A start

I’m Kate, I am fascinated by the depth and complexity of the person-centred approach. This blog is my offer to share things I’ve written, pictures I’ve taken, ideas I wish to experiment with

I’m doing this now because it is now.

The following was written a few years ago. I hope it is of interest.

II

Person-Centred Experiential Counselling for Depression Training

A view from both sides

This article tracks the emergence of Person-Centred Experiential counselling for depression (PCE-CfD)  within ‘Increasing Access to Psychological Therapies’( IAPT) and explores experiences of Person-Centred Experiential counselling for depression training and PCE-CfD in practice.

In 2008 at the World Association for Person Centered & Experiential Psychotherapy & Counselling Conference at the University of East Anglia,  Elliott and Friere shared the results of their meta-analysis, concluding that  Person-Centred/Experiential (PCE) Therapies Are highly Effective ¹

This research, funded by the British Association for the Person-Centred Approach, came at a crucial time for those interested in supporting person-centred experiential therapy within the academic mainstream. Research in England,in the last century into  the person-centred approach had dwindled in favour of developing the attitudes that characterized the theoretical stance, and any research that was carried out, focused on qualitative experiential data. No harm in that, however, it’s not the sort of data that is welcome, or even recognised in circles that hold budgets and power.

At the same time as the announcement on the results of the meta analyis, practically on the same day, Lord Layard announced an unprecedented investment   into ‘psychological therapies’, a policy named ‘Increasing Access to Psychological Therapies’ (IAPT)².

The announcement of this investment into psychological therapies caused shock waves across the country. Investing in mental health had been scarce, however, the bombshell was, counselling was not included in the guidelines.  Consequently many counsellors discovered they no longer had a job. The investment by the NHS was solely focused on training up a new workforce of CBT practitioners.

 In response, and in order to support their membership, BACP created ‘Person-Centred Experiential counselling for depression’ (PCE-CfD). This took great determination and hard work by numerous international researchers and practitioners. Some call the creation of PCE-CfD a desperate fudging in order to meet the agenda for  political game playing. It is not a popular topic in many circles. However PCE-CfD is characterised, without it, the chances that counselling would have diminished as a valid activity supported by the NHS, would be even greater than they are today.

 Person-Centred Experiential counselling for depression is a PCE therapy that incorporates aspects of emotion focused therapy  (EFT)  and has been validated by Skills for Health and NICE (National Institute of Health and Care Excellence)⁴. This evidence based approach incorporates the theoretical stance established by Carl Rogers (1959)⁵, that an individual, given the right facilitative conditions, will grow towards health regardless of the nature of the distress.

 In the case of ‘depression’, theory acknowledges the impact of discrepancies that emerge for a person when struggling with their feelings (see Sanders and Hill 2014)⁶ . These conflicts can flatten or overwhelm an individual and ‘symptoms’ emerge that are considered typical of a person diagnosed with mild to moderate depression. Frequently clients are characterised as feeling ‘stuck’. By enabling an environment that offers the necessary and sufficient conditions for therapeutic change (Rogers 1959),⁵ the therapist is alongside the  client  as s/he is able to explore all aspects of their life ,frequently resulting in the client  giving expression to  aspects of their experience that have been suppressed, flattened, criticised,  judged, overlooked , ignored or stifled.

EFT, a specific approach to working, and part of person-centred experiential therapies , offers theory around the function of emotions and various focused ways of enabling clients , who typically are ‘stuck’, to sustain  levels of emotional arousal. The evidence from EFT, mainly generated in Scotland, contributed greatly to the validation of PCE-CfD by NICE.

Gaining a secure place for person-centred counselling in the NHS has been a long hard road with a difficult and painful history. Since the introduction of PCE-CfD, new job opportunities for therapists within National Health Service (NHS) funded services are opening up. Numerous concerns exist in regards to the presence of the person-centred approach within the NHS. Is this collaboration with a diagnostic system a compromise too far? Surely existing as an independent service in GP practices was preferable to being incorporated into the NHS wholesale? Catherine Jackson’s Therapy Today article in July 2016 (p 6-9 ) ‘Does counselling make a difference?’ pointed out, the post code lottery- one of the main rationales for IAPT, is still very much in existence five years on from IAPT  being rolled out.

 Measuring Effectiveness

In order to support their investment into developing PCE-CfD, BACP commissioned an RCT (randomised control trial) called: Pragmatic Randomised Controlled Trial assessing the Non Inferiority of Counselling and its Effectiveness For Depression  (PRACtise)¹⁰. The results will be announced in 2019

One of the requirements of any IAPT service involves every therapist collecting session by session data using a tool called the Minimum Data Set (MDS)¹¹ . This data is essentially looking at symptoms and was originally devised for use with pharmacological treatments.

Anecdotally, many PCE-CfD clients report relief, are able to become less rigid in and more accepting of their feelings and discover new aspects of themselves that had either been suppressed or forgotten and are able to risk ‘authenticity’ which potentially prior to engaging with therapy was a rare experience or something that held too much risk of not being liked or accepted by others.

‘One day, to his amazement, Peter had made a decision to go and visit a relative

with his wife, a journey he had not made for a very long time. He felt that

as there was not pressure on him he could make a decision to go. He asked

me why I thought that, when he woke up at night, rather than worrying about

everything he felt a deep sense of peace. We explored why that might be and

he decided it was because he had been heard properly and that he no longer

felt any pressure to get better’ (pg 220  Hayes K)⁷

Presently, there is no way of capturing the nature of that shift Peter describes above using the MDS that PCE-CfD practitioners have to complete for IAPT. This awareness of the limit of MDS is shared with others who are involved in PCE-CfD services. In Jackson’s article (2016) Jessie Emilions states’

‘I support the use of outcome measures in principle, but I prefer CORE, because it includes a more subjective assessment of changes in a client’s experience of their life and their relationships, not just their symptoms.’(2016 p9)

 CORE isn’t used by IAPT and so evidence that more accurately capture the nature of a counselling client experience has no influence on NICE.  Vicky Palmer states:

‘I just keep telling them there is plenty evidence out there that counselling is effective, it’s just not in the form of trials that qualify for the NICE guidelines’(2016  p8)

The amount of evidence that is being collected from ‘counselling’ by the minimum data set, and reported in the 2014/15 HSCIC report shows ‘counselling’ as effective as CBT  in a shorter period of time.

The Therapists View: Training in PCE-CfD

Delegates who attend PCE-CfD courses are experienced and qualified therapists funded to train by their Clinical Commissioning Group  (CCG). The evidence for PCE-CfD is as a brief therapy for up to twenty sessions.

It is arguable that the investment into PCE-CfD by the NHS has had benefits to individual counsellors who up till then had felt previous CPD trainings lacked relevance. The following statements were offered between 2013 and 2015 from different therapists in different cohorts from different regions who attended PCE-CfD training.  

‘I had given up hope of my NHS work providing training and development that had relevance

‘I felt contained, educated and cared for throughout the five days .The delivery of the course has been exceptional from start to finish.  The trainers have facilitated a learning environment that I have treasured’(Debbie 2014)

‘I thoroughly found the course experiential I found the pace and content enjoyable It felt safe to make errors I enjoyed the democratic approach of the tutor. Very refreshing and real’

This does not match  how many perceive PCE-CfD training. ‘Our accredited counsellors see this as teaching them to suck eggs, but because PCE-CfD is recommended by NICE, and humanistic counselling hasn’t been, CCGs’ hands are tied’ (2016 p7)

Regardless of the seeming vortex of complications IAPT evokes, PCE-CfD training seems to be  a great opportunity to reconnect counsellors to the theoretical roots of their practice and encourage further understanding of the process of therapy. It commends the agency or as person-centred therapists would say, the actualising tendency, of the client and consider what that means within a phenomenological counselling relationship. Despite the name –Person-Centred Experiential counselling for depression- it is clear theoretically that the approach is not exclusively for depression and is an approach for many manifestation of distress or ‘incongruence’. It may have more meaning if PCE-CfD became PCE, ‘Person-centred and Experiential Person-Centred Experiential counselling for depression’. That would represent the approach more transparently and be less confusing for Humanistic or Integrative counsellors who may be expecting when they attend PCE-CfD training, something to add to a tool box, and instead encounter an attitudinal approach that is very true to the original principles established by Rogers in  1959.

These quotes are from past delegates who attended training between 2013 -2016.

 All have qualified in PCE-CfD and were from a variety of regions in England and from different versions of IAPT.

 NHS therapists have been expected to complete much training in their roles over the years and often that training had little connection to their initial training as a therapist.

One delegate responded enthusiastically,

 “Are you interested in completing a humanistic evidence-based training, endorsed by the Department of Health, for counsellors who already have grounding in a humanistic modality?”…This is not a question that I hear very often as an NHS counsellor. Hence my eager response of “When do I start?’

A more typical reaction is the one shared by a delegate from a different region: ‘When I was first told that I would need to attend PCE-CFD training, I suddenly felt de-skilled and feared failing, all within a heartbeat.’

PCE-CfD training encourages an experiential person-centred learning environment, so time is available for people to express their concerns and share their anxieties. This sharing has a beneficial impact and can contrast greatly with other approaches to training where people are expected to sit and listen.

‘On the first day, despite my anxiety, I was reassured that I was not the only one with ‘reservations’. This for me was reassuring and the group   started to have a cohesive feel. I felt the desire to learn, rather than my past feelings of dread and frustration’.

One delegate explained

 ‘I describe myself as an integrative counsellor with my roots embedded within the Person- Centred approach, and therefore training within the PCE-CfD model was the one that really appealed to me’

One delegate from the ‘other’ group stated

 ‘I felt the delivery was congruent with the modality. I found the model of person centred (sic) counselling integrated with emotion focused therapy to be very powerful. Also it fitted easily with my existing training’

 

 

PCE-CfD courses will vary, at Nottingham, video work is introduced very quickly so therapists are able to reflect on their practice. We request that participants who are talking as a client  bring real issues rather than  role play something. This adds an additional dimension to the experience and enables the phenomenological stance to be authentic as therapists engage with the process of evaluating their practice with peers.

After feeling more settled the word ‘video’ was mentioned, I did flap (again) but as we were now a group, took comfort in presuming that I would not be the only one, feeling like this.. In my role as Counsellor, it felt real, the video may have been there but what my ‘Client’ brought was more apparent and more meaningful to me, within that ‘session’, than the video running.’

The benefit of having experienced and qualified therapists attend the courses is evident in the capacity for delegates to self-challenge

 ‘My initial enthusiasm was met with the realisation of the challenge that lay ahead. … having worked as a therapist for 15 or so years, I should know what I’m doing and be able to get it right. It was useful at this point to recognise the incongruence-I am not expected to be experienced as the expert in my relationship with clients, it is all about collaboration and so why the expert now?

The end of the PCE-CfD course is marked by submitting a twenty minute video which is marked by the tutors against the Person-Centred Experiential Psychotherapy ( PCEPS) scale⁹. Each delegate is sent written feedback.

 ‘Having completed a DVD recording during our training, I found the feedback to be detailed, knowledgeable and constructive’

After completing the training, therapists submit up to- six taped recordings of client work, four of which must reach adherence to the PCEPS scale to obtain the PCE-CfD license. These recordings are initially taken to a PCE-CfD supervisor who supports the process beyond the training. The evidence we collected from our data showed that completion time varied from four to eighteen months.  Seventy percent of those who identified as purely person-centred completed between four and six months. None of those who identified as person-centred took over twelve months to complete.

Having noticed this discrepancy in completion time, particularly for those who did not identify as purely person-centred, we implemented ‘refresher’ PCE-CfD days with delegates. One delegate who took six submissions to complete fed back- ‘the refresher course with you in Nottingham was the turning point for me, something just seemed to switch on in my head’

 Feedback from delegates varies and in the same course some feel their needs are met and go far beyond what is expected, and others are less satisfied, seeking more detail about applying PCE-CfD in their work context. This is a challenge and as Catherine Jackson’s July 2016 article demonstrates, the implementation of PCE-CfD is extremely varied.

 ‘In some clinical commissioning groups (CCGs), counselling is available on a 50/50 basis; in some it is an integral part of the IAPT service, alongside CBT, with its own clinical governance structure. In some it has been outsourced to a third sector organisation but is still accessed through a single point of entry. In some it can be offered immediately; in others clients have to go through the stepped care process and have step 2 CBT before they can see a high intensity counsellor; in a very few it isn’t available at all’(2016 p7)

With this as the backdrop, what happens to each delegate once leaving the training environment is inevitably different. All delegates maintain their personal workplace supervision post training and get funded focused specific support for the PCE-CfD qualification from PCE-CfD supervisors. 

 ‘I was used to my own Supervisor and the thought of starting anew, with someone I did not know was challenging for me.’

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Another challenge for PCE-CfD delegates is the prospect of recording clients. I have frequently been told by PCE-CfD delegates that they find this aspect very difficult if not impossible. Others however have different feedback

‘I did not find any difficulty in taping clients. Reviewing the work and reflecting on it in supervision was very helpful. I found reviewing my work in this way gave me new insight and I believe helped me improve as a therapist. I will continue to use recording in my supervision process’.

All the correspondents who qualified shared an overall positive experience of working in this way.

Clearly this is not the case for all delegates who attend PCE-CfD training and for some completing is a necessary ordeal. As the years progress the increasing pressure to complete whilst being prevented from offering over six sessions adds to the mix. Different contracts introduce unexpected elements

and challenges . More and more we meet delegates who are on zero hour contracts, something I suspect is unlikely for those who work as CBT IAPT practitioners. Yet again, the real inequality for counsellors manifests its self in employment terms and conditions.

 

As already mentioned, the IAPT approach includes capturing data through the ‘MDS (Minimum Data Set)¹⁰ This data monitors symptom reduction and was developed for drug companies. It suited the initial purposes of IAPT as it was freely available with no cost to implement. It is not so inconsistent with the main model promoted by IAPT of CBT (Cognitive Behavioural Therapy) which usually focuses on symptoms which the MDS measures. However, a symptom focused measure is completely inconsistent with the PCE-CfD model, which is a model of growth. Being able to really engage in the principle of non-directivity has had benefits for therapists and clients it seems.

One delegate shared post qualification:

‘As a Person Centred counsellor I have always stayed with what the client brought, however the training had a new word for me now ‘Nondirectiveness’, enabling a better overview of me in practice. It is my belief that PCE-CFD training has enhanced my work, my focus and improved outcomes for my clients’

The opportunity we have with PCE-CfD is to collect data that is consistent with the growth model. If we have the chance to really connect to therapists as a result of this investment in PCE-CfD, it could be a great opportunity to also encourage meaningful data collection that will support the continuation of counselling in the NHS.

By articulating the emergence of positive aspects of the self in measurements, there is a validation that despite the terrible experiences people encounter throughout life there is always the potential for something different to emerge and offers a positive view of the human struggle. This positive psychology agenda, consistent with the growth model of PCE-CfD, is also compatible with the ‘wellbeing agenda’ promoted in mental health.

In terms of PCE-CfD developing, if we were able to introduce theory consistent data sets, or if clients themselves could identify the sort of change they wish to experience and measure that, we could gather a variety of evidence that is experienced by clients indicating growth, rather than symptoms. There could be a way for Peter, quoted earlier⁷ to capture the shift he experienced as a result of therapy. Some services have shown in Catherine Jackson’s article that PCE-CfD can be offered in an environment that supports it values in the way CBT is supported. PCE-CfD delegates need not be destined to engage in a confusing and contradictory process Recognising the value of PCE-CfD training and its significance as an investment into a non-medical approach is timely for those involved in managing services and their staff, who could find an experiential approach to client work refreshing and supportive.

Catherine Hayes, University of Nottingham

¹ http://www.pce-world.org/images/stories/meta-analysis_effectiveness_of_pce_therapies.pdf

2 Department of Health (2008).Improving Access to Psychological Therapies. Implementation Plan: National guidelines for regional delivery. [pdf] Available at http://www.iapt.nhs.uk/silo/files/implementation-plan-national-guidelines-for-regional-delivery.pdf

³http://www.iapt.nhs.uk/en/workforce/iapt-education-training-and-development/

⁴ http://www.ncbi.nlm.nih.gov/pubmed/24103190

⁵Rogers, C. R. (1959) ‘A theory of therapy, personality, and interpersonal relationships

as developed in the client-centered framework’, in S. Koch (ed.),

Psychology: A Study of a Science, vol. 3: Formulations of the Person and the Social

Context. New York: McGraw Hill. pp. 184–256

⁶Sanders, P. and Hill, A. (2014) Person-Centred Experiential counselling for depression. London: Sage.

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⁷Hayes.K  (2015) in  S. Palmer  The Beginner’s Guide to Counselling & Psychotherapy London Sage Pg 220   

⁸ Hayes, Murphy and Proctor  What factors predict successful completion of the Person-Centred Experiential counselling for depression training programme? Unpublished paper presented at BACP Research Conference University of Nottingham May 2015

⁹Elliott, R. and Westwell[ (2014) in P. Sanders and A. Hill, Person-Centred Experiential counselling for depression. London: Sage. pp. 186–91.

10 (http://www.metanoia.ac.uk/media/1398/thepracticedtrialpptx.pdf),

¹¹ MDS:  http://www.hscic.gov.uk/iapt