper, 2019). The current study supports these findings and adds that goal meaningfulness is not a static value that can be established when the goal is set, and then assumed to be consistent throughout treatment. Instead, whether the goal is meaningful should be continually revisited as the therapy progress as what is meaningful to the client might change over time. 5.6 Theoretical Proposition 6: Situational Constraints Might Hinder Goal Progression/Achievement Previous literature has indicated that situational constraints hinder goal pursuit which was also found in the current study. Martin names his relationship as a constraint from pursuing his goals. Removing this constraint (leaving his relationship) was meaningful to Martin’s overall wellbeing and made him able to pursue other things in his life. This might mean that removing situational constraints that keep clients from goal pursuit might be a valuable therapeutic 93 intervention in itself. Goal-setting theory explains these findings to the degree that situational constraints might hinder goal pursuit. The current findings add that, in psychotherapy, thinking about situational constraints is a valuable exercise and might even be more meaningful to the client than the goal pursuit. Removing what was constraining Martin from his goal pursuit, freed him up to pursue other life goals as well as psychotherapy goals. 5.7 Alternative Theoretical Frameworks Goal-setting theory makes interesting propositions about goal mechanisms based on a robust general evidence base and some of these mechanisms were found in the current study. However, the theory fails to account for some of the goal mechanisms which occurred that were slightly more complex. This begs the question, are there other theoretical frameworks that might better explain the findings and thus be more appropriate to apply to goal-oriented psychotherapy? The next section addresses this question. 5.7.1 Directional Arc Cooper (2019) suggests a directional arc with a phase model of directionality. This model was developed for psychotherapy and might explain the goal-mechanisms found in the current study. When coding data for the effects of tracking goals on goal achievement, what kept appearing concerned directionality of therapy and synergy between implicit and explicit goals. Cooper (2019) argues that people can have different goals they pursue at the same time. These goals can have synergy, where one goal facilitates the progress towards another goal, or have dysergy, where progress towards one goal interferes with the progression towards another. He also argues that goals are sometimes unconscious. The directional arc would account for the findings of the scores on the Goals Form indicating an interaction between the conscious and explicit psychotherapy goals and the unconscious directionality of therapy because it discusses unconscious directions and synergy/dysergy between goals. 94 Martin was not completely aware of his goals at the time the goals were recorded which led to the goals being less meaningful. Cooper’s directional arc suggests different phases which leads people towards their goals (emergence, awareness, evaluation, intention, planning, action, feedback, and termination). The directional arc framework might claim that when asked about his goals in the assessment, Martin was still in the emergence phase where his goals were not completely conscious and setting goals therefore became less collaborative. The directional arc might offer terminology that better explain some of the findings in the current study as it acknowledges unconscious goals, synergy/dysergy between goals, and the different phases of goal pursuits. 5.7.2 Goal-Focused Positive Psychotherapy Another attempt at theorising goal-oriented psychotherapy is the recently developed goal-focused positive therapy model which integrates goals work within positive psychology with humanistic, positive, and existential approaches (Conoley & Scheel, 2018; Winter Plumb et al., 2019). The theory claims that clients thrive when pursuing intrinsically motivated approach goals and the therapeutic adaptation of this framework involves formulating meaningful approach goals with clients (Hawley et al., 2020). Research on goal-mechanisms within goal-focused positive psychotherapy has found formulating goals as an ongoing process as meaningful and time-consuming. Interestingly, it has also been found when working within this theoretical framework that clients’ goals grew more specific over time (Hawley et al., 2020). This might explain the finding in the current study that goal specificity was not helpful because goals were set at the onset of therapy and Martin preferred that they were ‘ambiguous.’ If applying the goal-focused positive theoretical framework there might have been more dynamic relationships with the goals where they could be fine-tuned over time allowing Martin adequate time to formulate goals that were more specific to his most prominent issues. Goal-focused positive therapy also assumes that there might be goals underlying the explicitly stated goals (Hawley et al., 2020). If Goal 2 (future 95 worries) had been explored in terms of underlying goals, they might have picked up that Martin’s anxiety about his future was manifested in feeling stuck in his current relationship and re-phrased the goal to reflect this. Goal-focused positive therapy also claims that clients should be committed to their goals. Had goal-commitment been explored it might have been brought into awareness that there was a lack thereof and thus the goals-work might have been more fruitful because it had reflected the most meaningful change. The two theoretical frameworks mentioned above are both explicitly named as being applicable to psychotherapy. They both attempt to explain complex goal-processes which might occur when setting goals in therapy and, it could be argued that they offer explanations that better explain some of the goal-mechanisms that have been found in this study. When grounding goal-oriented practices in theoretical frameworks, it is important that these are suitable for psychotherapy. The theories mentioned above are still in their infancy and the evidence of applicability to psychotherapy is still scarce, but the current study indicates that they might be able to offer explanations for goal-processes specific to goal-oriented psychotherapy. 5.8 Limitations The researcher’s lack of contact with the participants (Martin and Amber) meant that opportunities to ask follow-up questions or explore certain issues in the interviews were lost. Qualitative research values the researcher’s personal impressions, these can be recorded and analysed when in face-to-face interactions with participants and offer some insights into what might have occurred in the room. The removal of the researcher in this study from the participants made this difficult. Considering this limitation, a reflexive research journal was kept throughout the project where impressions of what was happening between Martin and Amber were recorded. Verbal cues and silences within the sessions were also transcribed to ensure the interactions were captured as accurately as possible. Although the removal from the participants might create some 96 limitations, it also added some value to have naturalistic data where the therapeutic processes unfolded with minimal influence by a researcher. As data were collected from a wider research project, the interview schedule was not tailored to the research question for the current study and therefore some areas were not explored that would have been useful. There were also no interviews with the therapist, which meant there is a lack of Amber’s perspective on the goal-processes. As the current study adopted a case study method, there needs to be caution when making generalisations based on the findings. Rather than generalising, the aim was to test the applicability of a theory on in-depth case material. One limitation of case study research is that findings might be due to unique client factors and contexts and the application of the findings in the current study to other cases is still untested. Another limitation was that the study only represents one way of doing goal-oriented practice, there are many. Therefore, the findings from the current study might not be applicable to all goal-oriented practices, some of which might be embedded in a theoretical psychotherapy framework such as CBT, differing from the current therapy structure. What the current study can add is observations about goal-processes that might be worth considering for best practice when adding goals work to different theoretical frameworks. 5.9 Implications For Clinical Practice and What the Findings Add to Existing Guidelines Currently, no official evidence-based guidelines to goal-oriented practice has been published, however, several well researched publications exists that make helpful recommendations for best practice including Cooper and Law (2018b) and Law and Jacob (2013) (the latter publication focuses on working with young people). Although the current research used a single case method, it made certain observations about goal-oriented practice that might be applicable to other cases. The next section will outline clinical recommendations based on the 97 findings and discuss how these recommendations fit, or not, with the existing literature on best clinical practice for working with goals. 5.9.1 Set Goals Later in Therapy Several publications on working with goals suggests that goals should be the starting point for therapy (Law, 2018) and should ideally be formulated within the first three sessions (Cooper, 2015; Law & Jacob, 2013). Findings from the current study suggests that some clients might not know what their goals are upon entering therapy, therefore it might be helpful to set goals later in the work in order for the goals to best reflect the most important issue for the client, which might need some exploration. Setting goals early might risk some clients not feeling committed to the goals. This underlines Law and Jacob (2013) recommendation that therapy goals need to be owned by the client. Some clients also need to trust their therapist in order to raise their most important issues by the time the goals are set. 5.9.2 Engage in Specific Discussions About Goals Many publications on goal-oriented psychotherapy emphasise the benefits of collaborative goals work and shared decision making around goals (Cooper, 2015; Dryden, 2018; Law, 2018; Law & Jacob, 2013; Tryon, 2018). However, this study points out that with some clients, much of the goal-dialogue might be needed after the goals are set. Specifically, ensuring an understanding of what achievement means and whether this continues to be desirable for the client. It is also recommended to discuss which feelings goal progression/achievement brings up for the client and whether the goals reflect their most important issues. This is important to keep in mind when working with different goal-based outcome tools such as the Goals Form. These tools can be helpful in a myriad of ways (such as ensuring there is agreement on goals, creating clarity, and being an individualised way of measuring meaningful progress), however, these tools need to be used in conjunction with ongoing goal-based discussions. 98 5.9.3 Therapy Goals Can Be Non-Specific It is often stated that goals are most helpful if they are specific, and that setting SMART goals (specific, measurable, achievable, realistic, and time-bound) might be useful in psychotherapy (Hanley et al., 2015; Law & Jacob, 2013). However, the current study found that it was useful that the goals were ‘ambiguous’. This might allow clients to explore what they want, whereas if the focus becomes too narrow, it can feel restrictive for some clients. 5.9.4 Goals are Most Helpful When They Reflect the General Direction of Therapy If the therapist or client notices that the goals do not reflect the organic direction the therapy, the goals might need to be re-visited and potentially changed. It could be that clients have a pressing issue they want to address before returning to the goals, however, if the focus of the therapy is consistently not reflected the explicit goals, they might need to be reconsidered. 5.9.5 Have a Flexible Structure Related to the point above, it is important to be flexible when working with goals. This has been noted by previous qualitative research on goal-oriented practice (Di Malta et al., 2019) and is re-iterated by the findings here. It might be useful to be open to changing the goals if it is felt that they are no longer meaningful or reflect the issues the client wants to work on. 5.9.6 Consider Situational Constraints Situational constraints to reaching goals is less discussed in psychotherapeutic literature, but the findings suggest these are important to consider. This might involve discussing the therapeutic frame that best supports the client to reach their goals (for examples meeting more than once a week). It was also found that removing situational constraints was a therapeutic intervention in itself. Clients might have external issues that prevents them from pursuing therapy goals and so discussing situational constraints and helpful ways to remove these is recommended. 99 5.9.7 Be Open to Not Working with Goals Some clients might not benefit from working with goals, or ‘goal’ might feel like the wrong terminology. Consider clients circumstances, history, and preferences when deciding whether to work with goals. For example, clients diagnosed with depression a in the current case might find it difficult to envision a positive future and therefore setting goals might not be the ideal starting point. For some clients, categorising difficulties into goals might take away from seeing their story in a more wholistic and integrated way. Therefore therapists need to be open to not working with goals with all clients. It is also important when working with clients who want to set goals, to be open to not working with the goals for some sessions, depending on the client’s most pressing issue. 5.10 Suggestions for Further Research To develop reliability of the findings, another theory-building case study should be carried out, testing the findings against another case. This would be in-line with the guidelines for theory-building case study research (McLeod, 2010). There was not enough data in this case to draw conclusions about some of the theoretical propositions. It could be valuable to test these again with more appropriate data. For example, testing the effects of goal commitment. As other theoretical frameworks are being suggested to underpin goal-oriented practice, these need to be tested looking at in-depth goal processes in psychotherapy. For example a theory-building case study which codes data identifying the different phases of the directional arc, to see whether this theory holds up in goal-oriented psychotherapy. Theory-building case study research is a relatively unusual methodology which can offer a way of testing the extension of theories into other disciplines. Making generalisations from this type of research is challenging and the aim is therefore to discuss the application of theory, rather than directly generalising the findings. As pointed out in the literature review submitted for publication (Appendix E), many different analytic strategies are adopted when carrying out such 100 research and examples of clear and consistent process are scarce. This can pose a challenge to this type of research, however, as the paper (Appendix E) argues, theory-building case studies also offer a unique way of doing research which marries well with counselling psychology as it offers the possibility to work with richness and depth of data as well as theory application. In the current study, most of the insights into Martin’s goal processes and feelings towards working with goals were discovered in the interviews. These were conducted by a researcher post session four and at endpoint. For future research on clinical processes, interviews with clients might add a valuable contribution to session recordings. 5.11 Situating the Current Study Within the Counselling Psychology Context The current study raises questions about theory application to cases where the theory might not account for the details of the case or where theory falls short of helping the therapy forward. As has been pointed out in the literature, the relationship and the ability for true cooperation might indeed be more important than theory (Hanley et al., 2011). Counselling psychology has a long history of developing theory and practice based on cases (McLeod, 2010). Sigmund Freud used detailed clinical cases to develop his theory of psychoanalysis, Carl Rogers published transcripts of some of his cases and more recently, as discussed in this thesis, Stiles and colleagues have used case material to develop the theory of assimilation model for therapeutic change(Stiles, 2001). Psychotherapists are inevitably concerned with cases and systematic case study research offers a rich picture of what really happens in different therapies which can be used to further develop theory. Historically, there has been a trend in psychology and psychotherapy to place higher on value large scale randomised control studies which might reveal links between causal factors and outcomes (McLeod, 2010), than qualitative studies and case studies. However, this begs the question of what the experiences of many can say about the experience of one? It could be argued that therapy will never be an exact science and 101 will always be dependent on the unique therapeutic dyad, client and therapist factors, history, context, preferences etc. These factors can all be discussed in their complexities within case study reports. The current study does not argue for a hierarchy of evidence in psychotherapy where case studies are valued higher than other methodologies, but rather, for methodological pluralism (Hanley et al., 2011) where case studies can complement larger scale studies, offering detailed descriptions of context and process that might be missed otherwise. Goal-setting theory provides a rich evidence-based framework to understand goal processes, however, within counselling psychology it is also important to note individual differences/perspectives/contexts of clients. This might mean that one theory does not fit all cases. It appears that there are some differences in meanings between organisational psychology and counselling psychology which needs to be considered when applying goal-setting theory in a psychotherapy setting. The current study is clinically relevant and makes suggestions based on the findings to sensitise counselling psychologists and psychotherapists towards the complexities of goal-oriented practice. This study adds to the literature on goal-oriented psychotherapy, a practice that is in-line with the counselling psychology values of client engagement and empowerment. 5.12 Reflexivity Reflecting on the research journey, the most valuable experience has been the cooperation with other researchers such as learning from supervisors, as well as joining research groups. I had the priveledge to be invited to an international monthly ‘goals in therapy special interest research group’ with prominent figures in the field. Presenting the current study to this group provided me with valuable feedback on the project and helped me gain confidence to hopefully submit the research to be presented at future conferences, such as the international pluralistic therapy conference. This group also allowed me to engage with cutting-edge research within goals in therapy and collaborate with others with similar research interests. 102 The theory building case study group helped illuminate the different ways of doing and writing up this type of research. Engaging in discussion about theory building case studies highlighted the nuances and diversity of this methodology, not as challenges, but as opportunities for creativity and for creating clarity through systematic engagement in terms of conducting a literature review (see appendix G). In the future, I hope to continue to engage and conduct research and cooperate with other researchers will be my greatest motivator to do so. In addition, as I have a passion for case study research, I would hope to engage in research with clients where they take an active part in informing the research process. Were I to do this research project again, I would have made the client a co-researcher where preliminary findings would have been checked with him to ensure they represented his lived experience of the therapy. I became interested in goal-oriented psychotherapy because I connected with the stance that clients should be in charge of defining what meaningful change meant to them. After having completed the research journey, I have a more complex view of working with goals. Although I can see the value for some clients in this approach, I also keep an open mind and flexible structure in my clinical work where the clients take the lead. This means, in part, that rather than asking clients what their goals are, I assess whether they want to work with goals and when it might be helpful to set goals, if at all. I am more sensitive to the complexities of clients’ wishes, dreams, goals, and directions and how these might not always be conscious. Through doing this research project I am also more aware of the application of theory and where theory might fall short of describing clients and where theory might or might not be helpful. It has also made me see theory as a potentially helpful tool, rather than an explanation for what is going on. I believe that all people are, as Cooper (2019) writes, ‘on the way to somewhere’ (p. 18) and that if therapy can align itself with the direction that clients want their life to go, it can offer the most meaningful change. 103 6 Conclusion The current study is the first to look in-depth at goal processes in psychotherapy and more specifically, to investigate goal-setting theory in a psychotherapy setting. The findings indicate that the main proposition in goal-setting theory - that setting high and specific goals will improve goal performance - might not be the case in psychotherapy. However, the importance of goal meaningfulness to moderate the relationship between goal progression and affect was found to be the case in the current study. Goal-setting theory also offers a focus on situational constraints to goal pursuits which psychotherapy literature fail to address and was found to be relevant in the current study. Other theoretical frameworks are being developed that might better address goal processes that are specific to psychotherapy. Psychotherapy literature occasionally draws on goal-setting theory when using goal-oriented practice. It is helpful to have a theoretical basis for this work and goal-setting theory does offer some propositions based on a robust evidence base that might add to goal-oriented psychotherapy. 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Goal consensus and collaboration. Psychotherapy: Theory, Research, Practice, Training, 38, 385-389. https://doi.org/10.1037/0033-3204.38.4.385 Tryon, G. S., & Winograd, G. (2011). Goal consensus and collaboration. Psychotherapy, 48(1), 50-57. Uhl-Bien, M., & Graen, G. B. (1998). INDIVIDUAL SELF-MANAGEMENT: ANALYSIS OF PROFESSIONALS' SELF-MANAGING ACTIVITIES IN FUNCTIONAL AND CROSS-FUNCTIONAL WORK TEAMS. Academy of Management Journal, 41(3), 340-350. https://doi.org/10.2307/256912 Wallace, S. G., & Etkin, J. (2017). How Goal Specificity Shapes Motivation: A Reference Points Perspective. Journal of Consumer Research, 44(5), 1033-1051. https://doi.org/10.1093/jcr/ucx082 Wang, W., Li, J., Sun, G., Cheng, Z., & Zhang, X.-A. (2017). Achievement goals and life satisfaction: the mediating role of perception of successful agency and the moderating 120 role of emotion reappraisal. Psicologia: Reflexão e Crítica, 30(1). https://doi.org/10.1186/s41155-017-0078-4 Wiese, B., & Freund, A. (2005). 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The authentic personality: A theoretical and empirical conceptualization and the development of the Authenticity Scale. Journal of Counseling Psychology, 55, 385-399. https://doi.org/10.1037/0022-0167.55.3.385 Zaleski, Z. (1987). Behavioral Effects of Self-Set Goals for Different Time Ranges. International Journal of Psychology, 22(1), 17-38. https://doi.org/10.1080/00207598708246765 122 8 Appendices A) Goals Form (Including Instructions) Goals Form Guidance on use Mick Cooper, University of Roehampton mick.cooper@roehampton.ac.uk 12th April 2018 The Goals Form is a simple, personalised tool that can be used to set goals in counselling and psychotherapy, and to monitor clients’ progress towards them. Therapy goals Therapeutic goals can be understood as projected states of affair that clients hope to achieve through participating in therapy. It refers to what clients want to get out of therapy (e.g., ‘Not worry what others think about me’, ‘Have close relationships in my life’) rather than how they want therapy, itself, to be (e.g., ‘Feel valued by the therapist’, ‘Talk about my problems’). Goals may be specific (e.g., ‘I want to lose two stone’) or more amorphous (e.g., ‘I want to feel better about myself as a person’). It is the direction that clients want to travel in through the therapeutic process. Some clients (and therapists) do not like the term ‘goals’. It may be perceived as being too ‘success-oriented’, too rigid, or too focused on outcomes rather than the process of change. Here, it is quite acceptable to use alternate terms for directions in life, such as ‘aims’, ‘wants’, or ‘hopes’. As always, the priority is to engage with clients in ways that are meaningful and helpful to them. The value of goal setting and monitoring Within the psychological literature, there is robust evidence that people—in general—are more likely to get to their goals if they set, and record their progress, towards them. Within the counselling and psychotherapy field, there is also some evidence that goal setting may have a positive effect on treatment outcomes, and that clients find this a helpful process—including through the use of the Goals Form. In one study, for instance, clients gave the Goals Form an average rating of 4.1 on a 1 (very unhelpful) to 5 (very helpful) scale. Additionally, a recent survey found that approximately 60% of laypeople would like specific goals to be set in therapy; with 20% not wanting this, and 20% not minding. There is also evidence that agreement between client and therapist on the goals of therapy is associated with positive outcomes. Within the psychological field, goal setting and monitoring has been hypothesized to enhance outcomes through directing the individual’s attention to the identified goal, mobilizing effort, supporting persistence, and motivating people to develop strategies for their attainment. These effects have also been found in the mental health field; with evidence that it may also help to establish realistic expectations of therapy, facilitate insight, provide a safe and predictable structure for therapy, increase cooperation between therapists and clients, and support clients to see the progress that they are making. In addition, it has been argued that goal oriented practices may increase clients’ feelings of hope and empowerment, by “constructing” them as agentic, 123 intelligible beings, with the potential to act upon their worlds. Goal oriented practices in psychotherapy may also have an ethical imperative. McLeod and Mackrill write: [A]voidance of clarification around client goals could be regarded as an ethical breach, as it would make it impossible to know whether the direction and focus of therapy was congruent with the client’s views. That is, some kind of explicit checking-out of therapeutic goals is a necessary aspect of respect for client autonomy. The limits of goal setting and monitoring Clients may find it difficult to formulate goals, particularly at the start of therapy, and may feel ‘put on the spot’ by being asked to do so. Their self-identified goals may also not match their deeper wants and needs, or may become irrelevant over time. Consistent with this, research has suggested that explicit goal agreement is not necessarily present in the work of experienced, high alliance psychotherapists. This suggests that formal goal setting and monitoring may not be essential to establishing high levels of goal agreement. From a humanistic therapy standpoint, goal oriented practices have also been criticized for reinforcing clients’ ‘extrinsic’ desires—to achieve and ‘do’—rather than helping clients to ‘be’. In support of this, some clients may feel that they have failed if they do not progress towards their set goals; and others may feel that the concept of goals is too mechanistic or does not fit their way of being. Goal setting and monitoring, then, may have the potential to be helpful to some clients; but it cannot be assumed that all clients, at all times, will benefit from this. The Goals Form provides a means of offering clients the opportunity to set and monitor their goals, but its value will always be dependent on the preferences and context of the individual client. Research also suggests that goal setting is most helpful when it is done in a collaborative, flexible and unhurried way, with the therapist guiding and supporting the client through the process. Establishing goals Therapy goals can normally be set in a first/assessment session. However, some clients may need longer to identify meaningful goals, such that initial goal setting may not be concluded until a second or third session. Goals for therapy should be determined by clients, in collaboration with their therapists. The process should be a dialogic and iterative one. For instance, the client may give a rough idea of where they would like to get to, which the therapist then summarises, and the client then adds greater detail and nuance. It should be explained to clients that any goals can be modified, removed, or added to as the work progresses. Typically, therapists may start the goal setting process by inviting clients to describe what has brought them to therapy. This process should be given sufficient time (for instance, at least 20 minutes), and it is important that therapists develop a general, holistic sense of what their client’s current concerns are. Asking clients about their life circumstances—e.g., work, relationships and family—as well as some historical background, may help to deepen an understanding of where the client is ‘at’, and what they are wanting from therapy. Clients can also be asked more direct questions like: • ‘Where would you like to be by the end of our work together?’ • ‘What would you like to get from therapy?’ • ‘What are your goals/hopes/wants for the therapeutic process?’ • ‘What would you like to change in your life?’ 124 Based on the client’s narrative and their answers to the above questions, the therapist can begin to reflect/summarise what the client seems to be wanting from the therapeutic process. For instance, ‘It sounds like you want to feel more self-confidence, is that right?’ Therapist and client can then work together to agree specific wording for goals. Typically, clients will identify between two and five goals for therapy, though less or more is acceptable if clients show preferences in those directions. In agreeing goals for therapy, the following pointers should be borne in mind: • Clarify. Try to establish a specific sense of what the goal is. For instance, if a client says they want to be ‘happier’, you can clarify what that actually means for them (e.g., ‘Feel more energy in the mornings’). However, it is important that the goal remains broad enough to be meaningful and important for the client. • Concise. The wording of the goal should not be more than one sentence long (one or two lines of written text), so that it can fit on the Goals Form and can be easily assessed by the client. For instance, ‘Feel able to stand up to my father and tell him what I really think.’ • Single goals. Try to avoid having too many diverse goals within one goal. Ideally, each goal should represent one main thing, so it is better to separate out diverse goals. For example, ‘Feel vibrant’ (Goal 1), ‘Feel on top of things’ (Goal 2), rather than ‘Feel vibrant and on top of things’. • ‘Absolute’. Goals should be stated in ‘absolute’, rather than ‘relative’, terms. For example ‘feel happy’ rather than ‘feel happier’; ‘feel good about myself’ rather than ‘feel better about myself’. This is so that clients do not need to refer back to some reference point when rating. • Approach goals. There is some evidence to suggest that it may be better to formulate goals in approach terms (something the client wants to achieve) rather than as avoidance goals (something the client wants to get away from). For example, ‘Feel happy and at ease’ rather than ‘Feel less sad and tense.’ • Intrinsic. Research suggests that clients do better when they progress towards personally desired outcomes (e.g., ‘Be closer to friends’), rather than the standards and expectations of others (e.g., ‘Lose weight to make my boyfriend happy.’) • Achievable/realistic. There is some evidence that clients do better when their goals are achievable and realistic, rather than representing unattainably high standards. Larger goals can be broken down into smaller subgoals/substeps. Once wording is agreed, each goal can be written down on a blank Goals Form (by client or therapist). For each goal, clients should then be asked to indicate how much they currently feel they have achieved it by circling a number from 1 (Not at all achieved) to 7 (Completely achieved). They can also be asked to indicate which of the goals they would most like to prioritise/start working on. Although research indicates that most clients find it helpful to establish goals, some do not. It is therefore important to discuss with clients, before commencing a goal-setting process, whether they would like to establish goals and/or have them written down and rated on a weekly basis. There may also be times when it is inappropriate or unhelpful to focus on agreeing goals (for instance, if risks issues are present). Clinical issues should always take priority. 125 Transposing the goals onto a Goals Form Once sessions are complete, therapists should type up, or, write down clients’ goals (without ratings) onto a blank copy of the Goals Form. They should then make some copies of this personalised master form for use in subsequent sessions. Using the Goals Form At the start of each session, clients should be presented with their personalised Goals Form, and asked to spend a few moments rating how close they now feel they are to achieving each of their goals. Clients’ responses to the Goals Form may form the starting point for the therapeutic dialogue (for instance, if clients indicate that they have moved towards, or away from, particular goals; or if one goal shows much lower attainment than the others). Note: clients should not be presented with a blank Goals Form at the start of each session and asked to re-articulate their goals. Revising the Goals Form At any point in the therapy, clients or therapists may suggest that the goals on the Goals Form should be revised to more accurately represent the client’s goals for therapy. This may involve the deletion of goals, the addition of goals, or the revision of the wording of goals. Particular times this may be most likely to happen are: • When goals are achieved or no longer feel relevant to clients • At review sessions • Following completion of the Goals Form, for instance if clients note they are balking at particular goals or feels that something is missing. The client and therapist should agree revisions to the Goals Form through dialogue. A new master Goals Form of the client’s revised personalised goals should then be produced by therapists and copies made before the subsequent session, and this should then be used for following sessions. Clients are able to revise their goals as frequently as possible. However, for purposes of statistical analysis (and also, potentially, to maintain consistency in the therapeutic work), it is better if the goals stay relatively stable throughout the therapeutic work (e.g., each goal remains active for at least five sessions or so). Scoring Simple graphs can be made (for instance, on Excel) to plot changes in clients’ individual goals over time, and research suggests that many clients may find this a useful part of therapy. This is something that can be discussed with individual clients. To calculate changes over the course of therapy, for service evaluation purposes, use the following procedure: • For each client, calculate the mean score for the goals at first rating (the mean is the sum score for all of the goals divided by the number of goals). If a goal was established at the assessment meeting, this will be the assessment score; if it was established later on in the therapy, this will be the score at that time point. If goals are modified in any way, treat them as new goals. 126 • For each client, calculate the mean score for the goals at last rating. If a goal is active until the end of therapy, this will be the score in the final session. If it is deleted or modified prior to the end of therapy, this will be the last time it was rated. • Calculate the mean first score across all clients, and the mean last score across all clients. The difference between these two scores indicates how much, on average, clients have changed in your service. For evaluation reporting purposes, you can plot these scores on a graph. • Calculate an ‘effect size’ by dividing the mean amount of change by the ‘standard deviation’ of the first scores. An effect size is an indicator of the magnitude of change. An effect size of 0.2 is typically defined as ‘small’, 0.5 as ‘moderate’, and 0.8 as ‘large’. The standard deviation of the first scores can be calculated using the Excel command ‘stdev’. Example: Mean first score = 2.4, mean last score = 4.7, standard deviation of first scores = 1.5, Effect size = (4.7-2.4/1.5) = 1.53). Troubleshooting What happens if clients do not want to set goals? As indicated above, prior to any goal setting, clients should be asked if they think they might find it helpful, or not, to set goals, and monitor their goal progress on a regular basis. If clients indicate that they do not want to do this, the Goals Form should not be used. What happens if clients say they cannot think of any goals? It is always worth asking this question in a range of different ways, as above. For instance, ‘Where would you like to get to by the end of therapy?’ or ‘What would you like from our work together?’ The assumption, here, is that clients are intelligible beings who have come to therapy for a reason, and that therapists can help them reflect on—and articulate—what those reasons are. However, if clients continue to indicate that they do not know what they want from the work, it may be best to leave this question and come back to it at a later date. What happens if a goal become redundant? A client can delete this goal from their Goals Form. Should I comment on a client’s goal progress, as indicated on their Goals Form? This may not be relevant each week, but client’s ratings of goal progress can certainly be drawn on in the therapeutic work: for instance, if a client is showing steady progress towards their goals, or is struggling to achieve a particular desired outcome. Is it ok for clients to talk about things in sessions that are not related to their goals? Of course. The Goals Form provides only a rough guide to what clients want to work on, and is not intended to cover every issue and eventuality. If clients come to therapy with pressing issues that are not represented on their Goals Form, it is entirely acceptable for them to make these the focus for the session. However, if they continue to remain focal to the therapeutic work, it may be appropriate to add to, or revise, the explicitly recorded goals. Who should write the goals down? The ideal is probably that this is done by the client, so that they have most ownership over the goals. However, it is fine if this is done by the therapist, provided that the client agrees to the wording of the goal. Permission 127 The Goals Form is not copyrighted in any way and you are welcome to use the form without charge or formal permission. Please do let us know, however, about your experiences of using the form or any findings from its use. Also, if you revise the form or the procedure for its use in any way, please make this clear in any publications. Any publications or reports should also reference the original source for this form: Cooper, M. (2014). Strathclyde pluralistic protocol. London: University of Strathclyde. See www.pluralistictherapy.com Further reading Cooper, M., & McLeod, J. (2011). Pluralistic Counselling and Psychotherapy. London: Sage. Details the basic principles of using goals within a pluralistic approach to therapy. See, in particular, Chapter 3. Cooper, M., & Law, D. (Eds.). (2018). Working with goals in counselling and psychotherapy. Oxford: Oxford University. A range of practical, theoretical, and empirical chapters on goal oriented practices in counselling and psychotherapy. Goals Form Goal 1: Not at all achieved Completely achieved 1 2 3 4 5 6 7 Goal 2: Not at all achieved Completely achieved 1 2 3 4 5 6 7 Goal 3: Not at all achieved Completely achieved 1 2 3 4 5 6 7 Goal 4: Not at all achieved Completely achieved 1 2 3 4 5 6 7 Goal 5: Not at all achieved Completely achieved 1 2 3 4 5 6 7 B) Code Book from NVivo Name Description Files References Client initiated goal discussion 3 4 Depression 6 50 Explicit goal discussion Where the goals are explicitly discussed in the dialogue. E.g. ‘let’s talk about your goal of future worries’. 12 123 Partner 10 106 Goal 1 Loss Addressing loss of grandmother, including unresolved grief. Looking at the role of other losses in life including mother, stepmother. 3 6 G1a Loss of grandmother 11 79 G1b Loss of mother 2 7 G1c Loss of stepmother 2 7 G1d Other losses 3 5 Goal 2 - Future worries Addressing anxiety about own future including work and relationships. Looking at the role of anxiety about his father and grandfather. 5 10 G2a - anxiety about future 12 101 G2b - anxiety about work 8 38 130 Name Description Files References G2 - anxiety about relationships 6 22 G2d - anxiety about father 7 36 G2e - anxiety about grandfather 5 29 G2z - unspecified anxiety 4 9 G2z1 - anxiety about career 9 47 Goal 3 - Motivation Thinking about why motivation for everything in life has been decreasing recently. 6 14 G3a - decrease in motivation - explicit dialogue 8 44 G3x increase in motivation Discussion around things that make him more motivated 7 22 G3z - discussion around things that make him less motivated 4 16 Implicit goal discussion Where there is discussion that links to his goals, but it is not explicitly discussed as a 9 14 131 Name Description Files References goal. Other - not relevant to goals 5 35 Quotes for thesis 11 91 Setting up goals 6 19 Therapeutic change and helpful aspects of therapy - not linked to goals Dialogue where you can see improvements, not linked to goals. 8 56 Therapist initiated goal discussion 10 24 TP1 - specific, high goals - increased motivation and aid goal progress Setting specific, high goals will increase goal motivation and aid goal progress 1 22 Contradictive 8 40 High goals 4 6 Specific goals 6 18 Supportive 5 35 TP2 – goal monitoring – Improve goal performance Monitoring goal progress will improve goal motivation and performance 1 3 Contradictive 5 19 Feedback 2 9 132 Name Description Files References Monitoring 7 24 Supportive 4 12 TP3 - commitment to goals - more motivated Goal commitment will improve goal motivation and performance 1 1 Contradictive 6 11 Supportive 3 13 TP4 - meaningful goals - satisfaction when progressing Goal meaningfulness moderates the relationship between goal progression/achievement and affect. 1 4 Contradictive 4 9 Goals meaningful - lack of progression - dissatisfaction 0 0 Goals meaningful - progression leading to satisfaction 6 19 Supportive 6 16 TP5 - Implicit directions Implicit directions and goals that are not explicitly stated, might influence the direction of therapy. 2 8 133 Name Description Files References Contradictive 0 0 Supportive 6 48 TP6 - assigned goals Assigned goals are as effective in increasing performance as a goal that is set participatively. 2 9 Contradictive 2 6 Supportive 1 3 TP7 - situational constrains Situational constraints might hinder goal progression/achievement 0 0 Contradictive 0 0 Supportive 5 9 134 C) Interview Schedule Pluralistic Therapy for Depression Endpoint Interview Record Client code: Date: Interviewer: Helpfulness of measures record 1 = very unhelpful 2 = unhelpful 3 = neither 4 = helpful 5 = very helpful X = don’t know Patient Health Questionnaire (PHQ-9) (assm, every session, endpoint) Generalised Anxiety Disorder (GAD-7) (assm, every session, endpoint) Authenticity Scale (AS) (assm, reviews, endpoint) Goals Form (assm, every session, endpoint) C-NIP (assessment, reviews) Client Note Form (every session) Session Effectiveness Scale (every session) Alliance Negotiation Scale (ANS) (reviews, endpoint) Working Alliance Inventory (reviews, endpoint) Relational Depth Frequency Scale (RDFS) (reviews, endpoint) 135 Pluralistic Therapy for Depression Endpoint Interview Schedule (24/10/2016, adapted from Change Interview Schedule, Elliott, Slatick and Urman, 2001) Interview Strategy: This interview works best as a relatively unstructured, empathic exploration of the client’s experience of therapy, shared decision-making, and goals. It is best if you adopt an attitude of curiosity about the topics raised in the interview, using the suggested open-ended questions plus empathic understanding responses to help the client elaborate on his or her experiences. Thus, for each question, start out in a relatively unstructured manner and only impose structure as needed. For each question, a number of alternative wordings have been suggested, but keep in mind that these may not be needed. Also, keep in mind that, if clients have already covered the answer to a question earlier, they do not need to answer the question again. Ask client to provide as many details as possible; and use the ‘anything else’ probe (e.g., ‘Are there any other changes that you have noticed?’) -- inquiring in a non-demanding way until the client runs out of things to say. Remember, be willing to follow the client's story, and be curious about what they have to report, while at the same time making sure that all the questions are explored. Please remember that the interview is an opportunity for the client to reflect on their experience of therapy, and not a further therapy session. Empathic reflections should focus on the client’s experience of therapy only, and not probe further into the client’s extra-therapeutic experiences. The interviews are normally expected to last up to 90 minutes. As time is limited, it is important that the main areas of interest and concern are fully covered. These are as follows: • To ensure that the client has time to talk through any issues, concerns, questions or ‘unfinished business’ they have about the project and, if at all possible, feel that they are completing their involvement on a ‘positive note’. • To gather the quantitative endpoint data on the forms. • To find out the client’s views on what was helpful to them in the therapy (questions 5 and 6). • To find out the client’s experience of shared decision making and its impact • To find out the client’s experience of goal setting and its impact • To find out how the clients experienced the pluralistic elements of the intervention: the particular measured used, and the emphasis on meta-therapeutic communication and therapist flexibility (question 8). Materials to bring to the interview: • Audio recorder • Tablet • Paper copies of all forms not on the tablet 137 Endpoint Interview Schedule Begin by welcoming the client, introducing yourself and the structure and aims of the interview: that it is a chance to find out from them about their experience of the project, and to give them an opportunity to ask any questions and to say anything they want to. Explain your independence and that you have no knowledge and awareness of the client’s notes. Explain that you will briefly refer back to a previous answer from their first interview. Reiterate that this information is not traceable to them by their therapist. You may want to describe the rationale for the interview as follows: The main purpose of this interview is to allow you to tell us about the therapy and the research in your own words. This information will help us to understand better how the therapy works; it will also help us to improve the therapy. This interview is audio recorded for later transcription. Please provide as much detail as possible. This interview is also an opportunity for you to ask any questions or to tell us anything else you want about your involvement with the project, and please feel free to be as critical as you want, as well as positive. 1. Ask client to complete the following forms on the tablet: • PHQ-9 • GAD-7 • Goals Form • RDFS • ANS • WAI • AS Check OK to record and, if so, turn on audio recorder. 2. Changes: • What changes, if any, have you noticed in yourself since therapy started? (For example, Are you doing, feeling, or thinking differently from the way you did before? What specific ideas, if any, have you gotten from therapy so far, including ideas about yourself or other people? Have any changes been brought to your attention by other people?) • Has anything changed for the worse for you since therapy started? 3. Attributions: In general, what do you think has caused these various changes? In other words, what do you think might have brought them about? (Invite the client to include things both outside of therapy and in therapy. Please take some time on each change to help the client describe and ‘unpack’ the processes that may have brought the change about) 4. Helpful Aspects: Can you sum up what was helpful about your therapy? Please give examples. (For example, general aspects, specific events) • What were helpful things that you did in therapy? • What were helpful things that your therapist did? • What were the helpful outcomes of that? 5. Unhelpful Aspects: 138 • What kinds of things about the therapy have been unhelpful, hindering, negative or disappointing for you? (For example, general aspects, specific events) • Were there things in the therapy which were difficult or painful but still OK or perhaps helpful? What were they? • Has anything been missing from your therapy? (What would make/have made your therapy more effective or helpful?) • Was there anything you did that got in the way of your therapy? 7. Goals • Did you decide to set goals for your therapy? Why? • Was setting goals, with the Goals Form, helpful or unhelpful for you in your therapy? Why? • • Was it helpful, or not helpful, for your therapy regularly monitoring your goals? Why? • Overall, would you choose to have goals or work with goals in therapy again? 8. Review measures Show the client each of the measures/form used in the study on the tablet one-by-one, and ask them to rate each one in terms of how helpful or unhelpful they found it in terms of their change or development (e.g., did it help them reflect on their goals, did it give them a clearer sense of what they want from therapy). For each measure, invite them to explain why they rated it in that way, and what their experience was of completing it. • Patient Health Questionnaire (PHQ-9) (assm, every session, endpoint) • Generalised Anxiety Disorder (GAD-7) (assm, every session, endpoint) • Authenticity Scale (assm, reviews, last session, endpoint) • Goals Form (assm, every session, endpoint) • Therapy Personalisation Form/C-NIP (assessment, reviews) • Client Note Form (every session) • Session Effectiveness Scale (every session) • Alliance Negotiation Scale (ANS) (reviews, last session, endpoint) • Working Alliance Inventory (reviews, last session, endpoint) • Relational Depth Frequency Scale (RDFS) (reviews, last session, endpoint) 9. Suggestions. Do you have any suggestions for us, regarding the research or the therapy? Do you have anything else that you want to tell me? 10. Any further questions. Ask client if there is anything further they would like to say about the study, or anything they would like to know more about. Thank client for their participation 139 D) Cohen’s Kappa Calculation Agreement matrix Rater 1 Rater 2 TP 1 Limited contradictory evidence Limited contradictory evidence TP 2 Clear contradictory evidence Clear contradictory evidence TP 3 Insufficient evidence Limited contradictory evidence TP 4 Insufficient evidence Insufficient evidence TP 5 Limited supportive evidence Limited supportive evidence TP 6 Clear supportive evidence Clear supportive evidence Contingency table N= numbers of theoretical propositions (6) Σoij (the sum of agreed scores) = 5 Observed agreement proportion (Pa) is calculated as: Pa =Σoij 𝑁 Pa = 0.84 Expected frequencies under null hypothesis (zero agreement between raters) Sum of expected frequency of both raters by chance (Σeij) = 1.19TotalClear supportive evidence Limited supportive evidence Insufficient evidence Limited contradicotiry evidence Clear contradictory evidence Clear supportive evidence 1 0 0 0 0 1Limited supportive evidence 0 1 0 0 0 1Insufficient evidence 0 0 1 1 0 2Limited contradicotiry evidence 0 0 0 1 0 1Clear contradictory evidence 0 0 0 0 1 1Total 1 1 1 2 1 6Rater 1Rater 2TotalClear supportive evidence Limited supportive evidence Insufficient evidence Limited contradicotiry evidence Clear contradictory evidence Clear supportive evidence 0.17 0.17 0.17 0.34 0.17 1.02Limited supportive evidence 0.17 0.17 0.17 0.34 0.17 1.02Insufficient evidence 0.34 0.34 0.34 0.67 0.34 2.03Limited contradicotiry evidence 0.17 0.17 0.17 0.34 0.17 1.02Clear contradictory evidence 0.17 0.17 0.17 0.34 0.17 1.02Total 1.02 1.02 1.02 2.03 1.02 6.11Rater 2Rater 1 K =Σoij – Σeij𝑁 − Σeij K =5 – 1.196 − 1.19 Cohen’s Kappa = 0.79 142 E) Consent Form from Research Clinic for Larger Clinical Trial PARTICIPANT CONSENT FORM Pluralistic therapy for Depression: Research Clinic This study aims to develop a greater understanding of the process and outcomes of pluralistic therapy -- a collaborative, integrative therapeutic approach -- for people experiencing depression. We are particularly focused on the process of shared decision making with clients; and of identifying and progressing towards clients’ goals. For details of the study, please see Information Sheet. Investigator Contact Details: Mick Cooper Department of Psychology University of Roehampton Holybourne Avenue London SW15 4JD mick.cooper@roehampton.ac.uk 0208 392 3741 Consent Statement: I agree to take part in this research, and am aware that I am free to withdraw at any point without giving a reason, although if I do so I understand that my data might still be used in a collated form. I understand that the information I provide will be treated in confidence by the investigator and that my identity will be protected in the publication of any findings, and that data will be collected and processed in accordance with the Data Protection Act 1998 and with the University’s Data Protection Policy. I understand that, in circumstances of risk of serious harm to self or other, my referrer, or other appropriate service, may be directly contacted. I understand that data may be used for subsequent research projects and data analyses (by persons other than the present Chief Investigator) at the discretion of the Chief Investigator. Name …………………………………. Signature ……………………………… Date …………………………………… Optional 143 I give consent for audio recordings of my sessions to be used for teaching and demonstration purposes (please tick) Yes No Please note: if you have a concern about any aspect of your participation or any other queries please raise this with the investigator (or if the researcher is a student you can also contact the Director of Studies). However, if you would like to contact an independent party please contact the Head of Department Head of Department Contact Details: Dr Diane Bray Department of Psychology University of Roehampton London SW15 4JD d.bray@roehampton.ac.uk 0208-392 3627 144 F) Therapist Information Sheet from Larger Clinical Trial Pluralistic therapy for Depression (PfD) Therapist Information sheet Thank you for your interest in practising as a therapist in our Pluralistic Therapy for Depression protocol. This information sheet gives a brief overview of our protocol, what we will be asking you to do, and the information we would like to gather from your involvement in this project. What is pluralistic therapy? Pluralistic therapy starts from the assumption that different clients can be helped by therapy in different ways, and that therapists should work collaboratively with their clients to help identify the approach that works best for them. You should familiarise yourself with the pluralistic approach to therapy through reading Cooper and McLeod’s (2011) Pluralistic counselling and psychotherapy (Sage), Cooper and Dryden’s (2016) Handbook of pluralistic counselling and psychotherapy (Sage), and the Pluralistic Therapy for Depression (PfD) manual. Details of the specific kind of therapy to be offered to clients are detailed in the PfD ethical application pack and will be discussed with you at your induction. They will also be available to you to read at any point during your placement. Is there any payment? You will not be paid for delivering the therapeutic intervention and expenses, unfortunately, cannot be covered. Where will therapy take place? The therapy will take place at Parkstead House, Whitelands College, University of Roehampton. What does participation in the research involve? Pluralistic therapy for Depression draws on a wide variety of tried-and-trusted therapeutic methods for helping people feel better in their lives. Initial research shows that, on average, it is associated with reductions in symptoms of depression. However, there is still much to learn about what kinds of methods may be most helpful for particular people, and how the therapeutic approach can be tailored as effectively as possible for the individual client. For this reason, we are not only offering Pluralistic therapy for Depression, but also studying it, so that we can contribute to the development of this approach. The research component of this study means that, as a therapist, we will be asking you to complete session notes using a standardised online form, and we will also be asking you to complete some other therapy measures over the course of seeing your clients. 145 We also ask you to electronically record each of the therapy sessions using an encrypted audio recording device. The clinical component of this study requires you as a therapist to commit to a minimum of six months in the placement. It also requires you to work within the framework and guidelines specified below. In the first instance, you will be offered up to three clients to work with. Further clients may be negotiated with the Chief Investigator on a case-by-case basis. If you are still in training, it is your responsibility to ensure you meet your course requirements for supervision. The protocol offers one to one supervision at a ratio of 8:1. What are my roles and responsibilities as a therapist? Roles and responsibilities for volunteer therapist are as follows: 1. To provide pluralistically-informed psychological interventions to clients, as specified in the PfD Protocol. 2. To implement the PfD research protocols with clients, including therapist-completed measures. 3. To support clients to complete all measures -- both hand-written and through IPad/Pragmatic Tracker -- as specified in the PfD protocol. 4. To manage, save, store and organise all clients’ data as specified in the PfD Data Storage Guidelines. 5. To maintain familiarity with the PfD protocols and any updates as when approved 6. To commit a minimum of two hours per week to administrative tasks as part of the protocol, as agreed with the Clinic Coordinator. 7. To attend, wherever possible, PfD and Clinic Team meetings. 8. To attend, where advised, additional training in pluralistic therapy. 9. To participate in regular supervision, as agreed with the CC and to take responsibility for monitoring own supervision ratio requirements in liaison with supervisor and the Clinic Coordinator. 10. To follow health and safety procedures, as specified in the PfD protocol. 11. To respond to, and act on, all communications from the Crest Clinic promptly. What are the benefits and risks of participating in the research? The potential benefit of participating in this research is that it may help you develop your skills and awareness as a counselling practitioner. In particular, through the various measures we are using, you will receive extensive feedback -- both outcomes and process -- on your clinical work. The risk is that you may find some of this feedback uncomfortable or upsetting. You may also experience feelings of boredom or irritation in completing the forms. How confidential is the therapy? All therapists working within the project will be required to be in regular supervision, such that recordings of sessions or other details of the therapeutic work will be shared with supervisors, or members of a supervisory team. In addition, we ask for permission that audio recordings of the sessions can be used for teaching and demonstration purposes. Anonymised data, including transcripts from therapy sessions, responses to questionnaires and interviews, and case descriptions, may be used in full or part for published output, such as journal papers or book chapters. In these instances, every 146 effort will be made to ensure the absolute anonymity and confidentiality of clients: for instance, by altering some demographic details to disguise their identity. You may also use the data for case study submitted in partial fulfilment of their course requirements. How will data be stored and used? We will treat the data you provide us with the utmost care. It will be kept in a secure location at all times (password protected, encrypted computer file and/or locked filing cabinet). Audio recordings of sessions and interviews, as partially anonymised data, will be kept for a period of ten years before being destroyed. Transcripts of these sessions may be made, and all identifying details of the client (such as a partner’s name) will be erased. As fully anonymised data, these transcripts may then be kept for an unlimited period of time. Personal details of each therapist (name and contact details) will be stored separately from other data, and in a password protected, encrypted computer file. Data may be used for subsequent research projects and data analyses (by persons other than the present Chief Investigator) at the discretion of the Chief Investigator. Anonymised data may be kept for an unlimited period of time. Who is running the study and who can I contact? Chief investigator. The person responsible for all research processes is Mick Cooper. Mick is a Professor of Counselling Psychology at the University of Roehampton, and a chartered counselling psychologist. Mick has been in counselling practise for over 15 years, and has authored a wide range of texts on therapy, including Pluralistic counselling and psychotherapy (with John McLeod, Sage, 2011). Further questions. Any questions prior to, during, or after the investigation can be directed to Mick at mick.cooper@roehampton.ac.uk 0208-392 3741. Independent contact for the research. If you would like to contact an independent person about this research, please contact: Dr Diane Bray Department of Psychology University of Roehampton | London | SW15 4JD d.bray@roehampton.ac.uk| www.roehampton.ac.uk Tel: 0208-392 3627 Ethical approval. This project has been approved under the procedures of the University of Roehampton’s Ethics Committee on the 22nd Dec 2015 (PSYC 15/169). 147 G) Manuscript submitted for publication Theory-building case studies in counselling and psychotherapy: A critical exploration of analytic strategies and proposed guidelines Background: A theory-building case study is a scientific research methodology - a system of techniques that are employed to systematically describe and examine a case(s) to build on a theory that has accumulated within the field. However, limited guidance exists describing how to conduct theory-building case studies in counselling and psychotherapy. Aim: This paper aimed to contribute to good practice and provide further guidance on how to conduct theory-building case study research. Methodology: A systematic literature review was conducted of studies that were referred to as a ‘theory-building case study’ within counselling/psychotherapy. The results were reviewed through a consensual group process; specific analytic strategies and outcomes were identified. Findings: Results indicated no clear adherence to existing guidelines, significant variations in procedures and analysis, as well as a lack of clarity on ‘theory-building’. Discussion: While variation is an important element of this methodology, researchers might benefit from more specificity when considering analytic methods and discussing the results in the context of the theory-building/testing/confirmation/expansion. Additional suggested guidelines for researchers are proposed. Keywords: qualitative research, methodology, counselling psychology, theory-building, case study Background What are theory-building case studies? Case studies in counselling and psychotherapy are rife for epistemological, ethical, and philosophical considerations and although crucial, they are beyond the very narrow scope of 148 this paper. For those interested, we orient the reader to McLeod (2010), Stiles (2002; 2007; 2009; 2015) and McLeod, Stiles, and Levitt (2021). TBCSs differ from the more traditional clinical case studies in that their focus on the theoretical insights gleaned from case data observations (Stiles, 2005). They have been used in other fields of study such as management, information systems and human resources (see Eisenhardt, 1989) which also engage with theoretical and methodological questions (see for example Halaweh et al., 2008). TBCS are not a new concept; in its previous form, it existed as implicit knowledge without clear articulation of the process involved. One might say that the origin of psychotherapy lies in TBCS (ex: Freud), which were used to build theory by understanding the process and outcome of therapy (McLeod, 2010). Stiles (2007), and later McLeod (2010), have been explicit about the steps involved with TBCS (see figure A). In a way as clinicians, we are constantly engaged in theory-building; as Stiles (2007) highlights, that therapists are always modifying or extending theories of practice to incorporate clinical observations. TBCSs can also bridge the gap between theory and practice and be a helpful way for practitioners to accumulate and publish their experience of practice and contribute to research (Stiles, 2007). The field of case studies continues to evolve, but lacks critical appraisal; some researchers have recognised this and are working to further develop, refine, and build support for case study research (see, for example, Kaluzeviciute, 2021). McLeod (2010) suggests a series of steps for conducting TBCS aimed at identifying the key theory-building principles involved when adopting this methodology. Figure 1: Steps for conducting theory-building case studies (McLeod, 2010) 149 What is a theory and how is it built? Stiles (2009) and McLeod (2017) view theory as a set of semiotic ideas, descriptions, or observations that fit together to describe a universal phenomenon or process. Theories are seen as dynamic, changing, and grounded in a particular perspective and worldview, incomplete and fallible (Maxwell, 2021). Stiles (2009) explains three logical operations in TBCS – deduction, induction, and abduction. Theory-building begins with deduction - a set of logically consistent and connected theoretical statements. This is particularly important because it defines what the theory means and provides quality control (Stiles, 2009). Induction involves applying the observations to the theoretical statements and abduction involves modifying theoretical statements to match the observations – explaining new observations or constructing new hypotheses within the context of a theory. Modifications might include correcting previous errors in the theory, extensions to a domain, or elaborating an unappreciated aspect of theory. A TBCS must balance both theory and observation (Stiles, 2002) and, as with much qualitative research, it is an iterative process that moves back and forth between observations and theory statements until the theory is described. Although beyond the scope of this paper, epistemological and philosophical debates about what theory-building really is and considerations of issues such as, for example, the differences between theory-building or theory-enriching (Stiles, 2015) are indeed crucial. Personal research journeys The research path is rarely straightforward and often the unexpected calls for attention. The following work arose from such a call - a struggle and need for a better understanding of a methodology that we, as trainee counselling psychologists, were drawn to using in our doctoral research. All of us (PB, JG, SH, EP, FR) are at varying stages of completing our doctoral research and we are utilising a theory-building case study (TBCS) as our research methodology. As we began to delve into our data analysis, we struggled to find examples of ‘good process’ for TBCS analysis, resulting in a significant amount of work thinking about and developing appropriate analytic strategies. An overarching framework for conducting TBCSs exists 150 (Stiles, 2007; McLeod, 2010), but we were specifically interested in how to analyse our rich transcript-based data rigorously and reliably and how to approach the important theory-building element of the process. In 2020 we formed a theory-building case study group and decided to systematically investigate how researchers were conducting TBCSs in counselling and psychotherapy with the initial intention to inform our own work. We quickly discovered that TBCS methodology included a variety of ways of conducting research. Where some researchers adopted a specific analytic strategy within a TBCS methodology, others used TBCS as the only form of analysis. There was also often a lack of clarity on the outcome of the studies. If the aim of TBCS research is indeed to build on an existing theory, we discovered that this was not always the outcome reported in research using this methodology. Based on the above, if TBCS research is to have a place in counselling/psychotherapy research, it is important to identify the steps utilised by researchers who claim to adopt this methodology and suggest guidelines for TBCS research. Methodology Research group process As discussed, a research group was established to better understand how to apply the TBCS framework. We kept notes of our meetings, referencing steps of our decision-making. Throughout the process, the research team observed a collaborative approach and met fortnightly to discuss developments and reach a consensus for any steps taken. Aims and objectives This systematic literature review aimed to investigate how research that is explicitly labelled theory-building case studies have been conducted in counselling and psychotherapy research to date and provide guidelines on how to conduct TBCS. As there appeared to be large differences in the analytic strategies adopted and ‘theory-building’ elements of published TBCS papers, the current review had a particular focus on these elements. 151 Search strategy and protocol A systematic approach (see figure 3) was applied following PRISMA guidelines (Moher et al., 2009). After each group member piloted different search strings on EBSCOhost using various Boolean operators, the group agreed on: Theory building OR theory-building case stud*AND counselling OR counseling OR therap* OR psychotherap*. One researcher searched the PsychINFO and Web of Science database and provided access to the results, which were divided and randomly allocated to the five researchers. A large ‘initial search’ data bank was compiled. In the first step, each abstract was screened for inclusion criteria and documented in the data bank. Researcher allocation was reversed so duplicate articles were likely to be assessed by a second researcher. All initially included articles were moved to a new databank, on which duplicates were highlighted. Notes of observations on themes were discussed. Potentially relevant theoretical papers were added to a separate collection. All researchers read the first 5 articles to be included in the search. Further, any studies that were marked ‘unsure’ were re-assessed by all researchers and notes were discussed. A free-text search using Google Scholar was conducted to identify any papers that were missed by the database search but met the inclusion criteria. Finally, a ‘snowball search’ was performed to find any additional papers by searching reference lists of eligible literature. 152 Figure 2. Summary of the search and selection procedure The included papers were divided equally among researchers and individually summarised. The full-text analyses aimed to answer the following questions: What type of data was used? What theory was tested? Were there specific hypotheses? What analytic strategy was used? Were existing guidelines followed, and if so, how? Observations and reflexive notes were presented to the group. Following discussions, papers were examined based on analytic strategy, whether the analysis was driven by theory or case data (deductive vs. inductive), and theory-building outcome. The researchers individually categorised all yielded studies, created any necessary subcategories, and wrote their observations on the database. As a group, we reviewed each Following 2nd screening Literature Databases PsychInfo: n = 135 Web of Additional Literature Search: Snowball search and Following 1st screening Following rigorous assessment procedures including Papers were equally divided among researchers; abstracts are screened and notes were taken in databank based on inclusion criteria: Explicitly state TBCS Explicitly counselling research Empirical studies Peer reviewed Articles identified as relevant theoretical papers: Full texts were examined individually; summaries were kept on data bank and presented to the group. Articles excluded following individual 153 paper, defending any alternative positions until consensus was reached, confirmed the categories, and discussed the results. Risk of bias/Procedural limitations Throughout the review, we applied explicit and systematic methods (Moher et al., 2009). The inclusion criteria were applied rigorously during screening, placing emphasis on reducing researcher bias for the final inclusion. We used a consensual approach – all individual and group decisions were documented and questions about any decision-making were justified to the group. This was particularly important for the development of categories in the analysis stage. We acknowledge that we as a group of counselling psychology trainees hold bias and we specifically wanted to acknowledge that we have a personal interest in demonstrating that this is a valid and useful methodology to justify its use for our own research. Although the way we chose to categorise the results of the data may be deemed somewhat subjective and in service of our own needs, we believe that our group discussions mediated at least some of that bias. Results (Table 1) What analytic strategy was used? The current literature review findings shed light upon the broad range of additional analytic strategies TBCS researchers integrated within their theory-building analyses. We found that descriptions of researchers’ rationales for employing these specific analytic strategies were largely inexplicit. Out of the twenty-five papers reviewed, ten applied the assimilation to problematic experiences scale (APES) as an analytic strategy. Three used structural analysis of social behaviour (SASB) and three stated that theory-building case study was their method of analysis only. Consensual qualitative analysis plus either ACORN or CCRT was used in three papers, one used IPA and one used IPA and process analysis. One used intensive observational analysis, one used sequential model of processing, one utilised dialogical sequence analysis and one coded interactional frequency only. What theory was tested? Were there specific hypotheses? 154 Some of the TBCSs were driven by a named and established theoretical framework, such as the assimilation model, whereby the researchers clearly stated an aim of testing the theory in relation to a case, with the aim of confirming, re-testing, elaborating or refining the theory. However, we also found that several TBCSs reflected a broader ‘discovery-driven’ approach, in that researchers appeared to conceptualise a ‘theory’ as a relevant body of literature to which they aimed to contribute. Moreover, many of the TBCSs did not have a clear theoretical starting point and differed in justifications provided around the selection of theory. We also attended to whether researchers set out specific hypotheses; for our purpose, we considered the theoretical statements as equivalent to hypotheses to be tested. The results were split almost equally between unclear hypotheses, stated hypotheses and no hypotheses. There were some differences in whether these were testable hypotheses or theoretical tenets. Where it was unclear or no stated hypotheses, the authors described aims/goals/purpose. Out of the 25 studies reviewed, 20 used a theory-driven analysis, by which we mean that the authors utilised an explicit theory to organise and analyse their data. We found three studies that analysed their data based on a summary of literature (i.e., not an explicit theory, but rather ‘this is what the literature says about the phenomenon we wish to investigate), only one that was driven by the data itself and one that we were unable to categorise. What were the results/outcomes? We were curious to see whether researchers were explicit about theory confirmation, theory extension, or further theory testing on other cases. Much group discussion centred on whether theories that were extended were also implicitly confirmed. We decided that if one extends a theory, then one must implicitly agree on the initial tenets of the theory; therefore, we agreed that if something was categorised as extended, it was also an implicit confirmation of the theory. The majority, 19 out of the 25 studies had confirmed and extended a theory, even though this was not always explicitly stated as such. Two studies were testing a theory on a further case and three had an unclear outcome. Stiles & McLeod suggest that one should be “Turning the observation back on the theory in order to improve it” (Stiles, 2007, p. 125) and offer the following questions: “Does 155 the theory do justice to the complexity of the case? What are the segments or aspects of the case around which the theory has nothing to say? At what points did I feel frustrated or confused when I was using the theory to code or analyse the case?” (McLeod, 2010, p165). We found that these were often not explicitly engaged with; thus, the ‘theory-building’ element of the TBCS was often difficult to parse out of the results/discussion. One notable exception to this was Tickle and Murphy (2014), who provided a very clear table of theoretical gaps and how their results added to the theory. Westerman and DeRoten (2017) also provided clear theoretical tenets and specific discussions of how their findings extended the theory. Furthermore, it appears that several TBCSs were written with an emphasis on the complex and clinically interesting aspects of the case as opposed to the theoretical phenomena to be tested and therefore, the theory-building component. These highlighted questions concerning the degree to which TBCSs may be viewed as distinct from other case study research methodologies, such as pragmatic case studies. We chose to organise the results of the literature review through the three strands (analytic strategy, theory-driven vs. data-driven, and outcome) as these were the elements that we were most interested in exploring. However, we were struck by the variation amongst all the studies we reviewed, and other than all (except for one that utilised therapist notes) based on transcripts of therapy sessions as their data source, the methodology and structure differed vastly. Were existing guidelines followed and if so, how? None of the studies examined followed the guidelines (see figure A) explicitly (see Table 1) and varied with regards to which steps were defined and described. Some studies were much more explicit than others; in some, it was difficult to parse out the procedure. Such TBCSs were not systematic and hence would not be clearly replicable. However, we also want to highlight this methodology’s uniquely creative essence, one that is highly emblematic of the pluralism and creativity of the counselling psychology landscape. We want to encourage other researchers to engage with the research process with a degree of freedom and creativity while 156 maintaining scientific rigour and transparency. We hope that the recommendations below provide further structure but also maintain some of the methodology’s freedom and flexibility. Discussion & Recommendations In our literature review, we discovered that researchers varied in their assumptions of what it means to conduct a TBCS, and we would argue that without clear and explicit guidelines the methodology lacks validity. Based on our own experiences of TBCS research as counselling psychology trainees as well as the results of our literature review, we have provided some supplementary additions (See Figure 3) to the existing guidelines (see McLeod, 2010; Stiles, 2009, 2017, See figure A). Figure 3: Additional guidelines (in bold, italicised) interwoven with McLeod’s (2010) guidelines Developing a clear theoretical starting point (see Stiles, 2009; McLeod, 2010) We recommend that TBCS researchers start with a clear and explicitly stated theory (as discussed) through a process of familiarisation with research and identifying the main tenets of the theory. It will likely be helpful if it is clear to the reader why that specific theory is being tested with the case data and consideration of how well case(s) may be seen to fit the theory. We would also suggest that researchers have some initial ideas about what they want to achieve - to extend a theory, confirm the findings of a previous study with an additional case, or extend the evidence base of a theory by confirming the theory (Stiles, 2009). Some researchers choose to use findings, concepts, or ideas from existing literature as a starting point or let their data 157 guide their analysis, rather than starting with a named theory (McLeod, 2010). In this case, we suggest clearly stating what the researcher wishes to test within the study and remembering that TBCSs aim to build on theory. Extracting the theoretical tenets/ propositions/statements to be tested TBCSs aim to test theoretical propositions, which might serve as an alternative to a hypothesis or research question. Because TBCSs are based on rich case records, they create the opportunity to test several tenets of the theory. We recommend drawing out specific theoretical propositions from the theory to be tested (Cornelis et al., 2021; Westerman & de Roten, 2017). Extracting relevant theoretical statements, based on the objectives and available data, allows researchers to systematically identify ways in which a case corresponds with theory, thereby highlighting any potential gaps. Immersing into the case (see Stiles, 2009; McLeod, 2010) At this stage of analysis, researchers should bracket off knowledge of the theory and approach the data with an open mind. This step can include transcribing data, reading, and reading data from different perspectives (e.g., therapist and client), writing summaries and keeping reflective notes. Choosing the analytic strategy Some researchers choose to employ a specific analytic strategy within their TBCS methodology. We suggest thoughtful consideration of whether that is relevant for one’s specific study and to keep in mind that the choice of method will be highly dependent on what theory one is aiming to build. For example, if researching the experience of a participant (such as how a specific therapeutic framework - the theory - is experienced by the client) it might make sense to employ an interpretive phenomenological analytic strategy within a TBCS methodology. However, if the main aim is to test a theory on a case, there are steps outlined for TBCS analysis that might suffice for the analysis. Timulak & Keough (2016) recommend structuring the analysis based on the phenomena being studied or the theory being tested, warn against being limited by imposing analytic techniques, and call for the data to influence choice of analysis. In our own research, for example, SH’s project used goal-setting theory to organise 158 and analyse her data. FR has taken a similar approach by first identifying key moments based on attachment and mentalizing theories, followed by using existing assessment procedures to analyse the discourse. However, PB’s research on meaning in life in psychotherapy process and outcome, as well as JG’s research on change process in adolescents with ASD included thematic analysis as a first step to organising the data. This meant that PH and JG could remain open to all that the case might highlight before looking at their data from a more theoretical lens. EP utilised a phenomenological analysis from the start, which she then mapped onto a set of theoretical statements taken from the dissatisfied dropout literature. We decided on our analytic processes through engagement with our data, the scope of our individual projects, existing guidelines, and discussions with supervisors. As the data used is usually very extensive and rich, some approach to organising it is crucial. We recommend either coding data using the theoretical tenets that are to be tested in the study, and/or being explicit in how the data is initially organised. For example, all of us found it crucial to use either a narrative or thematic analysis to organise and understand the data as the initial step. It is important to note that many of the qualitative methodologies such as IPA, grounded theory, or thematic analysis, were developed for use on interview data and are used as stand-alone methods. What we found was that TBCS researchers are integrating these into their TBCSs, and we have also done the same. We do not feel that this is an issue per se, as the data must be organised and analysed in some way, but we need to be aware of the differences between interview and transcript-based analysis. As most TBCSs are using transcript-based data, we may need to consider some of the conceptual differences inherent in the transposition of these methods onto psychotherapy transcript data. Some theories that have been developed using mainly TBCS research, such as assimilation theory, have developed their own approach to analysis. Assimilation analysis involves specific steps (where different internal voices are identified in the transcripts) that can be employed as an analytic strategy within a TBCS. We suggest that if working with a specific 159 theory, it is important to look for other TBCSs investigating this theory and whether an analytic strategy has been developed that might be helpful to utilise. Whatever the choice of analysis, we suggest that it is organised in a way that makes sense in relation to the theoretical tenets and to be explicit in describing decision-making steps (Timulak & Keogh, 2016). The authors emphasise that sometimes, our need to be rigorously objective can lead us to not fully share our decision-making process. This can be particularly true in TBCSs as they can be criticised for lacking ‘power’. We encourage researchers to justify and be explicit in detailing their analytic choices – the analysis section of the research should be detailed enough for replication. Triangulate Triangulation in qualitative research often involves using two or more sources of data or two or more researchers to investigate a phenomenon. Traditionally, triangulation has been used to get closer to the ‘truth’ of what is happening in the data, however, some researchers argue for the use of triangulation as a way of getting a fuller picture, rather than a more accurate one (Braun & Clarke, 2013). The latter use of triangulation serves case study research well, and we recommend using different sources of data to construct a rich case record (McLeod, 2010). In addition, we recommend having different researchers to audit. This could involve having another researcher code extracts of data and use this to aid discussions and develop codes, or audit initially identified themes or codes. We found doing this in our research group very useful. Identifying gaps in the theory (see Stiles, 2009; McLeod, 2010) When analysing, consider whether the case can be explained by the theory and identify the areas (if any) of the case that are not explained by the theory. This is where the theory-building element comes in. Consider what the findings can add to the existing theory and be explicit about this (see below). Clearly stating the outcome One element of the process that we found particularly lacking in many of the studies we reviewed was a thorough discussion of the outcome. Researchers gave rich details of the 160 case and the results, but often only a brief discussion on its contribution to theory. We emphasize the theory-building component as the most significant part of TBCS research. We would therefore recommend being specific about how the results of this piece of work specifically confirm/extend/negate the theory (see, for example, Tickle & Murphy, 2014; Westerman & deRoten, 2017). This will allow for re-integration of the results with the theory and for theory extension. Limitations Our group found the variations and lack of guidance in TBCSs problematic, but we are aware that some of this discomfort lies with the ‘unknowing’ of not having enough guidance for our own research. Too much methodological freedom can breed anxiety and although we wanted to provide some more guidance for conducting TBCSs, we recognize our desire to facilitate our own projects. Further limitations include the choice of focal points/discussion of the literature review; we looked at what we found to be most challenging about our own projects. We came across several papers that appeared to be theory-building case studies but did not state that explicitly (Kasper et al., 2008; Hill et al., 2008; Mayotte-Blum et al., 2012). It is likely that more studies may have been missed in the initial stage. We see this as evidence of a lack of shared understanding or clear distinctions between different types of case studies. Although McLeod has outlined different types of case studies (McLeod, 2010), it appears that there remains uncertainty or confusion among case study researchers and highlights the need for further consideration/explication about theory-building. Conclusion This literature review aimed to investigate how TBCSs have been conducted to date. The inquiry was guided by methodological papers on TBCSs, existing guidelines (McLeod, 2010; Stiles, 2009), and our individual research journeys. We found that whilst there are many commonalities and shared values, most TBCSs varied in analytic strategy. We found most research to be theory-driven, though some studies did not explicitly outline theoretical starting points or stated hypotheses to test. This made it challenging to fully grasp the theoretical outcome. Finally, the findings show that the current literature does not necessarily follow the 161 existing guidelines. Whilst we highlight the importance of the creative aspects of TBCS, we feel this requires experience, confidence, and in some cases larger research teams. Although there remains work to be done in understanding the role of TBCSs in counselling & psychotherapy as well as further research on the analysis of psychotherapy session data, we have found this review process to be instrumental in our own research journeys. It is our hope that the suggestions offered here will be of use to those who are considering utilising this deeply rich, creative, and relevant methodology for their research. 162 References Braun, V. & Clarke, V. (2013). Successful qualitative research: A practical guide for beginners. SAGE Publications Ltd. Cornelis, S., Desmet, M., Meganck, R., Van Nieuwenhove, K., & Willemsen, J. (2021). Extending Blatt’s two-polarity model of personality development to dissociative identity disorder: a theory-building case study. Research in Psychotherapy: Psychopathology, Process, and Outcome, 24(1). Eisenhardt, K. M. (1989). Building theories from case study research. Academy of management review, 14(4), 532-550. Halaweh, M, Fidler, C, McRobb, S. (2008) Integrating the Grounded Theory Method and Case Study Research Methodology Within IS Research: A Possible 'Road Map. ICIS 2008 Proceedings. 165. http://aisel.aisnet.org/icis2008/165 Hill, C. E., Sim, W., Spangler, P., Stahl, J., Sullivan, C., & Teyber, E. (2008). Therapist immediacy in brief psychotherapy: Case study II. Psychotherapy: Theory, Research, Practice, Training, 45(3), 298–315. https://doi.org/10.1037/a0013306 Kaluzeviciute, G. (2021). Appraising psychotherapy case studies in practice-based evidence: introducing Case Study Evaluation-tool (CaSE). Psicologia: Reflexão e Crítica, 34. Kasper, L. B., Hill, C. E., & Kivlighan, D. M., Jr. (2008). Therapist immediacy in brief psychotherapy: Case study I. Psychotherapy: Theory, Research, Practice, Training, 45(3), 281–297. https://doi.org/10.1037/a0013305 Maxwell, J. A. (2021). The importance of qualitative research for investigating causation. Qualitative Psychology, 8(3), 378. Mayotte-Blum, J., Slavin-Mulford, J., Lehmann, M., Pesale, F., Becker-Matero, N., & Hilsenroth, M. (2012). Therapeutic immediacy across long-term psychodynamic psychotherapy: An evidence-based case study. Journal of Counseling Psychology, 59(1), 27–40. https://doi.org/10.1037/a0026087 163 Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & PRISMA Group*. (2009). Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Annals of internal medicine, 151(4), 264-269. McLeod, J. (2010). Case Study Research in Counselling and Psychotherapy. SAGE. McLeod, J. (2017). Developing research-based knowledge that enhances the effectiveness of practice. Transactional Analysis Journal, 47(2), 82-101. McLeod, J., Stiles, W. B., & Levitt, H. (2021). Qualitative research: Contributions to psychotherapy practice, theory and policy. In M. Barkham, W. Lutz, L. G. Castonguay (Eds.), Bergin & Garfield’s Handbook of Psychotherapy and Behavior Change (pp.351-384). John Wiley & Sons. Rosenwald, G. C. (1988). A theory of multiple case research. Journal of Personality, 56, 239-264. Stiles, W. B. (2002). What Kind of Research Can We Realistically Expect from the Practitioner? Journal of Clinical Psychology, 58(10), 1241–1264. Stiles, W. B. (2005). Case studies. In J. C. Norcross, L. E. Beutler & R. F. Levant (Eds.), Evidence-based practices in mental health: Debate and dialogue on the fundamental questions (pp. 57-64). Washington, DC: American Psychological Association. Stiles, W. B. (2007). Theory-building case studies of counselling and psychotherapy. Counselling and Psychotherapy Research, 7(2), 122-127. Stiles, W. B. (2009). Logical operations in theory-building case studies. Pragmatic case studies in psychotherapy, 5(3), 9-22. Stiles, W. B. (2015). Theory building, enriching, and fact gathering: Alternative purposes of psychotherapy research. In Psychotherapy research (pp. 159-179). Springer, Vienna. Tickle, E., & Murphy, D. (2014). A journey to client and therapist mutuality in person-centered psychotherapy: A case study. Person-Centered and Experiential Psychotherapies, 13(4), 337–351. https://doi.org/10.1080/14779757.2014.927390 Timulak, L., & Keogh, D. (2016). The Case of" Cora": Clinical and Methodological Perspectives. Pragmatic Case Studies in Psychotherapy, 12(3), 207-214. 164 Westerman, M. A., & de Roten, Y. (2017). Investigating how interpersonal defense theory can augment understanding of alliance ruptures and resolutions: A theory-building case study. Psychoanalytic Psychology, 34(1), 13. Source Data Theory Specific Hypotheses? Stiles or McLeod guidelines cited Analytic Strategy Theory/data-driven Outcome Schielkeet al. (2011) Video recordings and transcripts of sessions Theory of isomorphism as applied to couple therapy. Yes - Does isomorphism in the structure of inter-and intra-personal change processes follow the same model that has been shown to be true for intrapersonal changes in individual therapy? Not explicitly APES Theory-driven Extended theory (extended model's applicability to the interpersonal realm) Tickle & Murphy (2014) Session notes, audio recordings and transcription and research interviews. The theory of mutuality (person-centred theory) Aim to develop theory Not explicitly, referenced Stiles and some aspects of McLeod's steps could be found No named TBCS Data-driven Extended theory (implicitly confirmed) Halvorsen et al. (2016) Post therapy interviews (client & therapist), session evaluations, audio recordings & transcripts; quant measures. No explicit theory: what were the helpful aspects of therapy in this difficult case Unclear Not explicitly – theory-building analysis integrated into IPA stages IPA Discovery-driven Unclear (clinical recommendations) Gabriel et al. (2021) Session transcripts Assimilation Aim to assess and elaborate the assimilation model as it applies to bereavement /extends the model follows APES steps Qualitative Assimilation Analysis Theory-driven Tested already extended theory on further case Kramer & Meystre (2010) Extensive therapist NOTES (not transcripts) Assimilation Aim to demonstrate assimilation model enables identification of third-party effects and confirmation of meaning bridges/Extend the model follows APES steps APES Theory-driven Extended theory (implicitly confirmed) Kramer et al. (2016). Audio and video recordings of sessions. Outcome measures (four time points): OQ-45, IIP, BSL, and WAI. Assimilation Aim to use the assimilation model to understand internal multiplicity in BPD. Not explicitly, cites Stiles APES Theory-driven Extended theory (implicitly confirmed) Widdowson (2014) 3 case vignettes and case formulations in the form of vicious cycles. Transactional analysis Aim to test and extend the theory of TA in terms of vicious cycles in depression/anxiety. Not followed or cited No named TBCS Theory-driven Extended theory (implicitly confirmed) 166 Westerman (2011) Video recordings of sessions, psychometric measures, and DSM diagnosis Interpersonal Defense Theory Aim to test and illustrate theory/offer evidence supporting several tenets of IDT follows Stiles, discussion of the logic of theory-extension, SASB Theory-driven Extended theory (implicitly confirmed), support for TBCS van Rijn et al. (2019) Video recordings of onscreen images and audio recordings of counselling sessions; transcripts of interviews (client & therapist) Assimilation Aim to investigate how digital imagery was used in counselling through assimilation analysis. follows APES steps APES Theory-driven Confirmed & Extended Theory Kramer et al. (2014) Audio recordings and transcripts of three sessions. The Rupture-Resolution Model Aim to extend the emotional processing theory to extend the rupture-resolution model. Applied Stiles model - deduction, induction, and abduction The sequential model of processing Theory-driven Extended theory (implicitly confirmed) Gray & Stiles (2011) Session recordings & transcripts; outcome measures; process measure (APES) Assimilation Aim to identify the configuration of voices associated with anxiety. Follows APES steps APES Theory-driven Extended theory (implicitly confirmed) Welch et al. (2019) Therapist case notes; Video recordings of counselling sessions; outcome measures Emotionally Focused Couples Therapy Aim to understand the therapy processes that result in the creation of safety Applied Stiles model - deduction, induction, and abduction Intensive observational analysis Theory-driven Confirmed & Extended Theory Friedlander et al. (2021) Four cases of couples therapy from video recordings No explicit theory - behavioural manifestations of split alliances in couples therapy Research question re: the role of self-reported split alliances No, but explicit in analysis methodology - analysis was led by the theories. coding interactional frequencies Theory and Discovery-driven Extended theory (implicitly confirmed) Cornelis et al. (2021) Session recordings The two-polarity model of personality development Yes, clearly identified hypotheses and predictions Not mentioned. 6 team members worked on different elements of the analysis (quant/qual). CQA & Acorn Theory-driven Confirmed & Extended Theory Meystre et al. (2014) Session transcripts Assimilation Yes, clearly identified hypothesis and aim to confirm/disconfirm. Follows APES steps APES Theory-driven Extended theory (implicitly confirmed) 167 Cornelis et al. (2017) Session audio recordings, outcome measures; perspectives of client, therapist, and researchers Assimilation Yes, clearly identified hypotheses and predictions; aim to test, confirm and extend the theory Cites both Stiles and McLeod, however, guidance is not explicitly mentioned in the method CQA & CCRT Theory-driven Confirmed & Extended Theory Cornelis et al. (2017) Session recordings; outcome measures Symptom Specificity Hypothesis Aim to confirm the previous extension of theory Not explicitly followed in method; cites McLeod CQA, Acorn & CCRT Theory-driven Confirmed & Extended Theory Westerman & Muran (2017) Video recording of counselling sessions; outcome data Interpersonal Defense Theory Yes, clearly identified hypotheses and predictions; to test and extend theory. Not explicitly, cites Stiles and McLeod SASB Theory-driven Confirmed & Extended Theory Westerman & de Roten (2017) Session recordings & quant measures; existing data from umbrella study Interpersonal Defense Theory Yes, certain kinds of interventions contribute to alliance ruptures while others promote resolution. Not explicitly, cites Stiles SASB Theory-driven Confirmed & Extended Theory HaCohen et al. (2018) Audio recordings, outcome measures, DSM diagnosis relational psychodynamic theory/self-states development Yes, in successful treatment, the therapist's TPA levels would become temporarily congruent with the patient's TPA levels on a session-by-session basis. Modified/ followed APES steps Mixed-Method (APES, TPA, Regression) Theory-driven Confirmed & Extended Theory van Rijn et al. (2021) Video and audio recordings; interview transcripts Assimilation No clearly identified hypothesis; aim to compare an array of case observations with a theoretical account to assess fit and elaborate theory Implicitly follows the guidance, not clear on abduction aspect APES Theory-driven confirming & testing against another case Quinn et al. (2012) Recordings and transcriptions of participant interviews (2 participants & therapists) No explicit theory: understanding successful approaches for psychogenic non-epileptic seizures No clearly identified hypothesis; aims to develop an understanding of the area Not explicitly – theory-building analysis integrated into IPA stages IPA & process analysis Discovery- driven by literature without naming theory Unclear outcome (clinical outcome) Gunst & Vanhooren (2018) Session recordings and transcripts Theory of patterns of destructive functioning Unclear; vague aims to extend the theory Not followed, cites Stiles TBCS Unclear Unclear outcome 168 Caro Gabalda & Stiles (2021) Audio recordings and session transcripts; process and outcome measures Setbacks in Assimilation Aim to test and extend the theory Implicitly follows the guidance, not clear on abduction aspect APES Theory-driven Extended theory (implicitly confirmed) Zonzi et al. (2014) Audio recordings and session transcripts, comparative clinical trial data Assimilation Aims to test and extend theory; hypotheses are presented throughout. Not explicitly, cites Stiles Dialogical Sequence Analysis Theory-driven Unclear outcome (clinical outcome) H) Context of the case and treatment manual The case was selected from a pool of therapeutic dyads who were already enrolled in a wider research project undertaken by a university-based research centre offering up to 24 sessions of pluralistic therapy for depression to university students and people from the local community. The clients had been subjected to the inclusion and exclusion criteria for the wider research project, namely: being 18 years or older, having a PHQ-9 score consistent with a diagnosis of depression (Kroenke et al., 2001), not having severe mental health conditions including psychosis, severe personality disorders, or drug and alcohol addictions. At assessment, and at each session, clients filled out the Goals Form as well as the PHQ-9. Following session four and at endpoint clients were interviewed by a researcher about the experience of goal-oriented practice. Clients who chose to work with goals followed a protocol which entails: collaborative goal-oriented practice including the development of a collaborative relationship, establishing an agreement, contract, formulation or plan, engaging in activities intended to facilitate change in the direction of the client’s goals, and reviewing and consolidating progress (Cooper & McLeod, 2011). See below for the treatment protocol that was adopted. 170 A pluralistic approach to counselling and psychotherapy for depression: treatment manual v1 John McLeod, University of Abertay Dundee Mick Cooper. University of Roehampton September 2012 Contents Preface 1. Introduction to a pluralistic approach to therapy 2. Therapy for depression: a pluralistic perspective 3. Stages of time-limited pluralistic therapy for depression: overview 4. Stage 1: developing a collaborative relationship 5. Stage 2: constructing a shared formulation and plan 6. Stage 3: focusing on specific change tasks 7. Stage 4: looking beyond the end of therapy 8. Therapist training 9. Therapist supervision References 171 Preface Pluralistic counselling and psychotherapy represents a therapeutic approach that is in the early stage of development. The present manual has been prepared for use by a set of trainee therapists engaged in a multi-site pilot study of the effectiveness of pluralistic therapy for depression. It is intended to use the experience of these trainees as a basis for further articulation of the manual, for instance in respect of the inclusion of case examples, additional detail, and refinement of the adherence scale. The present version of the manual is therefore not intended for general use at this time. The trainee counsellors and psychotherapists for whom this manual has been designed are members of university-validated training programmes that carry an expectation of evidence-based practice, and requires students to write essays and carry out research, and to make effective use of independent study time. As far as possible, trainees who are using the manual are encouraged to use essays and research projects to extend their understanding of a pluralistic approach to depression. To this end, a number of items of essential reading are included. These items provide a start-point for essay and project work, and discussions within the supervision group. This manual has been prepared on an assumption that users will already know about professional issues in areas such as risk assessment, boundaries, ethical dilemmas, use of supervision, etc. These crucial issues are therefore not explicitly addressed within the manual. Depression represents a major and growing health issues in modern industrial societies. A significant proportion of those who seek counselling and psychotherapy exhibit at least some level of depressive symptoms. There exists good evidence for the validity of many different ways of understanding the factors that contribute to the development of depression, and the effectiveness of different strategies for treatment and intervention. The rationale for a pluralistic approach to depression rests on an acknowledgement of the value of a wide range of ideas and methods, and a belief that the most effective therapy will involve responsiveness to ‘what works best’ for each individual client. 1. Introduction to a pluralistic approach to therapy The approach that is described in this manual is based on the work of Cooper and McLeod (2011) in articulating a set of principles for pluralistically-informed therapy: A. Clients have their own ideas about what will be helpful for them, and are able to make use of cultural/community resources that can be of assistance to them – it is essential for the therapist to tap into these ideas and mobilise the client’s strategies for change; B. This can be achieved by engaging in collaborative conversations around: a. the ways in which both client and therapist understand the client’s problem; b. the client’s goals; c. the step-by-step therapeutic tasks that need to be accomplished in order to achieve these goals; d. the methods or techniques that will be used to fulfil these tasks. C. A competent pluralistic therapist is therefore able to: a. be sensitive to the language and worldview of the client, in order to identify his or her assumptions about problem causation, and the nature of healing and change; b. draw on a sufficient knowledge of counselling theories and interventions, from a range of approaches, in order to be flexible and open to different possibilities in relation to problem understanding and choice of methods; 172 c. offer the client a menu of tasks, from which he or she can construct a plan that will result in the achievement of their goals; d. be continually responsive to the client, and skilled in metacommunication and process contracting, and in order to create and take opportunities within the counselling process for collaborative conversations around understandings, goals, tasks and methods to take place; e. be aware of his or her own particular areas of competence, and areas for further learning, in order to respond with confidence to the needs of clients; f. be aware of the potential contribution of cultural and community resources, in relation to facilitating client change. The present manual has been designed to be used by trainee counsellors and psychotherapists who identify with these principles, and have had some initial training and experience in how to apply these ideas in practice. Essential reading: McLeod, J. and Cooper, M. (2011) A brief introduction to pluralistic counseling and psychotherapy. In C. Feltham (ed) The Sage Handbook of Counselling and Psychotherapy. London: Sage. Cooper, M. and McLeod, J. (2011) Pluralistic counselling and psychotherapy. London: Sage. 2. Therapy for depression: a pluralistic perspective A pluralistic understanding of the nature of depression, and therapeutic responses to depression, requires reflection on a range of relevant sources of knowledge. 2.1 The evidence base: effectiveness of psychotherapy for depression From a pluralistic perspective, there exist many plausible and effective strategies for helping people to overcome depression: These include pharmacological interventions, psychotherapy, and a wide range of lifestyle interventions. Research evidence suggests that no single intervention is associated with sustained effectiveness. Essential reading: Pluralistic therapists are expected to use research to inform their practice. Users of this manual need to develop confidence in the equivalence of alternative therapeutic approaches to depression, by familiarising themselves with the following reviews: Cuijpers,P., Andersson, G., Donker, T. and van Straten, A. (2011). Psychological treatment of depression: Results of a series of meta-analyses. Nordic Journal of Psychiatry, 65, 354–364. NICE (2010). The treatment and management of depression in adults. London: National Institure for Health and Clinical Excellence (available on-line). Wampold, B. E. (2001). The Great Psychotherapy Debate: Models, Methods and Findings. Mahwah, NJ: Erlbaum. Westen, D., Novotny, C.M. and Thompson-Brenner, H. (2004) The empirical status of empirically-supported psychotherapies: assumptions, findings, and reporting in controlled clinical trials. Psychological Bulletin, 130, 631-663. 173 2.2 The social and cultural context of ‘depression’ A pluralistic perspective requires awareness of the relevance of insights form sociology and history, as well as from psychology and the psychotherapy literature. These broader cultural conceptions are particularly relevant in respect of an understanding of the meaning of depression, because (a) ‘depression’ has only emerged as a major health issue over the last 20 years, and (b) there are powerful commercial and political groups that actively promote specific ways of making sense of depression (i.e., medicalised and pharmacological) and which have a strong influence on client beliefs, attitudes and preferences. Key reading The books by Greenberg (2010), Levine (2007) and waters (2010) offer accessible introductions to this area. The work of Healy (1999, 2006) represents some of the underlying socio-historical research that has been carried out. Greenberg, G. (2010). Manufacturing Depression: The Secret History of a Modern Disease. London: Bloomsbury. Healy, D. (1999) The Antidepressant Era. Cambridge, MA: Harvard University Press. Healy, D. (2006). Let Them Eat Prozac: The Unhealthy Relationship Between the Pharmaceutical Industry and Depression. New York: New York University Press. Levine, B.E. (2007) Surviving America’s depression epidemic. How to find morale, energy, and community in a world gone crazy. White River Junction, VT: Chelsea Green Publishing. Watters, E. (2010) Crazy like us. The globalization of the Western mind. New York: Free Press. (chapter 4. The mega-marketing of depression in Japan). The following studies illustrate some of the ways in which cultural discourses around depression are articulated in the professional literature: France, C.M., Lysaker, P.H. and Robinson, R.P. (2007). The “chemical imbalance” explanation for depression: origins, lay endorsement, and clinical implications. Professional Psychology: Research and Practice, 38, 411–420. Hansell, J. et al. (2011). Conceptually sound thinking about depression: an internet survey and its implications. Professional Psychology: Research and Practice, 42, 382–390. 2.3 Narratives of recovery from depression A pluralistic perspective places particular emphasis on the experience of clients, and the stories that clients tell about what depression means to them and how they recovered from it. Qualitative research studies that capture key aspects of the experience of depression are therefore centrally important to a pluralistic way of working. Reading these studies has the potential to sensitise therapists to the multiple possible ways in which depression can be exhibited, what it can mean to people, and how people deal with it. Knowledge from qualitative research provides a context within which the role of psychotherapeutic interventions can be understood. Essential reading: Users of the manual are required to have read at least three of the following studies: 174 Bell, R.A. et al. (2011). Suffering in silence: reasons for not disclosing depression in Primary Care. Annals of Family Medicine, 9, 439-446. Bendelin, N. et al. (2011). Experiences of guided Internet-based cognitive-behavioural treatment for depression: A qualitative study. BMC Psychiatry, 11:107. Danielsson, U.E. et al. (2011). “My greatest dream is to be normal”: the impact of gender on the depression narratives of young Swedish men and women. Qualitative Health Research, 21, 612–624. Goodman, L.A., Glenn, C., Bohlig, A., Banyard, V. and Borges, A. (2009). Feminist relational advocacy: processes and outcomes from the perspective of low-income women with depression. The Counseling Psychologist, 37, 848-876. Johnson, J. L. et al. (In press) Men’s discourses of help-seeking in the context of Depression. Sociology of Health and Illness Kinnier, R.T., Hofsess, C., Pongratz, R. and Lambert, C. (2009). Attributions and affirmations for overcoming anxiety and depression. Psychology and Psychotherapy: Theory, Research and Practice. 82, 153-169. McMullen, L.M. and Herman, J. (2009). Women’s accounts of their decision to quit taking antidepressants. Qualitative Health Research, 19, 1569–1579. Porr, C., Olson, K. and Hegadoren, K. (2010). Tiredness, fatigue, and exhaustion in the context of a major depressive disorder. Qualitative Health Research, 20, 1315–1326. Rautiainen, E. and Aaltonen, J. (2010). Depression: the differing narratives of couples in couple therapy The Qualitative Report, 15, 156-175. Roodesa, J. and Smith, J.A. (2010). ‘‘The top of my head came off ’’: An interpretative phenomenological analysis of the experience of depression. Counselling Psychology Quarterly, 23, 399–409. Rice, N.M., Grealy, M.A., Javaid, A. and Serrano, R.M. (2011). Understanding the social interaction difficulties of women with unipolar depression. Qualitative Health Research, 21, 1388–1399. Ridge, D. and Ziebland, S. (2006). “The old me could never have done that”: how people give meaning to recovery following depression. Qualitative Health Research, 16, 1038-1063. Ridge, D. and Ziebland, S. (in press). Understanding depression through a ‘coming out’ framework. Sociology of Health and Illness. Speedy, J. (2005). Collective biography practices: Collective writing with the unassuming geeks group. British Journal of Psychotherapy Integration ,1, 29-38. Valkonen, J., Hanninen, V. and Lindfors, O. (2011) Outcomes of psychotherapy from the perspective of the users. Psychotherapy Research, 21, 27-240. Wilson, J. and Giddings, L. (2010). Counselling women whose lives have been seriously disrupted by depression: what professional counsellors can learn from New Zealand women’s stories of recovery. New Zealand Journal of Counselling, 30, 23-39. 175 2.4 Systematic case studies of therapy for depression On the whole, research into the process and outcome of therapy for depression has tended to focus on the investigation of ‘brand name’ therapies such as CBT and interpersonal therapy. There have been few studies that have examined what happens in integrative or pluralistic approaches to therapy. Systematic case studies, based on multiple sources of data, represent a highly appropriate methodology for studying integrative/pluralistic therapy, because a good case study is sensitive to the complexity of real-life events. Even case studies of ‘brand name’ therapies, if written up in sufficient detail, can yield an understanding of how good therapists strive to be responsive to the needs and preferences of individual clients. Systematic case study evidence therefore comprises an essential source of knowledge for pluralistic practice. Essential reading Kenny, M.C. (2006) An integrative therapeutic approach to the treatment of a depressed American Indian client. Clinical Case Studies, 5, 37-52. Widdowson, M. (2012). TA treatment of depression - a Hermeneutic Single-Case Efficacy Design study: Peter. International Journal of Transactional Analysis Research, 3, 3-13. Wyman-Chick, K.A. (2012) Depression with complicated grief combining cognitive-behavioral therapy and interpersonal therapy. Clinical Case Studies published online 14 March 2012 2.5 Summary of key themes of a pluralistic response to depression Taken together, an overview of various sources of knowledge tends to suggest that depression can mean different things to different people. The concept of ‘depression’ can be regarded as comprising both a technical term that is defined within DSM, and also a term that has multiple cultural meanings within different communities, and across genders. An overview also makes it possible to identify a broad domain of change processes that are potentially relevant in the efforts that people make to overcome depression: (i) cognitive interventions (e.g., challenging irrational thoughts); (ii) working with feelings: expressing and being aware of feelings and emotions, understanding the meaning and significance of feelings, changing established patterns of emotional self-regulation; (iii) developing a coherent narrative/explanatory model that makes links between current difficulties, underling reasons, and possibilities for change; (iv) exploring and changing patterns of relationships; (v) planned behaviour change (e.g., use of homework tasks); (vi) use of self-help reading, movies, etc; (vii) information-giving (e.g., explaining relevant bits of psychological theory); (viii) identifying client strengths and how they can be applied; (ix) identifying cultural resources (e.g., friendships, activities, spiritual practices, art, etc.), and how they can be part of a more satisfying life; (x) enabling the person to understand the significance of their family system; (xi) enabling the person to appreciate the significance of cultural-political factors in their life (e.g., racism, attitudes to disability and illness, domestic violence, oppression at work, etc); (xii) expressive arts work/art-making; (xiii) coming to terms with circumstances (e.g., physical illness) that stifle hope; (xiv) identifying and making use of physical interventions to alleviate depression (e.g., antidepressant medication and other drugs, herbal remedies, dietary changes, physical exercise, exposure to sunlight, etc.. 176 3. Stages of time-limited pluralistic therapy for depression: overview Pluralistic therapy is similar to other forms of therapy, in recognising four general phases of therapy: • developing and collaborative relationship and eliciting the client’s story; • establishing an agreement, contract, formulation or plan of work; • engaging in activities that are intended to facilitate change in the direction of the client’s goals; • bringing therapy to an end, reviewing and consolidating progress, anticipating and preventing relapse. Pluralistic therapists are likely to have acquired models and strategies, for how to move from one phase to the next, and are encouraged to use these existing skills as a basis for their pluralistically-oriented work. The distinctive characteristics of pluralistic therapy, in relation to these stages, are (a) a strong emphasis on collaboratiion, and (b) an open-ness to multiple possibilities, in response to evidence of what works best for each client. One possibility that needs to be allowed is that therapy may not proceed according to these phases. In the following sections, the phases of therapy are described in relation to a national 16-session episode of therapy, because research suggests that around 16 sessions are necessary for clients experiencing moderate levels of depression. It may be that 16 sessions are too many (or too few) to be consistent with the usual policies of the therapy setting within which the trainee is seeing clients. Alternatively, some clients may wish to attend for fewer, or more sessions. . Stage 1: developing a collaborative relationship The starting point of a pluralistic approach to depression is a recognition that ‘depression’ is something that can be understood in different ways. For the purpose of the present pilot study of pluralistic therapy for depression, a client is included if he or she: a) records a pre-therapy assessment score at or above the ‘caseness’ range of the BDI; b) is willing to take part in the study (i.e., complete scales). The client may not describe their problem as being ‘depression’. The client’s description of their difficulties and goals should always be the starting point of therapy. A ‘diagnosis’ of depression represents the point of contact between the study and the therapy research literature as a whole. The client should not be required to accept this diagnosis in order to take part in the study – there may be some clients for whom the term ‘depression’ is seldom or never mentioned over the course of therapy. One of the fundamental assumptions of pluralistic therapy for depression is that effective work requires the establishment of an open dialogue between client and therapist. It is unlikely that the client will be able to participate in open dialogue at the outset, due to (a) the imbalance of power and knowledge between therapist and client (resulting in the client viewing the therapist as the ‘expert’), and (b) in some clients, a longstanding difficulty or reticence about expressing their own views and feelings, or believing that another person will value them and take them seriously. It is therefore necessary to prepare the ground, from the outset, for the possibility of dialogue, by: 177 i) providing the client with information about what is involved in therapy (through the inviting the client to read the Information About Therapy leaflet, then inviting questions and discussion); ii) the therapist being clear (in his/her own mind and verbally with the client) Usually, a 16 session therapy would commence with one ‘pre-therapy’ assessment interview, followed by one or two sessions that allowed the client to tell their story, and allowed the therapist to begin to get a sense of how the client might prefer to work. The purpose of these sessions is to identify: (a) the roles and responsibilities of both client and therapist; (b) the client’s goals for therapy (c) the ideas held by client and therapist around how these goals might be accomplished; (d) the social world of the client; (e) relevant aspects of the client’s life story; (f) the resources available to the client, including their personal strengths; (g) the resources available to the therapist; (h) the ways in which monitoring instruments can be used to inform therapy; (i) the client’s preferences around the best way of working within sessions; (j) the client’s preferences around the arrangements for therapy (e.g., timing of meetings). By about session 3, 4 or 5, the outcome of these conversations is to lead into the co-construction of a preliminary case formulation (which is kept under review throughout the course of therapy). Essential reading: client preferences Client preferences around relationship style and change processes are complex and subtle, and may change over the course of therapy. To become sensitised to client preferences, it is useful to read: McLeod, J. (2012) What do clients want from therapy? A practice-friendly review of research into client preferences. European Journal of Psychotherapy, Counselling and Health, 14, 19-32. McLeod, J. (in press). Developing pluralistic practice in counselling and psychotherapy: using what the client knows. European Journal of Counselling Psychology. Essential reading: depression It is essential to become familiar with the DSM criteria for diagnosing depression, so that a record can be made in the Therapist Note Form around which of the symptoms are manifested by the client, and whether these symptoms change. This information is valuable for the research study, to supplement the BDI data. It can also inform practice, for example by inviting the therapist to think about any symptoms that are not present (and what this absence might mean).. Stage 2: constructing a shared formulation and plan At an appropriate point (i.e., not when the client is in full flow) around session 3-5, the therapist should ask the client if it would be acceptable to share his/her ideas about what the 178 client has been talking about, and how therapy might help. It can be a good idea to signal this intention at the end of a previous session (“I was wondering if this is something we could look at next week?”), or at the start of a session, to give the client maximum scope to attend to other issues within that session, if they wish. There are many different models of how to construct a case formulation, and how to share this with the client. Pluralistic therapists taking part in this study will probably have had prior training in this skill, and are encouraged to draw on existing knowledge and experience. From a pluralistic perspective, an effective formulation is one that is: a. informed by the client’s language, metaphors, imagery, etc b. presented in a tentative, step by step fashion, with space, permission and encouragement to the client to disagree, add detail, make suggestions, etc; c. structured as a narrative that links up prior life events and experience, current difficulties, and possible ways forward (diagrammatic symbols such as arrows and connecting lines can be useful); d. inclusive of multiple ways of understanding the problem, and multiple possibilities for ways to facilitate change (tasks and methods); e. expressive of positive expectations and hope; f. grounded in observable, knowable, specific outcomes; g. acknowledging of the client’s strengths, resources and previous accomplishments; h. externalised in some way (e.g., drawn out on a flipchart page) so that the client and therapist can look at it together, rather than the ideas being ‘owned’ by one or the other; i. recorded in a form that is available for future reference (e.g., flipchart page or letter/email to client after the session). Usually, a pluralistic formulation will highlight areas of work that represent alternative change mechanisms. This has two effects: it allows the client to opt for the way of working that makes intuitive sense to them, and at the same time it gets them thinking about other possibilities that seem a bit odd or scary. Case example Dave is a 40 year old man who works as an electrician. His wife encourages him to come to therapy because he is extremely self-critical and depressed, and occasionally withdrawn and suicidal. At the third meeting, a formulation was offered that made sense of his life story from different perspectives: • the way you describe your childhood, it is almost as though you grew up with a sense of not mattering to your mum and dad – they were preoccupied with your brother, who was ill most of the time. It might be useful to look at all that in more detail, and try to make sense of how that has shaped the way you feel about yourself now; • what you have said about the way you live your life at the moment is that a lot of the time there is a running commentary in your head, questioning what you are doing and telling you how useless you are. One of the things that could be helpful is to try to figure out how to stop that process, and replace it with a more positive way of thinking; • one of the issues that you have talked about is that you feel very isolated, and are not able to talk to your wife or your friends about how you feel. Its as if you need to cope with everything on your own. This is another are we could look at – how you can get more support from other people when you are under stress; • another thing that struck me as I have got to know you is that you are a very thoughtful person, and have a really creative side to you that does not seem to have much of an outlet at the moment. I know that many people counteract their feelings of depression by finding ways to fulfil themselves or achieve their potential – I don’t 179 know if this makes sense to you, but I wonder if that is part of the picture for you, and part of how to move forward in your life; • having said all that, it is quite possible that I have missed something important, and that there are other ideas that you have yourself about what would be helpful in your counselling sessions. Having offered these possibilities, it is of course necessary for the therapist to feel confident that he or she can follow each of them through, for example by responding to the client questions such as ‘what do you mean by that?’, or ‘what would that involve in practice?’ or ‘how could that be helpful?’ Stage 3: focusing on specific change tasks The shift from a phase of talking about what ‘could’ be helpful (developing a collaborative formulation and plan) to a phase of putting the plan into action, is a key point in therapy. If the client comes up with a definite suggestion, it is usually a good idea to follow it up, even if it does not make a lot of sense to you. This is because the client’s ‘voice’, in respect of being able to articulate their needs, is likely to be fairly weak, and requires to be drawn out. On the other hand, if the client does not state a preference, it is useful for the therapist to be willing to make a suggestion around where they might start. A pluralistic way of working is not merely a matter of following the client. Philosophically, pluralism implies dialogue between different positions. It can be very useful to challenge the client around his or her assumptions of what might be helpful. It can also be useful to invite the client to try out something that might seem strange to them (“I have been thinking that it is hard for you to really get to the bottom of what all this means to you – I know that sometimes, it can be helpful to pay attention to what our dreams are telling us…could this be something that might be worth trying, just to see where it goes…?”). However, challenging and suggesting run the risk of silencing the client, and are perhaps best left until a bit later on in the process. One of the pitfalls of pluralistic therapy is to try to pursue too many possibilities for change. This can result in none of the change processes that have been identified, being pursued to a sufficient extent to actually make a difference. A potential advantage of ‘unitary’ therapy orientations is that the client goes back over the same territory over and over again (e.g., identifying the occurrence of negative automatic thoughts, expressing anger to an empty chair, discovering unique outcomes or exceptions). There are very few therapeutic interventions or activities that make a big difference at first time of being applied – it can be valuable to think about change as a process of re-learning based on practice. When a therapeutic task does not yield a positive outcome, it is therefore necessary to consider, with the client, whether it would be most effective to: • persevere with what has been agreed; • adapt or modify the activity in some way, in the light of experience; • shift tack and tray something quite different. A distinctive characteristic of pluralistic therapy is that several strands of therapeutic work may be on-going at the same time. For example, a focus on cognitive change, such as irrational beliefs or negative automatic thoughts might be central within therapy over four or five sessions. However, alongside this primary focus, the client may begin to realise that “these ideas come from the crazy family I grew up in” (leading to more autobiographical self-exploration) or that “this Buddhist group I went to last week really helped me to let go of these shitty ways of thinking” (leading to greater use of cultural resources external to the therapy room). 180 The phase of focusing on specific change tasks is characterised in pluralistic therapy by on-going use of feedback tools, and metacommunication to check out whether what is happening is helpful for the client, and to jointly decide how to modify activities, shift tack, allocate time, etc. As therapy proceeds, if things are going well the client will probably become irritated by being asked to complete feedback scales too often, because they will assume a position of feeling that they are well able to offer feedback on their own terms, when they wish. The regular administration of outcome measures (CORE, BDI and goals forms) is important throughout this stage. If positive change is not being recorded on these forms, it is essential to stop and review what is happening. If ‘wellness’ is being approached or accomplished, it is necessary review whether it is time to wind down the therapy. This stage of therapy might be expected to unfold between around session 4 and session 12. It is likely that routine reviews of progress will require some re-visiting of areas that were introduced in sessions 1-4 (e.g., there may be a crisis in the relationship, the formulation may need to be revised, the length of therapy might need to be extended or reduced, etc). It is important to emphasise that this stage of therapy is not a matter of using the exploration of client preferences to as a basis for deciding to ‘do CBT’ or ‘work in a psychodynamic way’. Most clients seem to want a bit of CBT, a bit of relational work, a bit of self-actualisation, etc. From the client’s point of view, there is nothing strange about talking about irrational beliefs one minute and then shifting to memories of childhood events. This is only strange to us, because we have been socialised into thinking about these activities as belonging in separate and incommensurable therapeutic domains. From a pluralistic perspective, whether it works for the client, is the primary criterion. Depending on the client, the depression-oriented therapeutic tasks that are addressed might include: (a) exploring and reflecting on the person's self-concept (e.g., defining self as worthless) and experimenting with alternative self-defining practices; (b) building a relational environment (inside the therapy room and in everyday life) in which the person can have the experience of being accepted and valued - and thus come to value him/herself as well as creating everyday relationships in which they are valued by others and 'matter'; (c) supporting the person to re-experience and reflect on events (e.g., abuse, loss, dislocation) that have contributed to a sense of worthlessness and a fractured self-narrative; (d) supporting the person to make new decisions about how they will live their life; (e) dealing with life transitions (e.g., job change, leaving home); (f) enabling/encouraging the person to discover or rediscover sources of meaning and value; (g) exploring emotional self-regulation and ‘rackets’ (e.g., being sad and depressed as a mask for anger or fear) and acquiring ways of tolerating and appropriately expressing the underlying primary emotions; (h) reviewing self-care practices and behaviours (e.g., around diet, exercise, time management); (i) learning new ideas and skills that can contribute to a more satisfying life; (j) building a framework for understanding how and why things have gone wrong, and what has been helpful in putting it right. It is essential to avoid any tendency to focus only on depression-oriented issues. It is quite likely that the client will also want to work on other issues (e.g., panic, anxiety. trauma, 181 social skills, relationships, life choices, etc). These other issues may represent the main focus of the therapy. Stage 4: looking beyond the end of therapy (to be completed) Sessions 13-16 Activating generativity. Examining ways in which what the client has learned can be used to make a contribution to society. Telling/writing their story in a form that will be of value for others, as well as comprising (a) a closing ritual for self, and (b) a reminder of what has been achieved. Strategies for preventing relapse. Part 2: Practice and development work 183 Year 2 Case Study: The Abandoned Boy 184 Introduction This case study includes an introduction, formulation, outcome and critical evaluation of the therapeutic process of working with a patient2 within the psychodynamic framework. It also entails a personal reflection of working psychodynamically within the counselling psychology philosophy. The context. The work reported herein took place in a clinic specialising in problem gambling. The sector of the clinic will not be disclosed due to issues of confidentiality. The service has two pathways: cognitive behavioural therapy (CBT) and psychodynamic therapy as well as offering medical treatment in the form of Naltrexone (Ward, Smith, & Bowden-Jones, 2018). The patient. Simon3 is a 48-year-old white, British, male from a middle-class background living in London. His family traditionally belong to the Church of England; however, Simon does not practice religion. During treatment, Simon was separated from his wife, with whom he has one son of ten and two daughters of 12 and 14 years. The racial demographic is similar to mine, but not nationalities. Our ages differ as I am 27 years old, during the work with Simon I was engaged, I am also heterosexual, but not religious and do not have children. The referral and psychiatric/medical history. Simon self-referred, reporting that he had been suffering from problem gambling since the age 14/15. After his initial assessment he completed a group CBT-programme and was referred on to psychodynamic psychotherapy following own request. He had no formal previous psychiatric diagnoses, although prescribed 20mg of citalopram (NHS, 2018) from his GP. He also suffered from asthma and chronic obstructive pulmonary disease. 2 Although there are many words describing people seeking help in psychological services, I have chosen to use the word ‘patient’. Deriving from Latin meaning ‘one who suffers’ I believe this word to be an accurate description of people I met in my placement and less pathologising than alternative synonyms. 3 Name of client, as well as other identifying information has been altered in order to maintain client confidentiality. 185 First impressions. When I first met Simon, I felt slightly threatened by him, as if he would test me and I would need to prove myself. I wondered if this was because he reminded me of my father, who is an unpredictable character in my life, or, whether this was how most experienced Simon. In my opinion he was dressed as if he was trying to deny his age by dressing ‘younger’ and I felt him sexualising me. I also experienced Simon as narcissistic in his lack of empathy and grandiose sense of self. The presenting problem. Simon described symptoms consistent with severe persistent gambling disorder (American Psychiatric Association, 2013). He also reported low self-esteem, feeling isolated and rejected following the separation from his wife and children. Current background. Simon is currently going through a divorce. His wife and children have moved out of the family home where Simon now resides alone. He works for a publishing company, where he often encounters difficulties with management and has described himself as being close to losing his job. He has had many positive ties to his community, however, since the separation has found himself isolated. Family and relationship history. Simon’s parents are married, his mother suffers from alcohol dependency and he described her as unpredictable during his upbringing, with frequent mood swings. Simon’s descriptions of his father varied between idealisation and denigration. He described his father as strict and occasionally condescending towards him. I got a sense of Simon’s father as engendering a conventional sense of masculinity where feelings are not discussed. He described his father as measuring him and his brother’s worth in their financial success. Simon has one older brother who he describes as the ‘golden boy’ in the eyes of their parents. Simon got married when he was in his early 30’s, and has a good relationship with his son, however, 186 he reports that he does not like his daughters and has decreased amount of contact with them following the separation. The contract and therapeutic aims. We agreed to a contract of 12 weekly 50-minute sessions with psychodynamic psychotherapy which has been reported to have successful outcomes in treating problem gambling (Mooney, Roberts, Bayson, & Bowden-Jones, 2019). I was mindful that within a Kohutian framework, this timeframe would limit our work and we ended up extending the therapy due to relapse. The price of sessions will not be stated due to issues of confidentiality. Simon was informed that confidentiality applied to our sessions and would only be broken in case of risk. Simon agreed for his data to be confidentially used for my training purposes and signed a consent form to this effect. Simon reported that he wished to use the therapy to investigate reasons why he had started gambling and to maintain his abstinence from gambling. He wanted to feel less isolated and make sense of his pending divorce. I hoped to offer a space where Simon could explore his feelings safe from judgement. I also thought it would be helpful for him to improve his ability to mentalize as Simon appeared to struggle with understanding other’s needs, feelings and reasons (Bateman & Fonagy, 2004). He also had some difficulty in understanding his own internal world. It became apparent that Simon struggled with self-regulating his emotions and tolerating negative feelings. I hoped that our work would start processes that would continue within Simon post treatment. Risk. Simon did not report suicidal ideation during our work. He disclosed altercations with his daughter which alarmed me to their wellbeing, this was reported to my supervisor and the safeguarding lead at the service as well as discussed with Simon. We monitored this throughout the work and supervision helped me understand how Simon experienced his anger and the importance of modelling empathy. Formulation 187 The formulation will be using the template outlined by Lemma (2016), however, will be amended to fit self-psychology and mentalization frameworks. Describe the problem. Simon described feeling abandoned; this manifested in his childhood and had resurfaced in his divorce, making Simon feel isolated and alone. He also experienced low self-esteem and gambles as a way of regulating his feelings. Describe the psychic cost of the problem. Simon’s difficulties resulted in him sexualising his relationships to women. I experienced Simon as wanting to connect with the women in his life, but feeling abandoned by them and acting out through rejecting or objectifying them. Simon also had difficulties with mentalizing which manifested in trouble understanding the minds of others, leaving him feeling isolated (Fonagy, Gergely, Jurist, & Target, 2004). Context of the problem. The feeling of abandonment was experienced by Simon already in infancy as he described his mother as unpredictable in her behaviour and misusing alcohol his whole life, potentially making her unreliable to pick him up when he was crying or attend to his needs. Kohut (1971) describes self-objects as objects experienced as parts of the self, typically either mirroring; which confirms the child’s sense of greatness or idealized parent imago which represents those the child looks up to as dependable, invincible and calm (Baker, & Baker, 1987). There are also twinship self-objects which lets the child feel as they are part of or merging with their self-objects. The effects of the potential failures in empathy by Simon’s self-objects (his mother and father) could have led to him not adequately developing the intrapsychic structures which regulate self-esteem (Rabstejnek, 2015). This left Simon overly dependent on people in the external environment to provide these functions (Baker & Baker, 1987). I noted that a comment, which could be interpreted as a criticism, was often experienced as catastrophic and 188 Simon would resort to omnipotence as a defence. His sense of self was fragile and often fluctuated between grandiosity and inferiority. Kohut (1984) argues that a child goes through many ‘frustrations’ in their developments and that the presence of supportive self-objects helps the child learn to tolerate these frustrations and self-soothe. This is termed optimal frustration (Kohut, 1984). However, for Simon, the self-objects were unable to soothe him and the frustrations became unbearable. He experienced sibling rivalry towards his brother who was the favourite. This was one of many narcissistic injuries or frustrations that Simon experienced during his childhood. He also experienced that he did not live up to his father’s expectations of him, leaving him with a feeling of not being good enough. Simon started gambling pathologically as a teenager which he links with an undiagnosed depression. The gambling could be formulated as a self-object which helped Simon to confirm whether he was a winner or a loser, thereby regulating his self-esteem. The gambling had similarities to his mother in its unpredictability and his father in indicating that you are only as good as your financial gains. The gambling confirmed what Simon’s father had reiterated to him throughout his childhood; that he was not worth betting on, except for the wins which gave him a feeling of omnipotence over his father. Pathological gambling has also been linked to neglectful parenting (Grant, & Kim, 2002) which Kohut argued could lead to an under stimulated self (Kohut, & Wolf, 1978). As Simon was growing up, he did not receive the required care and consideration and as his parents were seen as parts of himself (self-objects), Simon experienced himself as apathetic. Consequently, Simon began a pattern of ‘stimuli to create a pseudo-excitement in order to ward off the painful feeling of deadness’ (Kohut & Wolf, 1978, p. 417) in the form of gambling. The patient’s self-objects. Simon’s mother rarely reflected back to him an image of him which was favourable, he was deemed untrustworthy and unworthy. Later in his childhood his father mirrored an image of Simon back to him of not being worth betting on and only as good as his financial gains. 189 Simon experienced a loss of the idealized parent imago as his parents were not people he could merge with, which symbolised calmness and omnipotence. Later in his life his wife and daughters became self-objects. As Simon expected to have a sense of control over his self-objects (Kohut & Wolf, 1978), when these self-objects rejected him, it became catastrophic. Naturally, going through a divorce would be traumatic in most circumstances, however, in Simon’s case he experienced it as a rejection of parts of himself which was detrimental to his self-esteem. In the therapy I became a self-object for Simon which he looked to, to confirm his omnipotence and criticism became unbearable. Transference. Simon’s most obvious transference towards me was a sexualised one. I hypothesise that this transference is born out of a need for a twinship self-object, a want to feel a degree of alikeness. In his childhood there had been a lack of satisfactory twinship self-objects, leading to an intensified need for a twin in adulthood. Baker and Baker (1987) argued that the longing for self-object needs, which have not been met can often become sexualised. Simon and I differed in ages, education, nationality and other demographics, however, Simon wanted to become one with me. He found the therapeutic encounter difficult as it brought up a feeling of being unable to cope, however, if we found a oneness, this would make our relationship more bearable. I also experienced that he had some impotent rage towards me which was projected from his mother and wife. Countertransference. I experienced a strong negative countertransference towards Simon consisting of feelings of disgust and intimidation. In part, I believe this to originate from who Simon represented in my own internal world, including men who had objectified me, or a disapproving angry father. This led me to relate to him in a more submissive manner and I found it more difficult to challenge him than I did my other patients. Through supervision, I became more aware of this dynamic and learned to gently externalise it in the relationship with Simon. I would also hypothesise that some of my negative countertransference originated from how 190 Simon related to me. Through my work with Simon my countertransference towards him changed as he revealed more of his fragile self. I became more empathetic towards his very critical super-ego and his internalised anger towards himself. I wanted him to be empathic towards himself and so I became empathic towards him. Defences. Simon’s feeling of loneliness and being a failure was managed by projecting his own undesirable qualities such as failure or lack of empathy into his wife and his daughters. Kohut argues that projecting everything unpleasant and absorbing everything pleasant can be a part of building up new systems of perfection (Greenberg & Mitchell, 1983). His low-esteem was defended against by using omnipotence (Lemma, 2016). This manifested itself both intrapersonal as a fleeting, inflated sense of self-worth and interpersonal in the denigration of others (Lieberman, 2013). If he were to relinquish these defences, he might experience a collapse of his sense of self and his self-worth. Projection and omnipotence are both primitive defences which serves the function of protecting the ego from conflict by keeping apart contradictory experiences (Lemma, 2016). The Therapeutic Process Extracts from significant sessions. The following extract is recorded 19min into the fifth session. We had been discussing Simon’s relationship with his family, he had expressed a desperate want to get them back as well as anger towards them. I chose this extract to demonstrate how Simon and I got stuck and lost mentalizing. The negative counter-transference interfered with my ability to emphasise with Simon (McLean, 2007). The extract also demonstrates the key themes that Simon and I worked on through the course of the therapy. Dialogue Process comments Patient 1: because I said no, you get the nice things, this is control, you can call it Simon appears to have internalised a patriarchal authority (Gaitanidis, 2011). He 191 control or whatever, but I said you get me to do these favours for you, when you show me some respect, not the other way around because I am your father, I have done so much to earn your respect just one more thing? No! You’re going to have to learn to behave correctly and then I will do these things. Effectively they refused to behave correctly, you know? Therapist 1: how is it to be father for daughters? How do you see yourself as a father to daughters? is showing some insight into his need to control his self-objects. However, the narcissistic injury of being abandoned by his family is still being acted out by denial of his own needs for closeness (Bateman & Holmes, 1995). My intervention was aimed at getting us to reflect on Simon’s own role within the family and his needs. However, at this stage Simon had exceeded his optimal frustration (Kohut, 1984) and was unable to reflect with me. A more empathetic response (Kohut, 1984) might have been more helpful here in order to bring his frustration down. Patient 2: Mother takes up the space, there is only limited space to parent a child and you should be doing 50/50 she’s super-women in terms of parenting, ultra-organised no diary doesn’t need it. None of this flapping around that you see with, you know, that sounds derogatory to women but she is the one that would say that, ‘oh God I’m so sick of (name of female friend) she can never get her shit together’ you know? My wife is known to be very direct very organised, practical, does it all with a I believe Simon is experiencing the themes of feeling abandoned and not good enough. He is also struggling with issues related to his masculinity (Gaitanidis, 2011). Simon is maintaining an ‘other-reflection’ focus and I wanted to bring him towards a ‘self-reflection’ (Bateman & Fonagy, 2016a). 192 smile on her face and will do 20 things in a day. Therapist 2: and you? What about you? Patient 3: Left on the side-lines. Therapist 3: mhm, is that what’s so tricky do you think as well in relating to your daughters that you don’t feel like you have a relationship with them anymore? Although Simon had also rejected his daughters, I wanted to emphasise with the ‘validity and legitimacy of the patient’s own perception of reality’ (Kohut 1984, pp. 173). I also wanted to invite Simon to discuss the unconscious pain of rejection from his daughters. Patient 4: exactly, my wife has written me out of the story, this has been happening for two years, when I look back I can see that I was not sort of included in certain things where I might have been. In fact, I would go back 10 years and we would go on a Holiday together and partner’s excuse for me not to come was I need to earn more money. I need stay at home, get on the phone and earn more money. It will give you an opportunity to work without the hustle and bustle of children in the house. Therapist 4: yeah My intervention was unsuccessful in that we seem to be stuck in a ‘other reflection’ blame-game (Bateman and Fonagy, 2016a). Simon is also telling me about a feeling of failure of being the omnipotent father. It might have been better to enquire about his anger and the underlying pain. Patient 5: yeah, I have effectively been written out of the story. And that suits The affect become too much and he resorts to denial of his own experience of 193 me to a degree, sounds harsh but I think it’s best for the girls and best for me. And now I think how does a judge look at that? Therapist 5: but girls need a father. abandonment, by rejecting the other (Lemma, 2016). I let my own feelings about my father cloud this intervention and did not account for his idiosyncratic experience. I believe this challenge might have been useful later in the work when Simon’s affect had been brought down (Bateman and Fonagy, 2016b). A more relational intervention might have been more appropriate e.g. ‘does this suit you? Because I’m not sure it does’. Patient 6: Do they? Really? The law doesn’t say that. Therapist 6: what do you think? Patient 7: ehm, need? Need a father… no I don’t, I think society has become so feminised that they don’t. Unfortunately. Therapist 7: you don’t think your daughters need you? It might have been more useful to explore his feelings of not being needed (Bateman & Fonagy, 2016a). Patient 8: no, not any longer, well I’ve proven that haven’t I? My wife is bearing that out. She is showing them that they don’t need me. Therapist 8: So, show them that they need you. You are part of the story. You I want him to take responsibility for his children, just as I want my father to take responsibility for me. 194 seem to be part of the story that is excluding you. You are writing it with them. Patient 9: I don’t get any value from them and they don’t seem to want to get any value from me whatsoever. It is difficult to get isn’t it? Don’t forget I have been there, literally every day from the first one was born working from home, picking up from school. Therapist 9: So they do need you? Simon is saying that he is worthless and that I cannot understand what that feels like. He is worried about me seeing him as a bad father. An alternative intervention could have been to explore how he feels about how I see him by doing a here-and-now interpretation (Yalom, 2002). Patient 10: No they don’t any longer, I’ve been discarded. Therapist 10: But I feel that you are more an active part in that life when they were younger and that was you know very different but now, it seems that you are also excluding yourself. It is not just that you are no longer needed, it seems that you are almost unavailable. My intervention was aimed at creating insight into his power over the situation, helping him see that he could change his relationship with his daughters. Patient 11: Every night I text my son and he texts me back ‘love you’ love hearts all that sort of stuff. My daughters I tried for a week, two weeks most nights to send something… nothing. I think they are jealous of the relationship I have with my son. Therapist 11: That’s interesting, how do you feel about that? I believe he experienced me as not approving of his behaviour and consequently had a negative impact on his self-esteem (Baker & Baker, 1987). This triggered him to behave defensively about his role as a father. 195 Patient 12: I think they fucking well ought to be jealous because we have a fantastic relationship. He is portraying to me the inaccessible father he experienced. We have colluded into a non-mentalizing stance and have moved further away from thinking about his daughters’ feelings and his own (Bateman & Fonagy, 2016a). Evaluation In this extract I let my negative countertransference (Winnicott, 1994) shape my interventions and did not provide optimum empathic responsiveness for him to feel safe to relinquish his defences (Rabstejnek, 2015). In his transference, I represented his judgemental mother, disappointed wife and perhaps most prominently his argumentative daughters. The next extract is from session 17, 44 min into the session. We had been discussing his sexuality and the possibility of a new relationship. He had been able to state that the idea of a relationship with a man had crossed his mind, however, stated that he was not ‘gay’ and that he could not imagine being sexual with a man, but longed for connection. Dialogue Process comments Patient 1: I suppose you could have such an alienation from women generally, that… but then, that’s only a relationship thing in that that is not a sexual thing. Therapist 1: Do you feel alienated from women? My wish was to move from cognitively organised, detached discussion about homosexuality, to a more affectively aroused work relating to his feelings of abandonment (Bateman, & Fonagy 2016a). Patient 2: Do I think that I am alienated from women? 196 Therapist 2: Do you feel alienated from women? Patient 3: Absolutely! If you think about the women in my life my mum, my wife, my two girls. Therapist 3: mhm Simon is showing increasing ability to reflect on his relationships and draw links between them (Bion, 1959). Patient 4: Either they’re not talking to me or I’m not talking to them (laughs) or both. Therapist 4: yeah. In this extract Simon is able to discuss his own role in these relationships (Lemma, 2016). Patient 5: Which is not good is it? Do I come across as a women hater? Therapist 5: not to me. Simon is demonstrating exploratory behaviour, implying an increased ability to mentalize (Bateman & Fonagy, 2016a). From a Kohutian perspective it would probably not have been useful to give a full countertransference disclosure. My intervention was aimed at showing Simon that he could connect with women. It might have been better to think about the unconscious source of this question (Etchegoyen, 1991). Patient 6: Good, because I don’t intend to. But then somebody did accuse me of that just today actually. Therapist 6: But I do wonder if there is something about women that are a bit, like, threatening. We miss each other here, I am still in ‘Patient 5’. This is the first time Simon is exhibiting this curious stance and I deemed it appropriate to introduce an interpretation relating to his feelings towards women. 197 Patient 7: (sighs) Well women are powerful. Therapist 7: mhm Patient 8: They are brighter than men emotionally, certainly in general and women are powerful generally. So, eh yes, to be fearful of women, I am much more fearful of women than I am of men. Therapist 8: Mhm, that’s interesting isn’t it? Simon is sharing his experience of his self-objects and the fear of being rejected by them (Baker& Baker, 1987). I wondered whether he has experienced my interpretation as criticism. Patient 9: I mean I am not fearful of any man, I’m not generally. Not my father, not anybody. Therapist 9: Are you afraid of women? Simon is eluding to an unresolved oedipal feeling of rivalry and competitiveness towards his father as well as omnipotence (Freud, 1997). Patient 10: Yeah, I recon I generally am now. Therapist 10: Are you afraid of me? This transference interpretation aimed to bring into consciousness how I had come to represent other women in his life in the transference (Roth, 2001). Patient 11: Am I afraid of you? Therapist 11: In that way. Patient 12: You are recording me, of course I would be afraid of anybody’s intentions of recording me. Therapist 12: right, right. I had a dilemma regarding whether to pursue the topic of what the recording meant to him, however, this felt like a deflection. 198 Patient 13: ehm, am I afraid of you, no I don’t think so. I think, I don’t know, you’d have to demonstrate a certain power. Therapist 13: mhm Patient 14: that I couldn’t understand or understand how to influence it or control it, so if you had unbridled power like a wife has over her husband. Therapist 14: or a mother has over her son. It might have been more helpful to interpret the phantasy of me being his wife. We are both deflecting here due to a fear of an exploration of the sexual transference. Patient 15: or mother over a son. Therapist 15: mhm Patient 16: then, I would be distrustful of your motives. But you know, you don’t have those. You have the power of the training that you have to keep somebody talking. Therapist 16: right Patient 17: on a counseling one Therapist 17: right, so there is a kind of authoritative, like, status here, you mean? I wanted us to acknowledge the power that does exist within the therapeutic relationship and demonstrate that there can be power imbalances in relationships which are supportive and safe (Howard, 2017). Patient 18: yes. But I recognise that it is a different kind of authority. Therapist 18: right 199 Patient 19: and why it is necessary. But you think I deal with you in any particular way that you find is uncomfortable to you? Therapist 19: well the only thing I thought about, not uncomfortable, but I thought about whether when you said I have certain feelings about you, I fantasise about you and I thought about that whether it is easier to relate to me in a way that is kind of more, kind of, is not like a subject necessarily. Do you know what I mean? I believe this was an important moment in our process as Simon feels comfortable and curious enough to ask me this question. The inquisitive nature of this statement shows an improvement in mentalizing as Simon is curious about my mind and how his behaviour affects our relationship (Fonagy, Gergely, Jurist, & Target, 2004). An alternative response here would have been to be curious as to why he was asking this question (Lemma, 2016). However, I decided to go with a countertransference disclosure (Howard, 2017) as I wanted us to think about the dynamics that played out in our relationship. The delivery of my intervention is shaped by still experiencing Simon as slightly threatening and testing. Patient 20: Objective yeah. Therapist 20: Do you know what I mean? Whether it is easier to relate to me like that because I do come off a bit threatening because there is an authoritative stance in this relationship that is difficult to get away from, no matter how, because of the training and 200 because this is your therapy and all these kinds of things. Patient 21: mhm, well it is also a challenge, you know I like a challenge you know and put a challenge out there, playful. It is also a very serious process in a way. Therapist 21: yeah, can be playful but can be very serious at the same time, but if it is only serious it can get a bit draining. Play has been argued an important aspect of health (Lemma, 2016). Simon is also challenging me in this statement. I wanted to demonstrate an ability to hold both perspectives on our process as playful and serious. Patient 22: (laughs) yes exactly. You know for a bit of fun I throw a bit of a curveball in there also to test you to know that you know what you are doing. Therapist 22: right One of the great pleasures of working with Simon was seeing his increased humour in our sessions which is also linked to therapeutic transformation (Lemma, 2016; Kohut, 1971). However, Simon is also challenging me and at this point. Patient 23: and that I am not just sitting here wasting my time and that it is you know in case you were yours you know? So, you know I want to get something out of this as well, I do want you to, you know, I hope there’s things that you got through this process from me that you can apply in other aspects of your work you know? Therapist 23: Mhm, and I wonder if that is the part that wants to help me with I believed I missed an opportunity to acknowledge the increasing ability to display empathy towards me and instead interpreted his need to control the process (Kohut, 1971). My defensiveness about my role as the therapist influenced my comment. 201 something you don’t just want to get help, you know? You want to control some part of it as well. Patient 24: (laughs) Therapist 24: you know what I mean? or not control necessarily but kind of switch it around a bit so that I am also helping you and I hope you can use this, you know all these kinds of things. Patient 25: so yeah, which probably shows a lack of confidence on my behalf, that I can’t just accept the help I have to actually have to… Therapist 25: Is it lack of confidence though? I wonder if you just want to help. Or if it is hard to just get help. You know what I mean? I could have explored his feeling of lacking confidence further, however, I felt it important for Simon to get acknowledgement for his empathic qualities in our relationship (Kohut, 1971). Patient 26: I am not a saint, I know what you mean, yes, I think a lot of it is lack of confidence, but I do genuinely like helping people if I can. Therapist 26: Yeah, yeah. Simon is showing an ability to be vulnerable with me and relinquish, if only briefly, his previously held defences. His defences have been partially replaced by an ability to mentalize and a curiosity about himself and his relationships. Patient 27: Because I feel misunderstood in that way. Evaluation 202 In the second extract me and Simon have moved the conversation from what is going on in his relationships ‘out there’ to how these patterns manifests in our relationship (Lemma, 2016). He is able to discuss a lack of confidence rather than projecting negative feelings (Howard, 2017). Outcome and Critical Evaluation From the beginning of therapy, Simon and I worked on exploring why he started gambling. This exploration led us to go back to his childhood and his relationships with his parents. Through forming a relationship with me, Simon reported feeling less isolated, however, that this also brought up anxieties about the ending of our relationship. Simon started experimenting with new behaviours in his relationships (Howard, 2017) which manifested in his increasingly curious nature. He was able to occasionally relinquish his defences and be more vulnerable. His goal of making sense of his divorce proved difficult, however, we were able to explore some interpersonal difficulties. Through the therapy Simon started to incorporate some of the missing self-object functions into his internal psychic structure (McLean, 2007) and I could notice him finding some relief from his anxieties and having more internal peace. Through my work with Simon I have learned how to work with negative countertransference and how to use supervision openly. It also helped me understand how to explore a sexualised transference without judgement (Lemma, 2016). Simon helped me relate to my father in a more empathic way which is a great gift I will cherish. I found it difficult to overcome my own countertransference towards Simon, especially when I assumed the role of his daughters. We got caught in an enactment (Howard, 2017) where Simon’s vulnerability of his destructive self-objects interacted with my vulnerabilities in relation to my relationship with my father (Schore, 2012). I have learned how important it is for me to bring my whole self into supervision to bring into consciousness how my own history influence my interventions. The resistance towards the ending (Lemma,2016) manifested in Simon relapsing towards the end of our work. Upon exploration, Simon confessed to feeling hopeless and 203 wanting to start treatment again. I also had a sense that he was punishing me for not being a ‘good enough’ mother (Winnicott, 1994). The ending was prefigured to be difficult as Simon was going through a difficult ending with his wife. Simon missed his last session, which I hypothesised to be a way to turn the experience of being left from passive to active (Lemma, 2016). He was able to send me a goodbye letter acknowledging the progress he had made and expressing his gratefulness for the therapeutic experience. Relationship with Overall Philosophy and Implications for Professional Development as a Counselling Psychologist Yalom (2002) argued that ‘there is no better way to learn about a psychotherapy approach than to enter into it as a patient’ (p. 43), an argument I agree with. From the onset of training, I was excited about the psychodynamic approach and sought out a therapist with this orientation. This provided me with valuable insight into the processes and experience of this approach. Negotiating from the person-centred approach (Rogers, 2003), I found that psychodynamic offers a language for both negative and positive feelings evoked in both patient and therapist offering an opportunity to work with the whole person. I would have found it difficult to work with Simon in the person-centered framework, due to not experiencing unconditional positive regard (Bozarth, 2013) for him at the beginning of treatment. Working psychodynamically offered a language for the countertransference (Valerio, 2018) which opened up a pool of information. I found that the psychodynamic approach also offered a richer theoretical foundation for making hypothesis and formulations about the patient. This is particularly evident in the emphasis given to experiences and phantasies from a developmental perspective and how these might influence a person’s intrapsychic and interpersonal world (Howard, 2017). My expectations for the transition to CBT include that this might entail a more concrete way of working rather than the more abstract and symbolic thinking embedded in psychodynamic psychotherapy. This year has felt exposing and more relational than other 204 clinical work and I have kept clients in mind in a much more meaningful way. I hope to keep the relational stance throughout my career and development as a counselling psychologist. I am excited to learn more about the CBT approach and utterly grateful for the knowledge of the psychodynamic approach I have acquired this year, it has changed me. 205 References American Psychiatric Association. (2013). Diagnostic and statistical manual for mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596 Baker, H. S., & Baker, M. N. (1987). Heinz Kohut’s self psychology: an overview. The American Journal of Psychiatry, 144(1), 1-9. Bateman, A., Bales, D., & Hutsebaut, J. (2019). A quality manual for MBT [PDF file]. Retrieved from https://www.annafreud.org/media/7863/quality-manual-2018.pdf Bateman, A., & Fonagy, P. (2004). Psychotherapy for borderline personality disorder: Mentalization based treatment. 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Mapping the landscape: levels of transference interpretation. International Journal of Psychoanalysis, 82 (3), 533-544. Schore, A. N. (2012). The science and art of psychotherapy. New York: W. W. Norton. Sheehan, L., Nieweglowski, K., & Corrigan, P. (2016). The stigma of personality disorders. Current Psychiatry Reports 18(11), 1-20. Siegel, A. M. (1996). Heinz Kohut and the psychology of the self. Sussex: Routledge. Valerio, P. (2002). Love and hate: a fusion of opposites – a window to the soul. In D. Mann (Ed.), Love and hate: psychoanalytic perspectives. (pp. 253-266). Sussex: Routledge. Valerio, P. (Ed.). (2018). Introduction to countertransference in therapeutic practice: A myriad of mirrors. Oxon: Routledge. Ward S., Smith N., & Bowden-Jones H. (2018). The use of naltrexone in pathological and 208 problem gambling: A UK case series. Journal of Behavioural Addictions 7(3), 827-833. doi:10.1556/2006.7.2018.89 Winnicott, d. W. (1965). The maturational processes and the facilitating environment: Studies in the theory of emotional development. Oxon: Routledge. Winnicott, D. W. (1994). Hate in the countertransference. Journal of psychotherapy practice and research, 3(4), 350-356. Yalom, I. D. (2002). The gift of therapy: An open letter to a new generation of therapists and their patients. London: Piatkus. 209 Appendix 1 DEPARTMENT OF PSYCHOLOGY PSYCHD COUNSELLING PSYCHOLOGY DECLARATION OF SERVICE USER’S CONSENT TO USE MATERIAL FOR SUPERVISION, EXAMINATION AND RESEARCH PURPOSES N.B. THIS FORM MUST BE COMPLETED AND SUBMITTED WITH CASE MATERIAL (Do not include consent forms signed by service users.) I, (TRAINEE’S NAME) SOFIE HEIEN CONFIRM THAT I HAVE OBTAINED THE INFORMED CONSENT OF THE SERVICE USER WHOSE CASE MATERIAL I AM PRESENTING FOR MY PRACTICE ASSIGNMENT. TRAINEE’S SIGNATURE: DATE: 01.05.2020 210 Year 3 Case Study: When God enters the therapy room: A case study on separating religion from religious intrusive thoughts 211 Introduction This case study aims to explore the delicate process of separating a client’s religion from their religious intrusive thoughts. Religion, in this context, refers to the client’s own definition of their religion. Religious intrusive thoughts are reoccurring, persistent, intrusive images or thoughts of a religious nature that are unwanted and highly distressing. In the literature, intrusive thoughts are typically discussed in the context of obsessive-compulsive disorder (OCD) where intrusive thoughts are listed as a symptom (American Psychiatric Association, 2013). People suffering from OCD experience intrusive thoughts that are often followed by compulsions. Compulsions can be behaviours that are physical, such as repetitive checking that a light switch is off, or mental such as counting (American Psychiatric Association, 2013). Much of the literature on OCD suggests that blasphemous or religious intrusive thoughts are common within the disorder (Mind, 2019; Smith, Robinson, & Segal, 2021), however, there are limited references to the delicate ethical and clinical implications of working with religious intrusive thoughts in psychotherapy. Much of the literature on OCD is grounded in the cognitive and behavioural therapeutic framework (CBT) (NHS, 2019) and the national institute for health and care excellence (NICE) guidelines recommend CBT, and in particular exposure and response prevention (ERP) for treating OCD (NICE, 2005). This is grounded in an evidence base that suggests this approach leads to better outcomes (Reid et al., 2021). As this case study will argue, religious intrusive thoughts might, in some cases, need a different approach to OCD. The client in this case study – who suffered from a variety of intrusive thoughts followed by mental and physical compulsions – experienced her religious intrusive thoughts differently to her other intrusive thoughts. She felt the religious intrusive thoughts had more power over her and were more difficult to challenge as this triggered a fear of God’s punishment. Different therapeutic frameworks have different ways of conceptualising intrusive thoughts. Within the CBT framework, intrusive thoughts are normalised, and it is the meaning and cognitions about the thoughts that are seen as problematic (Kennerley, Kirk, & Westbrook, 212 2017; Leahy, Holland, & McGinn, 2012). For example, a thought that something bad will happen to a family member is not in itself problematic. However, if the person believes that the thought means that something bad will happen to a family member, and consequently feels an inflated sense of responsibility and engages in compulsions to prevent this from happening, this can significantly impact a person’s ability to strive. The psychodynamic literature pays much attention to the individuality of each case, therefore, making overarching conceptualisations about certain diagnosis within this framework pose some challenges (Jakes, 1996). However, some attempts to conceptualise OCD and intrusive thoughts has been made. DiCaccavo (2008) argue that intrusive thoughts arise in the absence of containment from the primary caregivers, leaving the child with an emotional void. If parents are unpredictable and the child experiences a fear of abandonment from a parent, it becomes impossible to express feelings of rage towards them out of fear that they will abandon the child. Therefore, the child adopts a strategy of splitting off feelings of rage as an attempt to keep the bad object apart from the good object or parent. The process of splitting off also involves splitting off a part of the child’s emotional experience. Intrusive thoughts become a form of protection from the loss of a good object through controlling it within the mind. Jake (1996) proposes an internal conflict between aggressiveness and submissiveness which may stem from a regression to the anal stage of development outlined by Freud (1913), which is associated with anger, aggression, and exercise of control over others. Adler (1964) explains OCD as a way of exercising control when a client might feel that they lack control over their circumstances. It has also been argued, that bringing unconscious conflicts and repressed anger into consciousness help decrease intrusive thoughts and that managing the anger through assertiveness can hugely benefit OCD clients (Malan, 1979). Some authors have argued that religious obsessions and excessive guilt that triggers compulsive behaviours warrant a separate diagnosis or subtype of OCD – scrupulosity (Abrahamowitz, 2001; Ciarrocchi, 1995; Miller & Hedges, 2008; Santa, 2017). Clients suffering from scrupulosity may feel engagement in therapy as a sin (Foss, 2019). Santa (2017, 213 p. 8) writes “Since the obsessive thoughts are associated with faith and spirituality, the entire experience of faith is marked with anxiety and fear instead of peace and strength”. Much of the literature on scrupulosity focuses on clients who are practicing organised religion. The current case study presents a client who no longer engages in organised religion, but, at the time of treatment, was searching for her religious beliefs and identity. Although some psychotherapeutic literature argues for the separation of religious obsessions and a client’s religious beliefs, the practicalities of how this plays out in the therapeutic encounter is seldom described (Foss, 2019). Therefore, this case study aims to add to the existing literature by exemplifying this in clinical practice as well as exploring issues that might arise in this process. Psychotherapeutic literature has had different attitudes towards working with religious beliefs in therapy. Freud (1928) described some religious beliefs as regressive, delusional, and stemming from a need for an omnipotent father figure, and saw religious practices as defences against sexual impulses. In more recent literature there has been a focus on the link between religion and well-being (British Psychological Society, 2017). Coyle (2010) writes that “Counselling psychology’s commitment renders it ideally placed to provide a model of open, respectful, contextualised engagement with client’s religious and spiritual issues” (p.272). Coyle (2010) also writes about the ethical dilemma that arises when a client’s religious images and meaning become problematic, stating that this represents a clash between a client’s autonomy and beneficence. Some authors have also pointed out the difficulties in placing a border between some client’s religious or spiritual paranormal experiences and psychosis, but this debate is beyond the scope of this case study (Clarke, 2001). The literature on OCD frequently discusses the concept of thought-action fusion where thoughts are regarded as equivalent to the corresponding action. For example, that thinking of hurting another person becomes equally bad as actually hurting them (Berle & Starcevic, 2005; Rachman & De Silva, 2009). When the intrusive thoughts are of a religious nature (such as blasphemous intrusive thoughts), thought-action-fusion can make the client believe that they are immoral and deserve to be punished. Within the counselling psychology literature there is 214 a focus on sensitivity and honouring clients’ religious views (Coyle, 2010). I therefore experienced this dilemma of separating a client’s religion from religious intrusive thoughts to be a delicate and difficult process, as I did not want her to feel that we were ‘treating’ her religion. The client presented in this case study suffered significantly with repetitive and debilitating religious intrusive thoughts that were followed by compulsions, triggering feelings of guilt and shame that stopped her from living the life she wanted. The work took place in a community counselling charity in London where I was doing my third-year clinical placement. The client Micha4 is a 35-year-old heterosexual woman born and raised in London who self-referred to the service. Her mother is British, and her father is Caribbean. She has one younger sister with whom she shares both parents and two half-brothers from her father’s previous marriage who she does not have much contact with. Both half-brothers suffer with mental health problems, and one has been diagnosed with schizophrenia, her father has been a voice hearer in the past. Micha was born into the Jehovah’s witness faith. From an early age she was taught religious doctrines with strict moral codes. The faith encompassed most areas of her early life including friends, family, and community, as well as playing a large part in her learning how to behave and be in the world. Through the faith she learned that sex outside of marriage, including masturbation, was sinful, this later became a source of distress relevant to our work. She describes the teachings as punitive and that growing up in the faith left her with feelings of shame and fear, in particular that she would not be accepted into Paradise. When Micha was 11, her parents decided to leave the faith. As the faith had provided her with moral codes and a belief system that made sense to her, she therefore experienced leaving as confusing and destabilising. 4 The name of client and other identifying information has been altered to maintain client confidentiality. 215 Micha describes her parents’ marriage as problematic and that there were frequent arguments in the house. Her mother was an unpredictable character who experienced mood swings. She describes feeling as though she had two mothers, one who was depressed and unable to cope, and another who looked after her. Micha was never sure which mother would appear and became hyper-vigilant of any subtle changes in her mother’s mood. When Micha was 16, her mother announced that she was leaving, and the following day, she moved out. She brought Micha’s younger sister with her, saying there was no room for Micha to come. After this, Micha stayed in contact with her mum and sister but lived with her father. Following the separation, Micha’s father became dependent on alcohol and his mental health deteriorated. Over the coming years, her father started hearing voices and became, what Micha describes as volatile towards her. There were incidents where he would sleep on her doorstep as she was afraid to let him inside. During this time, Micha finished her secondary education and did one year of college before dropping out and starting to work in a supermarket. Micha started developing symptoms of OCD at the age of eight but was not diagnosed until the age of 22. She did not have any psychological intervention during this time and was afraid to tell anyone about her symptoms. Eventually, she was diagnosed with OCD when she presented at a mental health charity and was offered a 10-week group support programme which she attended and describes as helpful, however, her symptoms persisted. Her OCD manifests in intrusive thoughts, either blasphemous or that something bad will happen to a family member. The following compulsion to neutralise the distressing thoughts are mental activities such as praying repetitively. This has caused great disruption to Micha’s life where she has been unable to engage in activities that bring her joy as the intrusive thoughts have become overwhelming and cause high levels of anxiety. Micha’s sexual development is also of importance to her difficulties. At the age of 13, Micha masturbated using an object that her mother later donated to charity. This has been a source of deep shame in Micha as she felt her sin had contaminated an object that was donated to charity. This has consequently been the content of intrusive thoughts that she has sinned and 216 needs to confess. Micha experienced her body and sexuality as something deeply shameful and is very fearful of the possibility that she will not be accepted into Paradise because of what she has done. Micha has had sex once in her early 20’s which she describes as a positive experience. However, at 35, she had not had sexual or intimate romantic relationships since. At the time of our work Micha was unemployed and lived with her sister. Her OCD symptoms got progressively worse during the pandemic as her normal coping strategies, including socialising and dancing, were unavailable to her. Micha and I were of similar ages, but differed in our racial identities, nationalities, family backgrounds, and religious views. I grew up in an atheist household with parents who reject organised religion. However, I developed an interest in religion in adolescence and would attend religious gatherings with friends or when travelling, but do not consider myself to be part of any one religious’ faith. Micha and I are both interested in the spirituality aspect of religion and how it can provide a source of comfort and strength. Theoretical approach My therapeutic approach is grounded in a belief that all clients are unique and that different therapeutic approaches might benefit different clients at different times. If counselling psychologists are to practice ethically with the client’s interest at the centre of the therapeutic encounter, our own affiliation to one therapeutic framework, needs to come second. Yalom (2002) argues for the need to create a new therapy for each client and that the psychotherapy needs to take account of the idiosyncratic nature each client’s inner world. Jung (1995) argues for creating a new language for each client. When Micha entered the therapy room, she already had ways of conceptualising her difficulties and expressed wanting to take a developmental perspective and make links between her childhood and current difficulties (Bion, 1959). She expressed having felt deeply out of control with her ever-changing circumstances. She also expressed wanting to face her fears of the intrusive thoughts and that she was highly motivated for change. 217 Based on the above, the psychodynamic framework offered itself to us as a way of exploring how her childhood might have shaped her current difficulties and strategies of coping (Lemma, 2016). Grounding our work in the psychodynamic framework allowed for us to look at how her relationships with her early attachment figures, and her childhood phantasies, might have shaped how Micha relates to others and the world. However, we considered that her wish to face her intrusive thoughts and reduce the anxiety might need a different approach. I presented ERP techniques to Micha as a possible way to work with her OCD symptoms. She was motivated to try this, however, did not want this to be exclusive as she wanted the sessions to be explorative. This is how Micha and I ended up with an assimilative integration grounded in a psychodynamic framework, integrating ERP techniques (Messer, 2003). In assimilative integration it is important to consider whether the different approaches can be integrated in a meaningful way that is helpful to the client. Is the language and views on causation in ERP techniques too different from the psychodynamic tradition that integrating the two becomes too messy? Smith argued as early as 1982 that the time of individual schools of therapy is ending and research suggests that the majority of therapists define themselves as integrative or eclectic (Jensen, Bergin, & Greaves, 1990; Norcross, Karpiak, & Lister, 2005). Micha and I incorporated meta-communication about the therapeutic process as an important pillar in our work (Cooper et al., 2016). This gave us the opportunity to continuously monitor the progress and reflect on the therapeutic work together as we integrated psychodynamic psychotherapy with ERP. My challenge within this work involved thinking about whether these different frameworks’ conceptualisations of intrusive thoughts (as outlined in the introduction of this case study) were too different to be meaningfully integrated. This was addressed through a both/and rather than an either/or perspective. I thought of these approaches not as opposing theories, but rather, that they both could make valuable contributions to the work. I did not experience these different approaches to hinder the work, but to aid it, with multiple 218 perspectives that could move the work forward. We could explore how her fear of abandonment in childhood might have led to splitting off parts of her emotional experience, and still discuss how to change her beliefs about the intrusive thoughts. Within the literature, several authors have also argued for the usefulness and richness that integrating psychodynamic psychotherapy with ERP provides when working with OCD (Bram & Björgvinsson, 2004; Garcia, 2008; Haverkampf, 2017; Woon et al., 2017). I presented my challenge of assimilative integration of two different approaches in supervision. In the context of Micha’s difficulties, I argued that it would not be keeping her best interest at heart to shut down either her explorations of her difficulties – which were more open in nature and often led us back to her childhood – or deny her the potentially helpful and well evidenced ERP techniques (Leahy, Holland, & McGinn, 2012; NICE, 2005). My supervisor was appropriately skilled in both approaches and frequently integrated approaches in her own work, and we agreed on this treatment plan. At the centre of our integrative approach was the meaning that Micha made of her difficulties and our relationship. Formulation This formulation is grounded in the psychodynamic framework as this approach formed the basis of our work into which other techniques were integrated. I hypothesised that given the variety of difficulties Micha was dealing with, different aspects of the psychodynamic framework could be beneficial in the work. Therefore, I chose not to limit our work to one school of thought. The formulation follows the template offered by Lemma (2016). Dallos and Stedmon (2014) argues that formulation is best used as a verb formulating, which is seen as a continuous process rather than an event. Micha and I formulated her difficulties in a dynamic way, as our trust grew and more information was added, the formulation developed and changed. Describe the problem Micha described debilitating intrusive thoughts triggering shame and anxiety which she neutralised with compulsions such as mentally repetitively apologising or praying. The 219 intrusive thoughts consisted of blasphemy (such as thinking ‘fuck Jesus’), and sexually shaming thoughts that she had to confess her sins. She was anxious that these thoughts were messages from God who would not let her into Paradise because she was a bad person. Although she could rationalise her intrusive thoughts, she was left with a fear of ‘what if’ it really is God. Describe the psychic cost of the problem Micha feels that her difficulties have kept her from living a fulfilling life, including finding employment. She struggles to form meaningful relationships with others, especially romantic relationships and she reports wanting to have a partner. She experiences low self-esteem and feeling like a failure. Contextualise the problem Micha was born into the Jehovah’s witness faith where she received powerful messages about sexual exploration as sinful outside of marriage. This developed into a limiting sexual script that provoked feelings of intense anxiety around her sexuality (Gargnon & Simon, 1973). Her early experiences exacerbated feelings of shame around sexual exploration. This led Micha to deem all sexual feelings unacceptable and supress them creating an internal conflict between her id and her super ego (Freud, 1923). The id seeks to discharge the sexual feelings she experiences. The super-ego – imposed by strong religious sanctions and morals from early childhood – seeks to supress her sexual desires. This forms an unconscious internal conflict. Another conflict, related to the above, was a strong fear instilled in her from the religious sanctions that God would punish those who did not live up to his word and Micha describes a deep-rooted fear of not being accepted into Paradise despite not practicing organised religion. In Micha’s childhood and adolescence, there was an apparent lack of control over her life circumstances, which made her struggle with uncertainty in adulthood. Her mother’s unpredictable behaviour triggered anxiety and hyper-vigilance from an early age. Micha experienced a crisis in her identity and moral grounding when her family suddenly left the faith and her community. Her mother abandoning her, but taking her sister, led to phantasies that if 220 she was a good girl, her mother would come back as well as guilt that she had been responsible for her mother leaving. She consequently felt responsible for her vulnerable father who went into a depression and started drinking. Since then, Micha has felt an inflated sense of responsibility for others which manifests in her intrusive thoughts that something bad will happen to a family member and consequent compulsions. This could stem from a real risk in her childhood that, given the unpredictability of her parents, something bad could happen to them. Given her dependence on them as a child this could have led to a feeling that her own life was at risk. Therefore these thoughts could be linked to a feeling of life and death anxiety. It could also be the only way she could express anger towards them for not taking responsibility. Through her childhood and adolescence Micha was not offered a safe space to express anger over the traumas she suffered. She became afraid that if expressed her anger this could have catastrophic consequences, such as her mother leaving or her father becoming more unwell. This led her to internalise her anger. Neither of her parents were strong enough to receive Micha’s aggression, hence it became split off from her experience (Winnicott, 1964). The compulsive behaviour might be a result of Micha unconsciously trying to compensate for lack of control over important aspects of her life (Adler, 1964). The intrusive thoughts and compulsions became a way for Micha to neutralise her difficult feelings. I also hypothesised that some of her blasphemous religious intrusive thoughts such as ‘fuck Jesus’ was her way of feeling anger towards the religion she had been born into. One of Micha’s half-brothers and her father are voice hearers, and I was mindful of the potential similarities between intrusive thoughts and hearing voices. However, when I carefully enquired about this, she said that her intrusive thoughts were not distinct voices, but rather that she experienced them as unwanted thoughts. Most dominant and reoccurring object relationships In childhood Micha learned from her faith that submission leads to protection (Fenichel, 1996). This rings true both within the Jehovah’s witness faith, where she was taught to submit to God’s will and live by his word in order to be accepted into Paradise. It is also true for her 221 OCD symptoms, where she believes that if she surrenders herself to the compulsions, and does not challenge them, her and her family will be safe. She consequently relates to others by being submissive. Micha also experiences herself as ‘less than’ others. She is worried that others will not like her and that she is different, although this might also be a safe way for her to feel special. She assumes an inflated sense of responsibility for others through her compulsions. In the therapeutic encounter, I experienced Micha as wanting me to take the lead. She assumed that I knew what was best for her and I felt that she surrendered herself to the therapy and to me. Defences Micha’s anxiety and disturbing intrusive thoughts are managed by ‘undoing’ (Lemma, 2016) where she attempts to cancel out the sexual or blasphemous thoughts by doing compulsions. In fear of acting on her intrusive thoughts or being perceived as sexually promiscuous, Micha has adopted the opposite character traits; abstaining from sexual activities, or what some authors have termed sexual anorexia (Sanderson, 2015). This is known as reaction formation and is often adapted as a defence against OCD symptoms (Stanford Medicine, 2021). If she were to relinquish these defences, Micha might feel an initial short-term increase in anxiety and feeling out of control and even panic. However, over time, through facing her feared situations, I would hypothesise that her anxiety would decrease. Aims of treatment When we discussed what we might do together, Micha reported wanting to explore the root of her difficulties, especially her intrusive thoughts and make links to childhood where she thought they originated. I agreed that bringing these links into consciousness through the work could be helpful in relieving some of her distress. She also wanted to face her intrusive thoughts as a means to alleviate some of the anxiety. The contract The length of treatment was dictated by the service as 16 weekly 50min sessions which is within the NICE guidelines for treating OCD (Nice, 2005). Micha said this felt like enough, 222 however, that she might seek long-term therapy at a later point. Due to the severity of Micha’s difficulties, and the progress we made in therapy, I would have preferred to work with her longer-term. I informed Micha that the content of the sessions was confidential and that I kept brief factual notes that were of limited access and stored on the service’s computer system. She was informed that in cases of risk to herself (such as planned self-harm or suicide) or others (plans to hurt someone else) I would be compelled to break confidentiality. Typically, this would be to her GP or a crisis team, and that I would always endeavour to discuss this with her first. Micha agreed for the sessions to be audio-recorded and consented to written material including transcripts could be used in academic assignments, professional practice seminars, and supervision (please see appendix 1 for a confirmation of this). As our work took place during the COVID-19 pandemic, our sessions were online using the video conferencing software zoom. I had completed training in online therapy, and Micha confirmed that she had a confidential space to conduct the sessions from her home. She was computer literate and comfortable using the software. I suggested that we start with ERP, then moved on to a more open exploration of the root of her intrusive thoughts, an approach referenced in the literature (Bram & Björgvinsson, 2004; Garcia, 2008; Haverkampf, 2017; Woon et al., 2017). Micha was not convinced by this plan, as she felt that she might not be up for exposure in the beginning and would like to first spend some time discussing her issues and making links to childhood where she felt they originated. We agreed to keep the structure relatively open, which Micha felt most comfortable with. It felt important for this work to be client-led and meaningful to Micha rather than to fit it within one therapeutic model or protocol. If I had insisted on exclusively using ERP, or psychodynamic psychotherapy, I fear we would have shut down processes that were important to Micha and worked as catalysts to therapeutic change. She later reported that taking the lead and deciding the focus and shape of the sessions triggered a feeling of empowerment. Therapeutic work and process 223 Initially, it was important to give Micha space to tell her story and build trust. Micha explained that her intrusive thoughts felt like messages from God and were shaming her for having explored her sexuality and urging her to confess her sins. In the transference, I became the priest that she could confess to and would absolve her of her sins. It took time for Micha to feel safe enough with me to tell me about her experiences of intrusive thoughts and their content as she felt a sense of shame over her symptoms. Working with religious intrusive thoughts in therapy poses significant ethical issues (Abrahamowitz, 2001) and I was aware of being respectful of her religious faith and background. I was also mindful of my own relationship with religion being very different from Micha’s. Mytton (2008, 2017) - who has written extensively on the challenges of growing up in and leaving cultic groups - argues that upon entering therapy it can feel impossible for the client to explain the experience of being raised in a cult. She argues for the importance of therapist sensitivity and facilitating the telling of stories, focusing on attachment, identity, trauma, and life and relationship skills (Mytton, 2017). Although there are debates as to whether Jehovah’s Witnesses constitute a cult, this work informed my approach to some of the religious themes in our work. As the work progressed Micha filled in an exposure hierarchy where she ranked situations that triggered OCD anxiety (Leahy, Holland, & McGinn, 2012). ERP urges clients to face increasingly challenging situations within and outside of the therapy space and to prevent themselves from responding to the situation by doing the compulsion. The aim is to experientially understand that without doing the compulsion, the anxiety will decrease with time. As the work progressed, it became clear that the religious intrusive thoughts had a different nature to other intrusive thoughts. She was able to face intrusive thoughts such as ‘something bad will happen to my sister’ without doing the compulsions in the sessions, and the anxiety felt manageable and decreased after about 10min. However, if she believed there was a chance these thoughts were coming from God, challenging them became much more difficult. Our discussion conceptualised her compulsions as being rooted in anxiety rather than 224 her faith. Abrahamowitz (2001) argues that ERP for religious intrusive thoughts and compulsions needs to be grounded in an understanding that the treatment aims to help the client practice religion as it was intended, rather than out of fear. This became part of our initial conversation and Micha was aware that this was not a treatment to rid her of religion, but to help with her anxiety. This extract is discussing her exposure work between sessions where she had experimented with postponing doing the compulsions for five minutes. Micha: Ehm, sometimes it worked, like, sometimes by the five minutes I’d forgotten the intrusive thought that I’d had in the first place. And, but then with other things, like, I felt I had to… it was more stressful for me to do, it depended on the thought I was having in that moment Therapist: Yeah, what were the ones that were difficult to postpone? Micha: I think the ones where it had to do with like, I’d have an intrusive thought and then I’d think is this like coming from myself or is this coming from God and that was more hard for me because I was like oh God says this is gonna happen to you… like I keep getting intrusive thoughts that are saying ‘pray’ and to me that is very traumatic for me. It became clear that the religious intrusive thoughts needed more exploration. She experienced these thoughts as triggering intense fear of God’s punishment. Exploring this led us back to her childhood where she was taught strict religious scripts from an early age. This provided Micha with a system in her otherwise chaotic life. The moral codes of her religion gave Micha a sense of purpose and structure, it also gave her a sense of control. By submission to God’s will, Micha learned that she would be let into paradise. God became an externalised super-ego imposing strict boundaries and rules to her life. Separating God from her religious intrusive thoughts posed the challenge of losing a familiar attachment figure in the omnipotent God she perceived the intrusive thoughts were coming from. Kirkpatrick (2005) argued that people who lack secure attachments to parental figures in childhood, are more likely to develop an attachment to God in their adult lives that 225 mirrors their attachment style to primary caregivers. Through her parents’ unpredictability, Micha developed a primarily anxious attachment style with fear of rejection and abandonment. In our work, it became apparent that her religious intrusive thoughts also related to a fear of rejection and not being accepted into Paradise. Bringing this into consciousness helped us consider the function that her religious intrusive thoughts might serve for her. Starting to separate religious intrusive thoughts from her religion also provided us with the challenge of addressing who God really was and led to an exploration of Micha’s religious beliefs. Although Micha was not part of any organised religion at the time of our work, she believed in God. When discussing her beliefs about God she stated that she believed God to be inherently good. This became an important part of our work as her representation of God was integral to her wellbeing. I gently enquired as to whether she believed that God would want her to suffer by sending her distressing intrusive thoughts triggering compulsions. The extract below is taken from these discussions which took place further into the work. Micha: I can’t imagine that God would want anything from you that makes you push further away from seeking him. I can’t imagine that he would want that. I guess in a way I am religious, like I am a spiritual person … but I don’t feel like I want to seek God out of feelings of coercion or stuff like that. Through these discussions about Micha’s beliefs about the true nature of God, she began the process of separating her religious intrusive thoughts and her religious beliefs. This involved a new picture of who or what God was, as well as what her intrusive thoughts were. It was difficult for Micha to accept her intrusive thoughts as just that because this involved a mourning of the time, effort and suffering she had endured. It also possibly represented a failure to trust in God’s goodness. Towards the end of treatment, we incorporated religious intrusive thoughts into exposure work and Micha was able to say blasphemous phrases in the sessions, abstain from doing compulsions, and feel her anxiety decrease over time. However, this was only after having spent many weeks exploring the meaning of her religious views. In our final sessions 226 Micha reported an increase in risk through thoughts of self-harm and a wish to extend therapy. We linked this to a fear of abandonment. We had anticipated that the ending would be difficult due to Micha’s experiences of abandonment and anxious attachment style. Micha was given a network-coordinator who would manage risk weekly and I signposted to other local services she could access. At the end of treatment, Micha’s intrusive thoughts and compulsions had decreased, although they were not entirely gone. She still experienced intrusive thoughts that she worried might be God, however, she was now able to challenge these thoughts, and rationalise them, based on her truth about the inherent goodness of God. Discussion and conclusion This case study offered an exploration of the process of separating religious intrusive thoughts from a client’s religion. I argue that intrusive thoughts of a religious nature might need a different approach to other intrusive thoughts due to the potentially different meanings attributed to them. Religious intrusive thoughts could be entangled with the client’s religious beliefs and identity, raising unique ethical dilemmas and considerations within the therapy. Treating religious intrusive thoughts in the same way as other intrusive thoughts runs the risk of the client feeling misunderstood or feeling their religion is not welcome in the therapy room, or that their religion is under attack from the therapy, which naturally raises anxiety and can increase feelings of shame. As a counselling psychologist trainee, I am sceptical of any manualised one-size-fits-all approach, and this case demonstrates just how important it is in therapy to see meaning making and context of the client as idiosyncratic and worthy of exploration. ERP undoubtedly offers valuable contributions to the treatment of some clients suffering from OCD as is demonstrated by the evidence. However, in this case, it was not enough. Though exploring her relationship with religion and God, Micha began to separate this from her religious intrusive thoughts. Her authentic relationship with religion and her true beliefs were that God is good. God wanted her to live a full life, free from the restraints of the intrusive thoughts that dictated so much of her life at the time of our meeting. Although counselling psychology policy and 227 literature address the importance of sensitivity to religious views in therapy, as well as the potential detrimental or harmful effects of some religious views, I would argue there needs to be more focus on the delicate clinical processes of this work. Based on this case study, I would recommend that work in this area maintain an explicit, exploratory, and non-judgemental exploration of client’s religious beliefs. As well as not assuming that religious intrusive thoughts can be treated in the same way as other intrusive thoughts but need a more explorative nature. In addition to this, to consider the attachment to and meaning of a client’s God and religion and how this might influence the work. Religiosity has the potential of being hugely beneficial in creating purpose and contributing towards people living their fullest lives and creating communities. I believe that through exploring clients’ religious beliefs and separating these from harmful experiences can bring forth the full potential of clients engaging with their religion in a helpful and meaningful way. 228 References Abrahamowitz, J. S. (2001). Treatment of scrupulous obsessions and compulsions using exposure and response prevention: A case report. Cognitive Behavioural Practice, 8, 79-85. https://doi.org/10.1016/j.cpr.2004.12.001 Adler, A. (1964). Compulsion Neurosis. In H. L. Ansbacher. & R. R. Ansbachter. 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Obsessive-compulsive and related disorders. https://med.stanford.edu/ocd/treatment.html 232 Winnicott, D. W. (1964). The child, the family and the outside world. Pelican Books Woon, L. S., Kanapathy, A., Zakaria, H., & Alfonso, C. (2017). An integrative approach to treatment resistant obsessive-compulsive disorder. Psychodynamic Psychiatry, 45(2). 237-257. https://doi.org/10.1521/pdps.2017.45.2.237 Yalom, I. D. (2002). The gift of therapy: An open letter to a new generation of therapists and their patients. Piatkus. 233 Appendix 1 DEPARTMENT OF PSYCHOLOGY PSYCHD COUNSELLING PSYCHOLOGY DECLARATION OF SERVICE USER’S CONSENT TO USE MATERIAL FOR SUPERVISION, EXAMINATION AND RESEARCH PURPOSES N.B. THIS FORM MUST BE COMPLETED AND SUBMITTED WITH CASE MATERIAL (Do not include consent forms signed by service users.) I, (TRAINEE’S NAME) SOFIE HEIEN CONFIRM THAT I HAVE OBTAINED THE INFORMED CONSENT OF THE SERVICE USER WHOSE CASE MATERIAL I AM PRESENTING FOR MY PRACTICE ASSIGNMENT. TRAINEE’S SIGNATURE: DATE: 31.05.2021 234 Reflexive integration essay 235 Introduction I discovered that I wanted to become a psychologist in a therapy room in Norway ten years ago. Since then, I have been on a journey towards this goal that has taken me to unexpected internal and external places. Using directionality (Cooper, 2019) as an underlying framework, this essay outlines my journey towards becoming a counselling psychologist and my direction for the future. Directionality Locke and Lathan (2013) argue that all living organisms instinctively engage in goal-directed actions and that even our bodily functions, such as our hearts beating – albeit it an automatic process – are goal-oriented. Having consciousness means we can choose our goals on a day-to-day basis, as well as our longer-term life goals and although some of our actions are driven by unconscious processes or instinct, being able to choose our goals and directions, separates us from other species who act mostly on instinct alone. Cooper (2019) takes this argument further by describing directionality as ‘a universal feature of human existence’ (p. 17). He also states that humans are by nature directional and that this directional way of being on-the-way-to-somewhere is what separates us from, say, a computer. Rogers (1980) stated that ‘we can say that there is in every organism… an underlying flow of movement towards constructive fulfilment of its inherent possibilities’ (p. 117). He saw humans as having the actualizing potential within us and argued that if we can find our way to our most authentic selves, we can fulfil our potential, a process therapy can be beneficial in. These theories all argue for humans as agentic beings, interacting with their worlds. If we see humans as agentic beings, this will also shape how we interact with them in the therapeutic encounter. I adopt this outlook because it makes sense to me, both when applied to my own life, and in my clinical work. Personally, I have felt a drive towards the future for most of my life, even when it was unclear what it looked like, there has been something inside me that moves towards self-actualisation. I have had different goals at different times and often, there is synergy between them, where progressing towards one goal would mean progressing 236 towards the other – for example getting 450 clinical hours and handing in this essay both moves me towards completion of this training. Other times there has been dysergy, such as wanting to spend time with my mother in Norway as she undergoes cancer treatment, and at the same time wanting to start analysing data for my thesis. In clinical practice I do not see my job as guiding clients in any particular direction, but rather, helping them to find their own way by aligning myself with their directions and aims and being part of the journey with them (McLeod, 2018). I recognise that this is a complex process which involves different levels of alignment and re-alignment and considering that people often have different directions or goals that they are pursuing at the same time. It also involves explicit exploration around their direction and how this might fit with their values. My journey through the training It was difficult to identify my expectations for the course, as it was something so unlike any previous experience. The first year focused on person centered and experiential theory and practice (Rogers, 1951). Learning and practicing within this framework grounded me in the humanistic values that underpin the ethos of counselling psychology (Cooper, O’Hara, Schmid, and Bohart, 2013). I connected with the concept of the actualising tendency because I witnessed it in my clients (Rogers, 1961). In my school counselling placement, I met children who were growing up in the least favourable circumstances, yet they found a way to grow and develop. I have often returned to Rogers’ description of the winters’ supply of potatoes, left in the dark, cold basement that still managed to sprout (Rogers, 1980). In my clinical work, I occasionally experienced the non-directive way of working with some frustration. There would come a time in the therapy where clients might ask me ‘Ok, but what do we do about it?’ I found myself wanting to offer a way forward. However, I learned that if we stayed with the process and found a way to access clients’ true authentic selves, they would know where to go. I deeply value the focus that the humanistic therapies give to the empathic stance towards the idiosyncratic lived experience of another (Rogers, 1951). This is 237 something I will take with me on my journey forward, both inside and outside the therapy room. Moving from the person-centered to the psychodynamic framework presented a challenge. These frameworks both offer ways of seeing human development and use different interventions in therapy based on these underlying theories. As I immersed myself in the psychodynamic way of thinking and working, my way of seeing humans changed. As trainees we are asked to adopt a different theoretical framework for each year, and with this comes a yearly new way of understanding the human condition. Although I adopted a critical stance towards the theory, the psychodynamic arguments felt compelling. What rang true to me in psychodynamic thinking was the idea that the past has a way of presenting itself in the room (Jacobs, 2012). Working in clinical placements within the different modalities, I discovered that they both led to positive therapeutic change. Seeing theory come to life in the therapy room and help someone, has been one of the greatest privileges on this training. Through theories such as the repetition compulsion (Freud, 1920/2003) and objects relation theory (Klein, 1957), I began to understand more of the fundamental importance of development in our ways of being in the world. Howard (2017) argues that people internalise a template of the world and others which can be mainly safe or hostile, and that this gets applied to the world they inhabit. Bringing this into consciousness though explorations in the therapeutic relationship can lead to profound change. One of my greatest joys of working psychodynamically is the focus on the relationship and the transference/countertransference. Exploring this, opens up to a wealth of information. It was also eye-opening to see the parallel processes that played out in supervision where I might take on some aspect of the client when discussing them, and exploring how I reacted to different clients and what that might say about them, and about me, and about us. Moving on to cognitive and behavioural theory and practice (CBT) in the final year felt lighter. I experienced working within the CBT as empowering to clients because it focuses less on what had happened to them in childhood that might have shaped how they interact with the world (although this is also considered within the CBT framework), but rather, on behaviour 238 change and awareness of cognitions and how these might influence emotions. This gives clients the power to change. I greatly value the focus within CBT that clients can do something about their difficulties and that the interventions and protocols are grounded in a strong evidence base. However, I felt a return in my practice to the psychodynamic way of formulating. I was told by two of my clinical supervisors that I should pursue psychodynamic work in the future as this suited my way of thinking the most, this rang true to me as well. Positioning myself as a therapist As a counselling psychologist trainee, I believe it is important to be able to hold multiple – and sometimes contradictory – perspectives in mind (Orlands, 2011). This course has offered me a deep dive into person-centred, psychodynamic, and CBT theory and practice. Although my practice might skew slightly more towards some than others, I still see all these approaches as offering valuable contributions to different people at different times. Attending the first and second international pluralistic therapy conferences was highly influential to my clinical practice. The pluralistic framework puts the client’s needs above the therapist affiliation to a specific framework (Cooper & Dryden, 2016). Emphasising the idiosyncratic nature of people’s lived experience means, in part, that applying a one-size-fits-all therapeutic approach to all clients based on therapist affiliation would be counter-productive – if not unethical. The research on effectiveness of psychotherapy also indicates that all approaches have something to offer to different clients (Cooper, 2008). Although some approaches might be more beneficial for certain specific problems e.g., exposure and response prevention for obsessive compulsive disorder, I see it as my duty as a counselling psychologist to offer a variety of ways of working whilst staying within my competence. Reviews of the literature of factors leading to therapeutic change, suggests that therapist qualities include empathy, care, a skilled way of relating to clients, and collecting feedback from clients (Cooper, 2009; Norcross, 2011). Clients’ level of involvement in the therapy is also vital. These findings provide insight into the common factors that might lead to change in the therapeutic process. However, therapy is never going to be an exact science and every client 239 and therapist dyad is different. In my practice, I adopt a research informed approach (Hanley, Cutts, Gordon, & Scot, 2013). To me, this means that research is incorporated into decision making for treatments, but it is not the only factor. Research suggests that across psychotherapy trainings and orientations, the factors influencing clinical practice include experiences of working with clients, supervision, and personal therapy (Orlinsky, Botermans, & Rønnestad, 2001). Accommodating client preferences to therapeutic interventions has also been argued to enhance alliance and improve outcomes (Norcross & Cooper, 2021). I believe it is crucial to keep informed of the ever-evolving literature within counselling psychology, as well as the wider psychotherapy and psychology fields. Whilst at the same time understanding that each client is unique, and position myself to create a new therapy for each client via formulation (Yalom, 2002). As I have described above, my main position as a therapist is based on individual client needs. However, when formulating, I have come to find some theoretical frameworks lend themselves more to my way of thinking than others and that I often borrow from the psychodynamic literature. Writing psychodynamic formulations often considers the client’s object relations (Klein, 1957; Leiper, 2014; Lemma, 2016) and the idea of the other that we carry in our minds which influences how we relate to real others. These often become apparent in the transference relationship. I have also found that the psychodynamic literature offers a rich language for the therapist’s feelings towards the client in the countertransference. Personally, I adopt a psychodynamic thinking to my own development and difficulties. But I also borrow from the behavioural field when thinking of ways to illicit change in myself. In my personal life, I relate to others in a person centered way. I believe that people tend to have an actualizing tendency within them and that everyone’s’ journey is different. Therefore, I am cautious about giving and taking advice, it is like offering a road map to a place you have never been. I find active listening and empathy to be much more effective and helpful ways of relating to one another. Engaging in clinical practice placements 240 When applying for clinical practice placements, my intention has been to get as diverse an experience as possible, both in terms of placements, and client populations. I have been lucky to get the placements I wanted and been able to experience different services. My placements have included a secondary school in an ethnically diverse area of London, an NHS substance misuse service, a gambling addiction clinic, and a community counselling charity, where I have worked with children, adults, carers, and groups. Working in different placements has not only allowed me to work with different populations, but also to experience the different service management and supervision styles, team dynamics, and policy. I prioritised engaging in service development wherever I had the opportunity, for example being involved in developing a group therapy programme as well as extending the school counselling service to parents and teachers. In supervision I have experienced a shift in myself when presenting clients from describing content of the sessions, to exploring processes in therapy. I believe counselling psychologists learn many skills that are transferrable to leadership. In my placements, I have seen leaders who are engaging and motivating and handle conflicts with respect and consideration, enabling their colleagues to do their best work. I have also experienced environments that trigger anxiety and confusion – the consequence often being a high turnover of staff, and the effect rippling out to clients, and to the wider community. At the beginning of the training, I intended to become a clinician. However, after witnessing different ways of managing services, I see the rippling effects of good leadership, and I now recognise this as a rewarding potential direction in the future. I have seen an increase in service user involvement in the running of services, for example in co-production groups. Clients with lived experience of accessing services are experts in client needs and thinking about how policy effects people accessing services. Many clients also described co-production as an empowering experience and that they felt listened to. This is something I would aspire to bring into any future leadership role. Becoming a researcher 241 For me, adopting the research aspect of the counselling psychologist identity has been the most challenging part of this training. My way of engaging with research has been through linking it to clinical practice. Seeing research have an impact on clients’ lives made it come alive for me. My thesis uses a theory building case study methodology where many statements of a theory are tested against a rich case record (McLeod, 2010). The case data might offer insights into areas where the theory needs to be extended to account for the new findings. Counselling psychologists are continuously engaging in activities similar to theory building in clinical practice. In therapy, the theoretical framework – be it humanistic, psychodynamic, or CBT – is applied to the client; however there might be parts of the client’s difficulties that are not accounted for by the theoretical framework adopted, and so the therapist amends or extends the theory to account for the new material (Stiles, 2009). This way of thinking and doing research made the most sense to me, as I felt the link to clinical practice. Through my research journey, I have become passionate about the richness of case study research because counselling psychologists constantly engage in cases and the application of theories (McLeod, 2010). Case study research also offers the reader rich context of the case and insight into delicate processes that large scale studies might not focus on, nor have the capacity to pick up in detail. I have found great support in a fortnightly case study research group of peers where we discuss the research process. I have also been lucky enough to be invited to a special interest research group for goals in therapy, which is the topic of my research. Learning from this international community of experts in the area has been an immense privilege in my development as a researcher. Within psychological research there has been a paradigm shift over the past 20 years from a reliance on the quantitative research paradigm, to a pluralistic approach of embracing both qualitative and quantitative research (Ponterotto, 2005). In more recent times, authors in the larger public health and medicine have argued that establishing causality in health research, calls for evidential pluralism (Rocca & Anjum, 2020). There is a recognition that different methodologies can produce different – albeit equally important – knowledge. Case study 242 research can make a rich contribution as we continue to extend our evidence base and theoretical understanding in the psychotherapy and psychology fields, and I will aim to continue this type of research post qualification. I have found it difficult to position myself on the epistemological spectrum. This is because I believe that different epistemological assumptions can be adopted depending on the question asked (Willig, 2013). As I move through my career and hopefully continue to engage with research, I do believe that I could situate myself within different epistemological standpoints at different times, depending on the question under investigation. The phenomenological approach places great emphasis on idiosyncratic experience, as well as situating experience within a wider social and cultural context (Spinelli, 2005). As counselling psychologists, these ideas about how to gain knowledge are important because they value the experience and meaning making of the individual, rather one singular ‘truth’. Social constructionism concerns itself with how reality is constructed through language. This is also relevant in the therapy room as therapy is an exercise of meaning making through language (Burr, 2003). Critical realism assumes that there is a reality that exists independently of the researcher and the researched and that data can say something about this reality. However, this requires interpretation in order to get closer to the underlying structures that generate the subject under investigation (Willig, 2013). Although I have not fully positioned myself as a researcher in either one of these epistemologies, I am left with an ability to reflect on these different positions and consider the underlying philosophical assumptions about knowledge production. My journey through personal therapy Yalom (2002) argued that ‘there is no better way to learn about a psychotherapy approach than to enter into it as a patient’ (p. 43). When starting the training, I felt drawn to the psychodynamic approach and met with three psychodynamic and psychoanalytic therapists before deciding whom to work with. Through being selective about my therapist from the beginning, I reaped the benefit that I have now been with my psychodynamic therapist for four 243 years because I took the time to find someone I felt safe with. When entering personal therapy, I expected it to be a supportive and holding space. In some ways, this expectation was met, but at the same time, I was struck by the challenge of the work. The process pushed me to go into parts of my psyche I had never dared venture before. At times, it provided me with support from stress and pressure from the university demands whereas other times it felt like an additional pressure. When reflecting on personal therapy, I have leaned more towards the social constructionist position. Because the language we used in therapy differed to the language of my childhood, I found discussing issues of my childhood challenging. I experienced language and memory as intimately linked. In my day-to-day life, I have adopted my thinking and speaking to the English language quite effortlessly, however, exploring my childhood in English felt removed from the experience. I found it easier to be vulnerable in English because my construction of myself in English was more mature than my Norwegian self. I have experienced how my reality changed through changing my main language from Norwegian to English. I found that through expressing myself in a different language to my mother tongue, I became a slightly different person, because there are ways of being that do not translate. Occasionally in therapy I became frustrated with having to translate my childhood, and at other times I felt like I hid behind a language that felt detached. Although I set goals for my therapy in the assessment session, we never returned to them, and it became a ‘set and forget’ process. But although we never worked towards explicitly stated goals in the therapy, it had direction, and a lot of change processes unfolded in the work. Some sessions focused on pressing issues, however, some of the most meaningful sessions started with me saying ‘I have no idea where to go today’. Although my therapist and I might have moved towards different directions at times, it felt like the therapy organically flowed towards meaningful change. In addition to changing me profoundly, being in personal therapy certainly informs my approach to clinical work. As a therapist, it taught me deep empathy for the vulnerability of the 244 client position and the impact of the interventions and therapeutic relationship. It has also taught me to take risks as a therapist. I have gone through disagreements with my therapist and found repairing and reflecting on the rift meaningful. I have also felt an occasional frustration with the process, especially with the ‘blank screen’ and have challenged my therapist. Together we came up with an approach that suited us both. This has helped me recognise my needs and being assertive within relationships. I experienced the power of working with the transference, deep diving into dreams, and interpreting phantasies. This process also inspired my interest in psychodynamic thinking further because I experienced the power of the psychodynamic therapeutic encounter on my own life. The pandemic The COVID-19 pandemic has been a most unwelcome guest, shaping most aspects of my final year on the training. I cherish the experiential, embodied learning and the relational aspects of the training, something the pandemic robbed us of, as we migrated online. For me, this experience highlighted the importance of boundaries. Seminars, lectures, client work, personal therapy, and supervision, all happened in my private space. I felt invaded as boundaries blurred. We are required to wear many hats at different times when training, and during the pandemic, the buffers between these different roles were removed (such as the short cycle to personal therapy or chatting with my peers before the morning lecture). Something intangible got lost in the interactions by not having bodies in rooms together. There was closeness, but it felt different, there was no eye-contact, and body language felt difficult to read, the rhythm of the interaction felt different and lacked flow. My productivity decreased during this time and a dull headache developed, lasting for months. Being stuck in my house felt claustrophobic, but there was also the claustrophobic feeling of not being able to go home and see my family, whom I have missed immensely during this time. It felt like everywhere around us there was sickness, fear, isolation, pain, and death. Services were quick to adapt and move therapy online, however, this also came with challenges such as upholding the therapeutic frame as clients might sit on their beds during the 245 therapy or have family members walk into the room. Clients also felt invaded in their private spaces and that they had been robbed of a ‘proper’ experience of therapy. However, the pandemic also brought with it opportunities. We learned to sit with uncertainty and adapt fast to ever changing circumstances. There was a universally shared pain and sense of isolation, and therapy could be a point of connection that brought me closer to my clients as we moved through the pandemic together. The pandemic also highlighted the differences in resources and access to services in our society and I would argue that counselling psychology has a crucial role to play in ensuring that psychological care reaches the most vulnerable as we together shape ‘the new normal’. Moving towards self-care One of the many insights I gained in my four-year embarkment on personal therapy, is my tendency for martyrdom. And one of the most valued changes, has been the rejection of it. Within the psychotherapeutic communities, I have come to find that martyrdom often creeps up, perhaps this is even what attracts us to the profession. In my first year, I found it increasingly hard to look after myself through the academic and the personal demands that come with the training and I decided to change my mode of study to part-time. This did not involve changing my direction, the goal was still the same, but I changed how I interacted with it. Rather than rushing towards my goal, I chose to focus on the journey. By giving myself another year, I was able to slow down and immerse myself in the experience of the training more fully. With this change, the time pressures evaporated, and the training took on another quality. I no longer rushed my assignments or worried about getting my clinical hours and I had more time to dedicate to placements. One aspect of working ethically is to continually assess our own fitness to practice and make sure we are looking after our clients’ therapist. Respecting my own boundaries also models assertiveness and self-care. Regardless of this, there are still times when life, unexpectantly, throws me a challenge. My mother getting diagnosed with cancer in my final year felt like a gut-punch, just as I was trying to digest the worst year of my life. However, I 246 have come to find that my emotional challenges – when properly processed in personal therapy – can be sources of deep-felt empathy and understanding to my clients’ difficulties. If I can dip into that felt experience of pain without it becoming enmeshed with my clients’, I can use it to deepen understanding, and my pain thus helps me become a better psychologist. As our experiential group facilitator pointed out, this also means that I have not suffered for nothing. And that brings me light in darker times. Coming home – the counselling psychologist identity The counselling psychology identity means to me, a curious, reflective, and non-judgemental stance synonymous with the ‘I-thou’ position (Buber, 1958). It means welcoming the other and having an ability to reflect on context and valuing of idiosyncratic experience, whilst feeling the common humanity. Counselling psychology emphasises a language of formulation as an alternative to diagnosis. This is a continuous process with developments such as ‘the power, threat, meaning network’ (Johnstone & Boyle, 2018) taking on the problems with diagnostic language and offering an alternative that puts meaning making and context, centre stage. Counselling psychology aims to empower clients, rather than treating illness and relate to clients as equal partners in the therapeutic journey, rather than taking an expert stance (Cooper, 2009). Since 2010, there has been a growing focus on social justice issues in the counselling and psychotherapy literature in the UK (Winter, 2019). Counselling psychologists continually witness the effects of political and systemic issues of discrimination in our work. However, we are not merely observers of reality, we co-create it. Hicks (2010) writes that ‘we are not just therapists and observers of human behaviour, but our very being in society means that we help shape, reinforce and challenge social stereotypes and assumptions’ (p. 254). I would argue that how we, as counselling psychologists, position ourselves cannot – and should not – be politically neutral. We share a responsibility to enter the wider discussion on mental health, politics, and policies that affect people’s lives. That is to say, it would be impossible for me to work with clients who describe their experience of discrimination and then position myself as 247 politically neutral. I will be an ally to all those who fight for equal rights for everyone. In her historic paper ‘the personal is political’, Hanisch (1970) wrote about therapy groups for women as political action. In the therapy groups she attended she found that the issues did not lie within the individual woman, but rather, that they were reacting to societal pressures, discrimination, and harassment. A supervisor echoed this sentiment when she said to me that if a frog gets sick, it would not be given antibiotics, but rather, we would look at what was wrong with the pond. Mind (2020) reports that one in four people experience some kind of mental health problem each year in England. Based on this, I would argue that we live in a pond that is making us sick and pathologizing individuals with mental health problems become problematic. As counselling psychologists, we need to fight for a pond that fosters positive experiences and celebrates difference, however, at the same time, we need to offer support to people who are responding to living in our imperfect world with difficulty. We need to offer support to people who are struggling and at the same time, fight for a better world for future generations. I see psychotherapy as radical space where assumptions are checked at the door as much as possible. Now that I have come to the end of the training, what I am left holding closest to my heart is the humanistic values that counselling psychology treasures. The truth I hold is that every person’s idiosyncratic reality is valid, that everyone has the right to find their own way in life and use their voice - and that we are all of equal value. My direction forward As I have discussed above, I believe that humans to be inherently directional, that we are constantly moving, evolving, and responding to the world around us. Through this perspective, I have also become very interested in goal oriented therapeutic work and directionality in therapy (Cooper & Law, 2018). Many psychotherapists ask their clients about goals in assessment, however, what follows, varies greatly. Some psychotherapists work with clients towards explicitly set goals and discuss progress towards goals in each session. For others, it becomes a process of ‘set and forget’ and the therapy takes on a more open structure. If goals are not openly discussed with clients, research has showed that clients and therapists 248 often report working towards different directions (Tryon & Winograd, 2011). I would argue that all therapy is directional, whether there is therapeutic change, or it feels stuck, there is always a direction, a process. How this directionality correlates with goals is an area I look forward to investigating more. Through my clinical work, I have also developed an interest in sexuality. The theme of sexuality has been a common denominator in all my clinical placements. It encompasses embodiment, trauma, masculinity, femininity, body-related issues, relational, and intrapsychic aspects. Learning to talk to my clients about sex and sexuality without so much anxiety (Lemma, 2016) opened up for a wealth of rich explorations of experiences. This is an area I look forward to continuing developing knowledge and skills in. After becoming a registered member of the BACP in my final term, I started a small private practice and greatly value the autonomy of this work. However, as the pandemic has restricted us to our houses, I have found myself longing for the experience of being in a team. Although I will keep doing part-time work in private practice, my current vision for the future is to also apply for jobs in the NHS or charity sector which would offer me more of a community. Rhodes (2021) writes that life unfolds in cycles and that after a period of productivity there needs to be a period of rest. Although I am greatly excited for my career as a counselling psychologist, I also recognise the toll that this training has taken on me and look forward to a new cycle in which productivity and work might not take centre stage in my life. My Norwegian heritage taught me the importance of life balance, and the last four years have felt slightly off balance, I look forward to restoring that. After the pandemic there needs to be time of healing and restoration. Like so many others, I am mourning what feels like a year of memories lost, of not seeing my family and friends and feeling disconnected from my home country that I have not been allowed to visit. What this time has taught me, is that work is not enough to fill a life. 249 I am currently in the infancy of my journey as a counselling psychologist and by no means do I see myself as a finished product. Becoming the best counselling psychologist I can be, is a journey that will take a lifetime, but fortunately, a lifetime is exactly how long I have. 250 References Buber, M. (1958). I and Thou (R. G. Smith, Trans.; 2nd ed.). T&T Clark. Burr, V. (2003). Social constructionism (2nd ed.). Psychology Press. Cooper, M. (2008). Essential research findings in counselling and psychotherapy: The facts are friendly. Sage. Cooper, M. (2009). 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Goal consensus and collaboration. Psychotherapy, 48(1), 50–57. https://doi.org/10.1037/a0022061 Willig, C. (2013). Introducing qualitative research in psychology (3rd ed.). Open University Press. 253 Winter, L. (2019). Social justice and remembering “the personal is political’ in counselling and psychotherapy: So, what can therapists do? Counselling and Psychotherapy Research. 19, 179-181. https://doi.org/10.1002/capr.12215 Yalom, I. (2002). The gift of therapy: An open letter to a new generation of therapists and their patients. Harper Collins. 254 Appendices ‘Learning and development record’ 8.1 Appendix 1: Practice placements: Cumulative training record PsychD in Counselling Psychology Cumulative Training Record form Name of trainee: Sofie Heien This record summarises the clinical and professional experience you have gained in your training to date across different placements and is benchmarked against HCPC and BPS training requirements. It should be reviewed and updated annually, by compiling data from your individual Placement Experience Record forms and ticking all relevant boxes that apply. This will assist you and your clinical tutor in reflecting on your learning and planning future placements and ensuring you have accrued an appropriate range of experience by the end of your training. By the end of the programme the minimum requirements are that you will have gained experience of the following: • Two models of psychological therapy • Two of the different intervention timeframes listed (not including ‘assessment only’) • Providing psychological interventions to individual adults • Providing psychological interventions to one other service user group, either in terms of: o age of service user (i.e. infant, child, adolescent or older adult) or o level of intervention (i.e. couple, family, carer/parent, community or organisation) • Two of the different organisational settings listed • The five areas of ‘essential’ additional experience listed You are also encouraged to gain experience of some, or all of the additional experiences listed as ‘desirable’, as this may further enhance your employability. 256 Please note: it is not expected that trainees will engage in 8 different placements over the course of their training, but space is provided below for this in case needed. If you happen to gain experience in more than 8 placements over the course of the programme, please include these on a separate sheet. Experience type (tick as applicable) Placement 1: Aylward Academy (Beehive) Placement 2: The Grove Placement 3: National Problem Gambling Clinic Placement 4: MIND CHWF Placement 5: Placement 6: Placement 7: Placement 8: Model of psychological therapy Person-centred/humanistic X X Psychodynamic X X X Cognitive-behavioural X X Pluralistic/integrative X X Other (specify) Intervention timeframe Assessment only X Short-term X X X X Long-term X X X Open-ended X X Level of intervention Individual X X X X Couple Family Via carer / parent Group X X 257 Community Organisational Organisational setting NHS (based or commissioned) Primary care (e.g. IAPT, counselling) Secondary care (e.g. CMHT, specialist) X X Tertiary care (e.g. inpatient, secure) Experience type (tick as applicable) Placement 1: Placement 2: Placement 3: Placement 4: MIND CHWF Placement 5: Placement 6: Placement 7: Placement 8: Organisational setting - continued Charity/non-for-profit service X Private sector service Social / residential service Prison service Primary School Secondary School X College/University CREST clinic Other (specify) Presenting issues Depression / depressive disorder X X X X Anxiety / anxiety disorders X X X X 258 Generalised anxiety disorder X X X Social anxiety disorder X X X Panic disorder X Agoraphobia Specific phobias Obsessive compulsive disorder X X X Post-traumatic stress disorder X X X Work related difficulties X X X Loss and bereavement X X X X Trauma X X X X Health conditions (acute or chronic) X X Cognitive/neurological problems Eating disorders X X X Experience type (tick as applicable) Placement 1: Placement 2: Placement 3: Placement 4: Placement 5: Placement 6: Placement 7: Placement 8: Presenting issues - continued Personality disorders X X X Bi-polar disorder X Psychosis Addiction and substance misuse X X X X Challenging behaviours X X X ADHD X Autistic Spectrum Disorder X Risk to self (self-harm, suicide) X X X X 259 Risk to/from others (abuse/violence) X X X Psychosocial problems (e.g. housing, economic) X X Coping and adaptation X X X X Other (specify) Parental mental illness X X Problem severity Mild to moderate X X X Moderate to severe X X X X Severe and enduring X X X X Acute/crisis X X X X Service user diversity Age: Infancy/pre-school Child X Adolescent X Adult X X X X Older adult X Experience type (tick as applicable) Placement 1: Placement 2: Placement 3: Placement 4: Placement 5: Placement 6: Placement 7: Placement 8: Gender: Female X X X X Male X X X Trans/non-binary X Other (specify) 260 Ethnicity: White X X X X Mixed X X X X Asian X X Black X X Other (specify) Sexuality: Heterosexual / straight X X X X Gay / lesbian X X X Bisexual X X Other (specify) Religion: No religion or unknown X X X X Christian X X X X Buddhist Hindu X X Jewish Muslim X Sikh Experience type (tick as applicable) Placement 1: Placement 2: Placement 3: Placement 4: Placement 5: Placement 6: Placement 7: Placement 8: Religion - continued Other (specify) Seventh day evangelist X 261 Jehovah’s witness X Disability: Mobility / physical impairment X Physical health condition X X Head injury Visual impairment Hearing impairment Cognitive / learning disability X Other (specify) ASD X Additional experience areas ESSENTIAL – some evidence of each of these types of practical experience must be evidenced in at least one placement by the end of the programme 262 263 8.2 Appendix 2 Supervisor evaluation forms 265 8.2.1 Year 1 Supervisor Evaluation first term 266 267 268 269 270 271 272 8.2.2 Year 1 Supervisor Evaluation second term 273 274 275 276 277 278 8.2.3 Year 2a Supervisor Evaluation first term placement one: National problem gambling clinic 279 280 281 282 283 284 285 8.2.4 Year 2a Supervisor Evaluation first term placement two: The Grove 286 287 288 289 290 291 292 8.2.5 Year 2a Supervisor Evaluation second term placement one: National Problem Gambling Clinic 293 294 295 296 297 298 8.2.6 Year 2a Supervisor Evaluation second term placement two: The Grove 299 300 301 302 303 304 305 8.2.7 Year 2b Supervisor Evaluation first term The Grove 306 307 308 309 310 311 312 8.2.8 Year 2b Supervisor Evaluation second term The Grove PSYCHD IN COUNSELLING PSYCHOLOGY PLACEMENT SUPERVISOR EVALUATION FORM Thank you for completing this evaluation form on the trainee. Placement supervisor feedback is central to the monitoring and assessment of trainees’ practice and development on the programme. Please complete sections 2 and 3 of this form. In section 2, you will be asked to rate the trainee’s practice against specific competencies in 10 broad areas based on HCPC and BPS standards, using a 3-point scale (1 = below expectations, 2 = meets expectations, 3 = exceeds expectations). If the trainee has not had the opportunity to practice or be observed on any of the competencies listed, this can be indicated by ticking ‘N/A’. In section 3, you will also be asked to provide an overall evaluation of the trainee and some written feedback. You will need to complete two evaluation forms each year: one in the spring, around the academic year/placement mid-point, and one in the summer, towards the end of the academic year/placement. The specific dates by which the evaluations need to be completed will have been communicated to you in the email from the trainee’s clinical tutor at the start of the placement. The first evaluation provides an opportunity to review how the trainee is progressing so far in the placement; the second enables a fuller assessment of how the trainee has performed in the placement overall. The feedback provided on each form will be discussed by the trainee with their clinical tutor, to assist review and planning of further development. If you raise any concerns about the trainee’s practice, their clinical tutor will contact you, and the trainee, to discuss and agree an appropriate response. Ideally any issues should be picked up by the mid-point evaluation, so they can be addressed and any necessary actions or support put in place. If concerns remain at the second evaluation point, the trainee may be assessed by the programme as having failed the placement, and required to undertake further placement work to bring their practice up to an appropriate standard before they can proceed. If at any point during the placement a supervisors has serious concerns about a trainee’s practice they should contact their clinical tutor immediately. Section 1: Trainee and placement details Trainee’s name Sofie Heien Mode of training (full-time or part-time) Part-time Stage of training (Year 1, 2 or 3) (part-time: 1a, 1b, 2a, 2b, 3a, 3b) 2b Clinical tutor’s name Dr Onel Brooks Name of placement The Grove 313 Model of therapy used Psychodynamic Supervisor’s name Dr Catherine Athanasiadou Supervisor’s position (internal or external) Internal Line manager’s name (if not supervisor) Same as supervisor Date of evaluation: 20.04.2020 Section 2: Supervisor’s evaluation of specific competencies Rating scale: 1 = below expectations 2 = meets expectations 3 = exceeds expectations N/A = not applicable Competency area 1: Ethical principles and practice Competency 1 2 3 N/A 1.1 be able to practise within the legal and ethical boundaries of their profession x 1.2 understand the need to act in the best interests of service users at all times x 1.3 be able to exercise a professional duty of care x 1.4 understand the importance of and be able to obtain informed consent x 1.5 understand the need to maintain the safety of both service users and those involved in their care or experience x 1.6 understand the complex ethical and legal issues of any form of dual relationship and the impact these may have on service users x 1.7 understand the need to establish and maintain a safe practice environment x Competency area 2: Confidentiality and safeguarding Competency 1 2 3 N/A 2.1 understand the importance of and be able to maintain confidentiality x 2.2 be aware of the limits of the concept of confidentiality x 314 2.3 understand the principles of information governance and be aware of the safe and effective use of health, social care and other relevant information x 2.4 be able to recognise and respond appropriately to situations where it is necessary to share information to safeguard service users or the wider public x Competency area 3: Professional standards and self-care Competency 1 2 3 N/A 3.1 understand the need to maintain high standards of personal and professional x 3.2 be able to manage their own workload and resources effectively, and to practise accordingly x 3.3 be able to manage the physical, psychological and emotional impact of their x 3.4 be able to maintain fitness to practise x Competency area 4: Inclusive practice Competency 1 2 3 N/A 4.1 understand the impact of difference, such as gender, sexuality, ethnicity, culture, religion, age, socio-economic status, education and disability on psychological wellbeing or behaviour x 4.2 be able to adapt practice to take account of the nature of relationships throughout the lifespan x 4.3 understand the requirement to adapt practice to meet the needs of different groups and individuals x 4.4 understand the power imbalance between practitioners and service users and how this can be managed appropriately x 4.5 be able to practise in a non–discriminatory manner x Competency area 5: Psychological assessment and formulation Competency 1 2 3 N/A 5.1 be able to undertake and record a thorough, sensitive and detailed assessment, using appropriate techniques and equipment x 5.2 be able to critically evaluate risks and their implications x 5.3 be able to choose and use a broad range of psychological assessment methods, appropriate to the service user, environment and the type of intervention likely to be required x 315 5.4 be able to use and interpret psychological tests and/or outcome measures appropriate to their practice x 5.5 be able to formulate service users’ concerns within the chosen therapeutic model x 5.6 be able to use psychological formulations to plan appropriate interventions that take the service user’s perspective into account x 5.7 be able, on the basis of psychological formulation, to implement psychological therapy or other interventions appropriate to the presenting problem and to the psychological and social circumstances of the service user x 5.8 be able to decide how to assess, formulate and intervene psychologically from a range of possible models and modes of intervention with service users and/or service systems x Competency area 6: Communication and collaboration Competency 1 2 3 N/A 6.1 be able to demonstrate effective and appropriate verbal and non-verbal skills in communicating information, advice, instruction and professional opinion to service users, colleagues and others x 6.2 understand the need to provide service users or people acting on their behalf with the information necessary to enable them to make informed decisions x 6.3 be able to communicate ideas and conclusions clearly and effectively to specialist and non-specialist audiences x 6.4 be able to explain the nature and purpose of specific psychological techniques to service users x 6.5 understand the need to implement interventions, care plans or management plans in partnership with service users, other professionals and carers x 6.6 be able to use psychological formulations with service users to facilitate their understanding of their experience or situation x Competency area 7: Relational sensitivity Competency 1 2 3 N/A 7.1 understand explicit and implicit communications in a therapeutic relationship x 7.2 be able to initiate, develop and end a practitioner–service user relationship x 7.3 understand the dynamics present in relationships between service users and practitioners x Competency area 8: Psychological knowledge and skills 316 Competency 1 2 3 N/A 8.1 demonstrate an appropriate level of theoretical understanding and practical skill in the specific model of therapy being used (e.g. humanistic, psychodynamic, CBT, integrative) x 8.2 understand theories of human cognitive, emotional, behavioural, social and physiological functioning relevant to counselling psychology x 8.3 understand theories of psychopathology and of change x 8.4 understand social and cultural contexts and the nature of relationships throughout the lifespan x 8.5 understand the impact of psychopharmacology and other interventions on psychological work with service users x Competency area 9: Reflective practice and evaluation Competency 1 2 3 N/A 9.1 be able to reflect critically on their practice and consider alternative ways of working x 9.2 understand models of supervision and their contribution to practice x 9.3 be able to understand and make effective use of supervision to support their practice and learning x 9.4 be able to critically reflect on the use of self in the therapeutic process x 9.5 be able to use research, reasoning and problem-solving skills to determine appropriate actions x 9.6 be able to revise formulations in the light of ongoing intervention and when necessary reformulate the problem x 9.7 be able to evaluate intervention plans using recognised outcome measures and revise the plans as necessary in conjunction with the service user x 9.8 be able to recognise when further intervention is inappropriate, or unlikely to be helpful x 9.9 be able to practise safely and effectively within their scope of practice x 9.10 know the limits of their practice and when to seek advice or refer to another professional x 9.11 able to practise as an autonomous professional, exercising their own professional judgement x 9.12 Service-user feedback/outcomes generally indicate benefit from working with the trainee x 317 Competency area 10: Organisational functioning and knowledge Competency 1 2 3 N/A 10.1 be able to maintain respectful and professional relationships with colleagues x 10.2 be able to work in a reliable, punctual, organised, appropriately presented manner x 10.3 be able to use information and communication technologies appropriate to their practice x 10.4 understand the organisational context, policies and legal frameworks within which they practice x 10.5 be aware of applicable health and safety legislation, and any relevant safety policies and procedures in force at the workplace, such as incident reporting, and be able to act in accordance with these x 10.6 demonstrate competency in appropriate record keeping and report writing to enhance communication with other practitioners from the same and related fields x 10.7 be able to make and receive appropriate referrals x 10.8 be able to contribute effectively to work undertaken as part of a multi-disciplinary team x 10.9 contribute to the management and auditing processes of the organisation at a stage-appropriate level x Section 3: Supervisor’s overall evaluation 1. What do you consider to be the trainee’s main strengths? Sofie has consistently demonstrated a professional, ethical and committed approach towards her caseload and placement responsibilities. She is hard working, invested, knowledgeable, intuitive, reliable, trustworthy and responds to feedback from supervision very well. She is also a highly valued member of the team who works within a team spirit and collaborates well with colleagues. 2. What do you consider to be areas that require further development (eg. in this or the trainee’s next placement)? In terms of her stage of training, I would recommend to continue gaining experience in long term work but also focus on shorter term contracts in order to strengthen her skills in time-limited approaches. 318 3. Based on your experience of the trainee’s work to date, would you rate their practice and competence overall in this placement as satisfactory or unsatisfactory (please tick)? Satisfactory x Unsatisfactory If unsatisfactory or you have concerns about the trainee’s practice or conduct in any area, please provide further details (below, on a separate sheet or via email to the clinical tutor), including any suggestions regarding how the issues might be addressed or steps that have already been taken. Please note: the trainees’ clinical tutor will liaise with you and the trainee to discuss this further: 4. If you do not have any concerns, would you like the trainee’s clinical tutor to contact you to discuss the trainee for any reason (please tick)? No x Yes If you answered ‘unsatisfactory’ or ‘yes’ to questions 3 or 4, please provide a contact number and days/times when the trainees’ clinical tutor can contact you: Supervisor’s Signature:___C. Athanasiadou-Lewis____________Date: 20/4/2020 Section 4: Trainee’s response to evaluation 1. Please comment on the feedback provided by your supervisor, including any concerns raised if applicable: 319 I agree with the feedback provided. I have greatly enjoyed and appreciated the opportunity to work within a multi-disciplinary team at the Grove and have learned a lot from this placement and the supervision provided here. I feel I have developed psychodynamic skills from the supervision and how to formulate within this framework. This placement has also helped me develop towards becoming a counselling psychologist and working within specialist care and with complex clients. I think learning more skills in short-term treatments would be beneficial towards my development as well as towards employment and I will endeavor to gain as varied experience as possible in my final year of training. I greatly appreciate the opportunity that the Grove has provided me with over my two year placement there. 2. Please outline how do you intend to address any areas for development identified: In my final year of training I will look for a placement that offers me opportunity to work with clients at different time frames in order to develop more skills in both short and long-term therapies. Trainee’s signature: Date: 20.04.2020 Section 4: Clinical tutor’s response to evaluation This section is to be completed by the trainee’s clinical tutor after discussion of the evaluation has taken place with the trainee, and supervisor if appropriate. 1. Please comment on the main outcomes of your discussion of this evaluation form with the trainee and any actions agreed. If any concerns were raised, please specify the implications or plan for addressing these: Discussion of the evaluation has not been undertaken with the supervisor or trainee, as this seems to be a very good report in which the trainee meets or exceeds expectations in all areas, the supervisor has not expressed any concerns or asked me to contact, and the trainee’s response to the supervisor’s comments are appropriate. 320 Clinical tutor’s signature date: 5th May 2020 321 322 8.2.9 Year 3 Supervisor Evaluation first term: Mind 323 324 325 326 327 328 329 8.2.10 Year 3 Supervisor Evaluation second term: Mind PSYCHD IN COUNSELLING PSYCHOLOGY PLACEMENT SUPERVISOR EVALUATION FORM Thank you for completing this evaluation form on the trainee. Placement supervisor feedback is central to the monitoring and assessment of trainees’ practice and development on the programme. Please complete sections 2 and 3 of this form. In section 2, you will be asked to rate the trainee’s practice against specific competencies in 10 broad areas based on HCPC and BPS standards, using a 3-point scale (1 = below expectations, 2 = meets expectations, 3 = exceeds expectations). If the trainee has not had the opportunity to practice or be observed on any of the competencies listed, this can be indicated by ticking ‘N/A’. In section 3, you will also be asked to provide an overall evaluation of the trainee and some written feedback. You will need to complete two evaluation forms each year: one in the spring, around the academic year/placement mid-point, and one in the summer, towards the end of the academic year/placement. The specific dates by which the evaluations need to be completed will have been communicated to you in the email from the trainee’s clinical tutor at the start of the placement. The first evaluation provides an opportunity to review how the trainee is progressing so far in the placement; the second enables a fuller assessment of how the trainee has performed in the placement overall. The feedback provided on each form will be discussed by the trainee with their clinical tutor, to assist review and planning of further development. If you raise any concerns about the trainee’s practice, their clinical tutor will contact you, and the trainee, to discuss and agree an appropriate response. Ideally any issues should be picked up by the mid-point evaluation, so they can be addressed, and any necessary actions or support put in place. If concerns remain at the second evaluation point, the trainee may be assessed by the programme as having failed the placement and required to undertake further placement work to bring their practice up to an appropriate standard before they can proceed. If at any point during the placement a supervisor has serious concerns about a trainee’s practice, they should contact their clinical tutor immediately. Section 1: Trainee and placement details Trainee’s name Sofie Heien Mode of training (full-time or part-time) Full-time Stage of training (Year 1, 2 or 3) (part-time: 1a, 1b, 2a, 2b, 3a, 3b) 3 Clinical tutor’s name Dr Edith Steffen Name of placement Mind CHWF 330 Section 2: Supervisor’s evaluation of specific competencies Rating scale: 1 = below expectations 2 = meets expectations 3 = exceeds expectations N/A = not applicable Competency area 1: Ethical principles and practice Competency 1 2 3 N/A 1.1 be able to practise within the legal and ethical boundaries of their profession x 1.2 understand the need to act in the best interests of service users at all times x 1.3 be able to exercise a professional duty of care x 1.4 understand the importance of and be able to obtain informed consent x 1.5 understand the need to maintain the safety of both service users and those involved in their care or experience x 1.6 understand the complex ethical and legal issues of any form of dual relationship and the impact these may have on service users x 1.7 understand the need to establish and maintain a safe practice environment X Competency area 2: Confidentiality and safeguarding Competency 1 2 3 N/A 2.1 understand the importance of and be able to maintain confidentiality x 2.2 be aware of the limits of the concept of confidentiality x 2.3 understand the principles of information governance and be aware of the safe and effective use of health, social care and other relevant information x 2.4 be able to recognise and respond appropriately to situations where it is necessary to share information to safeguard service users or the wider public x Competency area 3: Professional standards and self-care Competency 1 2 3 N/A 3.1 understand the need to maintain high standards of personal and professional conduct x 3.2 be able to manage their own workload and resources effectively, and to practise accordingly x 3.3 be able to manage the physical, psychological and emotional impact of their practice x 3.4 be able to maintain fitness to practise x Competency area 4: Inclusive practice Model of therapy used Integrative Supervisor’s name Fenik Adham Supervisor’s position (internal or external) Internal Line manager’s name (if not supervisor) Josephine Basedow Date of evaluation: 06.04.2021 331 Competency 1 2 3 N/A 4.1 understand the impact of difference, such as gender, sexuality, ethnicity, culture, religion, age, socio-economic status, education and disability, on psychological wellbeing or behaviour x 4.2 be able to adapt practice to take account of the nature of relationships throughout the lifespan x 4.3 understand the requirement to adapt practice to meet the needs of different groups and individuals x 4.4 understand the power imbalance between practitioners and service users and how this can be managed appropriately x 4.5 be able to practise in a non–discriminatory manner X Competency area 5: Psychological assessment and formulation Competency 1 2 3 N/A 5.1 be able to undertake and record a thorough, sensitive and detailed assessment, using appropriate techniques and equipment x 5.2 be able to critically evaluate risks and their implications x 5.3 be able to choose and use a broad range of psychological assessment methods, appropriate to the service user, environment and the type of intervention likely to be required x 5.4 be able to use and interpret psychological tests and/or outcome measures appropriate to their practice x 5.5 be able to formulate service users’ concerns within the chosen therapeutic model x 5.6 be able to use psychological formulations to plan appropriate interventions that take the service user’s perspective into account x 5.7 be able, on the basis of psychological formulation, to implement psychological therapy or other interventions appropriate to the presenting problem and to the psychological and social circumstances of the service user x 5.8 be able to decide how to assess, formulate and intervene psychologically from a range of possible models and modes of intervention with service users and/or service systems x Competency area 6: Communication and collaboration Competency 1 2 3 N/A 6.1 be able to demonstrate effective and appropriate verbal and non-verbal skills in communicating information, advice, instruction and professional opinion to service users, colleagues and others x 6.2 understand the need to provide service users or people acting on their behalf with the information necessary to enable them to make informed decisions x 6.3 be able to communicate ideas and conclusions clearly and effectively to specialist and non-specialist audiences x 6.4 be able to explain the nature and purpose of specific psychological techniques to service users x 6.5 understand the need to implement interventions, care plans or management plans in partnership with service users, other professionals and carers x 6.6 be able to use psychological formulations with service users to facilitate their understanding of their experience or situation x Competency area 7: Relational sensitivity Competency 1 2 3 N/A 7.1 understand explicit and implicit communications in a therapeutic relationship x 7.2 be able to initiate, develop and end a practitioner–service user relationship x 7.3 understand the dynamics present in relationships between service users and practitioners x 332 Competency area 8: Psychological knowledge and skills Competency 1 2 3 N/A 8.1 demonstrate an appropriate level of theoretical understanding and practical skill in the specific model of therapy being used (e.g. humanistic, psychodynamic, CBT, integrative) x 8.2 understand theories of human cognitive, emotional, behavioural, social and physiological functioning relevant to counselling psychology x 8.3 understand theories of psychopathology and of change x 8.4 understand social and cultural contexts and the nature of relationships throughout the lifespan x 8.5 understand the impact of psychopharmacology and other interventions on psychological work with service users x Competency area 9: Reflective practice and evaluation Competency 1 2 3 N/A 9.1 be able to reflect critically on their practice and consider alternative ways of working x 9.2 understand models of supervision and their contribution to practice x 9.3 be able to understand and make effective use of supervision to support their practice and learning x 9.4 be able to critically reflect on the use of self in the therapeutic process X 9.5 be able to use research, reasoning and problem-solving skills to determine appropriate actions x 9.6 be able to revise formulations in the light of ongoing intervention and when necessary reformulate the problem X 9.7 be able to evaluate intervention plans using recognised outcome measures and revise the plans as necessary in conjunction with the service user X 9.8 be able to recognise when further intervention is inappropriate, or unlikely to be helpful x 9.9 be able to practise safely and effectively within their scope of practice X 9.10 know the limits of their practice and when to seek advice or refer to another professional X 9.11 able to practise as an autonomous professional, exercising their own professional judgement x 9.12 Service-user feedback/outcomes generally indicate benefit from working with the trainee x 333 Competency area 10: Organisational knowledge and team working Competency 1 2 3 N/A 10.1 be able to maintain respectful and professional relationships with colleagues X 10.2 be able to work in a reliable, punctual, organised, appropriately presented manner X 10.3 be able to use information and communication technologies appropriate to their practice X 10.4 understand the organisational context, policies and legal frameworks within which they practice X 10.5 be aware of applicable health and safety legislation, and any relevant safety policies and procedures in force at the workplace, such as incident reporting, and be able to act in accordance with these x 10.6 demonstrate competency in appropriate record keeping and report writing to enhance communication with other professionals x 10.7 be able to make and receive appropriate referrals from other professionals x 10.8 be able to contribute effectively to work undertaken with other professionals, agencies and multidisciplinary teams x 10.9 contribute to the management and auditing processes of the organisation at a stage-appropriate level x Section 3: Supervisor’s overall evaluation 1. What do you consider to be the trainee’s main strengths? Sophie’s main strengths are Her ability to use her training, knowledge and understanding of different modalities flexibly according to her client’s needs. Sophie is able to reflect on herself, her work and her clients in supervision. She demonstrated good understanding of the importance of Transference and Counter Transference in her work. Sophie is able to engage in supervision, present her cases clearly and demonstrate her clinical thinking skilfully. 2. What do you consider to be areas that require further development (eg. in this or the trainee’s next placement)? I can’t think of any. 3. Based on your experience of the trainee’s work to date, would you rate their practice and competence overall in this placement as satisfactory or unsatisfactory (please tick)? Satisfactory x Unsatisfactory If unsatisfactory or you have concerns about the trainee’s practice or conduct in any area, please provide further details (below, on a separate sheet or via email to the clinical tutor), including any suggestions regarding how the 334 issues might be addressed or steps that have already been taken. Please note: the trainee’s clinical tutor will liaise with you and the trainee to discuss this further: Supervisor’s Signature:_ F.Adham __________Date: _06/04.2021 ____________ Section 4: Trainee’s response to evaluation Trainee’s signature __ _____________________Date: ____09.04.2021 4. If you do not have any concerns, would you like the trainee’s clinical tutor to contact you to discuss the trainee for any reason (please tick)? No x Yes If you answered ‘unsatisfactory’ or ‘yes’ to questions 3 or 4, please provide a contact number and days/times when the trainees’ clinical tutor can contact you: 1. Please comment on the feedback provided by your supervisor, including any concerns raised if applicable: As I am now coming towards the end of my placement and the training, I am grateful for the opportunities I have received at Mind. In recent times, I have been allocated clients with co-morbidity and more complex presentations which has provided me with new learning opportunities. I was somewhat disappointed with the scoring in this report as I have previously received more scores of 3, however, I recognise that meeting the expectations of doctoral level training is also an achievement (as indicated by the scores of 2). 2. Please outline how do you intend to address any areas for development identified: Moving forward I will continue to develop my own identity as a counselling psychologist, which is informed by the psychodynamic framework. 335 Section 4: Clinical tutor’s response to evaluation This section is to be completed by the trainee’s clinical tutor after discussion of the evaluation has taken place with the trainee, and supervisor if appropriate. 1. Please comment on the main outcomes of your discussion of this evaluation form with the trainee and any actions agreed. If any concerns were raised, please specify the implications or plan for addressing these: We discussed the evaluation form and Sofie’s disappointment at receiving lower scores than previously. We talked about the possible impact the pressures surrounding the service and changes within the service itself and the supervision arrangements may have had on Sofie’s placement experience, and while considering the systemic aspects of this, we also wondered about individual learnings that Sofie can take from this experience, such as raising issues around service environment and process and how this may impact individual practitioners, and inevitably their work with clients within supervision. We reviewed Sofie’s overall clinical learning, particularly over this last year, and we noted particularly the variety and richness of experience that Sofie has gained. I wish her all the best in her future professional career. Clinical tutor’s signature ____ ___________Date: _____13/05/2021__ 336 8.3 Appendix 3a Year 1 Reflective Learning Statement This reflective learning statement aims to demonstrate an ability to adopt a reflective stance towards my experience of the different aspects of the PsychD Programme. Before starting the programme, I was very motivated, having high expectations for the teaching, as well as how I would develop as a person through the programme. I expected the academic level to be above my ability and that especially research would be challenging for me. Starting the programme, I realised how supportive it felt and how rather than competition, it aided support both amongst peers and staff. I was struck by how the quality of the teaching made complex concepts understandable. I decided to become a psychologist as a teenager after entering personal therapy. I experienced the power of telling my story in a non-judgemental environment and feel understood and respected. Being offered a placement at a secondary school working with teenagers therefore felt as though I was returning to my original purpose. The placement was challenging in many ways and I found that as a person who is very organised, it was quite destabilising to enter a placement where the procedures were not always clear. I learned how to structure my work through asking for clarifications. When I arrived in the morning, I would list what the expectations of me were for the day and make sure all were completed by the afternoon. I occasionally found it difficult to negotiate the outcomes the school wanted for the pupils, often including better behaviour in the classroom and improved academic achievement, and the ethos of the person-centred framework. I tried to manage this through attending meetings with the teachers where we discussed the pupils’ best interests and wellbeing. What I am left with as the most significant I have learned in terms of my professional practice is to welcome complexity and see each client as their own unique being, to be understood in their own frame-of-reference and never to judge. I have learned the importance of opening my mind to different and unique ways of seeing the world and being in the world, and to try and gently enter another’s world and emphasize. I believe learning the person-centred framework has laid down the foundation for working within the ethos of Counselling 337 Psychology. Although we will be learning the psychodynamic framework next year, I believe the underlying principles of the person-centred way of being will still be practiced throughout my career. I found learning about unconditional positive regard (UPR) (Bozart, 2013) most useful. It allowed me to accept the whole person and care deeply for them. I found it easier to apply this principle to others if I attempt to also apply it to myself as I have become aware I am often self-critical. The most challenging aspect of working within the person-centred framework would be to hold myself back from trying to ‘make something happen’ or push the process forward rather than trusting each client’s actualizing tendency (Rogers, 1980). The most significant I have learned in research is the importance of being systematic from the onset and think every step through. I have learned the importance of perseverance in the process of rewriting large pieces of work. Although the informal feedback has sometimes been disheartening and I have found the process of going back to the work to redraft quite tedious at times, this process has taught me the importance of re-writing and making ideas and procedures clear, rather than over-complicated. The placement offered group supervision which was not specifically person-centred and did not fulfil the 1:8 quota, hence, I quickly decided to get a private supervisor in addition. There was also a line-manager at the placement working within the systemic-framework. At times I found it difficult to navigate between the input of my two supervisors and my line-manager as this was not always aligned. At the same time, I experienced my relationship with my supervisors as having a therapeutic element, as it helped me relieve my anxieties around the placement. Judy Graham, the supervisor I met with most frequently, taught me to trust my own instincts and be assertive. She would ask how I felt being with clients, this helped me be congruent (Cornelius-White, 2013) and recognise the effect my clients had on me and how this might influence the work. It is difficult to choose one experience that has been the most formative to my learning, however, entering personal therapy has played a crucial part. It has made me develop an awareness of how vulnerable one feels and how difficult and demanding attending therapy can 338 be. Having a sensitivity to this has been very important in my clinical work. My expectation of personal therapy was for it to be a space where I could recharge, get support, and feel understood. While all of my expectations were met, I was also struck by the other dimension of therapy; how emotionally demanding it can be. I was very eager to present and get feedback on my clinical work in the professional practice and development (PPD) groups. When transcribing fragments of sessions I picked up on processes I had not noticed in the room. Getting feedback from my peers and clinical tutor helped build my confidence and encouraged me to think about how to use the person-centred framework to conceptualize and formulate the client’s difficulties and to use this to find helpful ways of working with them. I was invested in the PPD group and felt as though I could bring my whole self into the group. The group did create some anxieties around passing the process report and I was very worried I would not be able to produce a recording of the required quality. I was very lucky to be able to start my placement early, so I had the opportunity to present many times and get feedback before handing in the process report and I am grateful for my time with the PPD group. I have been very pleased with the feedback that I have received on my work so far. Although I am realising that the level that is required is very high, I do feel that the marking and feedback has been fair, and I agree on the areas that have been suggested for improvement. The feedback will be taken into consideration and re-visited before I hand in any work next year. I believe that one of the strengths I have developed through readings, lectures, clinical-work, supervision, and peer-groups is an ability to establish psychological contact (Wyatt, 2013) and connect with people who are different to me. I have been provided with the opportunity to work in a multicultural area and with a diverse client group. I believe this has helped me develop a sensitivity to different ways of being and the importance of openness to difference and genuine interest in the other. I believe my ability to trust my own judgement and feel more confident could be improved. I have also found myself trying to please others 339 and taking on too much and almost burning out. I would like to develop skills in being assertive and setting boundaries for myself. This is being addressed through consideration of a part-time place, in order to improve self-care and prevent burnout. I am very excited for my next academic year and to develop skills in another model of therapy. I also have some concerns about the experiential group, and I believe that making these explicit in the group would help me overcome and address my concerns. Having never worked in the NHS this is something I would like to gain experience in next academic year. I would like the opportunity to work in a placement that is more structured where the procedures are clear, in order to gain experience with working systematically within a team. I hope to gain experience in different settings and do not have a particular population I would prioritise over another, but rather, would aim to get experience with different populations. I have been for an interview with an NHS service with a psychodynamic emphasis offering counselling for alcohol and drugs dependency which would provide me with the opportunity to work with a different population than I have and gain experience within the NHS. The service also has a focus on psychodynamic formulations which would help me build on this skill. Hopefully at the end of next academic year I will feel that I have further developed my therapeutic skills and confidence. I will have a thorough understanding of the theoretical aspect of psychodynamic therapy and be able to bring this into practice. I will also understand my own unconscious processes and how these might influence me and my clinical work. References Bohart, A. C. (2013) The actualizing person. In M. Cooper., M. O’Hara., P. F. Schmid & A. C. Bohart (Eds.), The handbook of person-centred psychotherapy and counselling (2nd ed.). (pp. 84-101). London: Palgrave McMillan. 340 Rogers, C. R. (1980). A way of being. New York: Houghton Mifflin Harcourt Publishing Company. Wyatt, G. (2013). Psychological contact. In M. Cooper., M. O’Hara., P. F. Schmid & Bohart (Eds.), The handbook of person-centred psychotherapy and counselling (2nd ed.). (pp. 150-164). London: Palgrave McMillan. A. C. 341 8.4 Appendix 3b Year 2 Reflective Learning Statement Going into the second academic year of this programme, I was unsure of my expectations for what the year would entail for me, however, I was full of excitement and openness to the experience. I had decided to change my mode of study to part-time which felt out of character for me. Typically, I work hard and move fast towards my goals. However, throughout this training, I have learned the importance of acknowledging my own needs. Changing my mode of study was, for me, a way of taking time to reflect on this experience rather than rushing through it. It also allowed me to immerse myself in the psychodynamic framework as I engaged in a placement spanning two calendar years where I worked within this model. Through this academic year, I have learned to think in a different way. The psychodynamic framework allows for abstract and symbolic thinking. It also opens up a pool of information that one can gain about individuals through the transference and countertransference. The concepts from the module that particularly stayed with me has been the repetition compulsion and object relations and I found it to be an eye-opening experience to learn about how the past might get enacted in our relationships with others and how bringing this into consciousness can have a profound effect. During this year, the most important aspect of my learning has been a combination of the different components of the course that form a wholistic personal and professional development. However, this year did offer me the opportunity to work with a specific client population over a prolonged period of time. It has been a great privilege to be able to work with clients long-term which facilitated the opportunity for in-depth relational work. Having been interested in the psychodynamic framework from the onset of the training, I chose of enter personal therapy with this orientation at the beginning of year one. Yalom (2002) argued that ‘there is no better way to learn about a psychotherapy approach than to enter into it as a patient’ (p. 43). I have now been a patient in psychodynamic psychotherapy with a Kleinian orientation for three years. My learning through my experience of personal therapy 342 go beyond picking up techniques. There is a deep empathy that I experience for my clients due to also having gone through the painful journey of diving into the unconscious. I have also learned to listen with an analytic ear to my clients, for what is being said explicitly and to what is being communicated through the transference and countertransference. Attending the experiential group taught me the importance of paying attention to the process that is unfolding in the relationship here-and-now (Yalom, 2002). The group formed a ‘micro-environment’ for processes that might be enacted in our day-to-day lives and provided us with the opportunity to really focus in on those processes. Although I was often quiet in the group, I went through a lot of internal processes and development. I discovered the role I adopt in groups which is a need to comfort others, make them laugh, be liked, and not take up too much space. Through that experience, I learned to challenge myself, to use my voice more, and to validate my own voice in the group, which is a valuable gift the group gave me. The group also enabled me to discuss the processes in the room between me and my clients with less anxiety and more safety, which I believe is a gift the group have given to both me my clients. For me, research is the most challenging aspect of this course. Ongoing feedback from my research supervisory team has been that I need to improve my academic writing abilities. I take this very seriously and I want to find an academic writing course that I can attend over the summer to improve my writing and my English. Writing in my second language is adding another layer to the challenge of getting my academic skills to the level expected of a doctoral student. I also plan to address this challenge by engaging more with the academic literature around my topic, methodology, and research paradigm in order to integrate research more into my life. I see myself more as a clinician than a researcher and find it challenging to integrate research into my identity as a trainee counselling psychologist. Feedback provided by my placement supervisors has been overall positive and I have been very grateful to have developed good relationships with both the supervisors I have worked with over this academic year. I want to gain more experience in working short-term and more ‘practically’ with clients rather than the more abstract long-term work I have been 343 doing. I have also had two placements in addiction this year and would love the opportunity to work within a non-specialised service next year. Working relationally with a client group that typically presents with co-morbidity, complex trauma, as well as ongoing opiate dependence has been challenging both professionally and personally. Next academic year, I would like to gain experience working with a population that present with milder symptoms. I would like to also have experience with a different client group in order to have the opportunity to develop skills in short-term cognitive and behavioural therapies. In order to gain this experience, I will attempt to get a placement for next year in a general counselling service and to develop skills working within a CBT framework through academic teaching, reading, clinical work, supervision, and PPD discussion. I am mindful about the ongoing COVID-19 lockdown and will need to be able to adapt to the circumstances, both in finding a placement, the clinical work, and in the academic learning. This academic year which has spanned two calendar years for me, has, at times, felt disconnected. I was very close with, and felt held by, my cohort and leaving them was more difficult than I had anticipated. I experienced a loss when entering into year 2b and although I formed friendships in the new cohort, I experienced them as already being an established group. Although I was provided a PPD tutor in year 2b, I did not participate in PPD groups. This made my placement and clinical work feel separated from the university. This separation was amplified by not having psychodynamic teaching in year 2b which was mainly research focused. Finishing this year in social isolation feels slightly symbolic of the experience of this academic year for me. I am very excited about my final year on the training. I want to learn more about cognitive behavioural therapies and to continue developing as a counselling psychologist. However, I am mindful of the current situation with regards to the guidelines on social distancing and have reservations about the prospects of doing the first term of teaching potentially online. I also worry about the experience of doing this course, which emphasises relational and experiential teaching, and what that will mean for my development. In addition 344 to this, I have some anxiety about the increased pressures of changing my mode of study to full time after having had two years part-time. Although there are many uncertainties going into the next academic year, I feel that the course has prepared us for living with uncertainty and adapt in an environment that is challenging in many ways. As with previous years I am approaching this year with excitement and a sense of wonder of what challenges lies ahead. My dream for the next academic year is to be able to complete this training and become a competent and eager-to-learn counselling psychologist and not let anxiety or a global pandemic stand in my way. 345 References Yalom, I. D. (2002). The gift of therapy: An open letter to a new generation of therapists and their patients. London: Piatkus. |
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