A PORTFOLIO OF ACADEMIC,

THERAPEUTIC PRACTICE AND RESEARCH WORK

Including an investigation of

Holding the tensions within evidence-based practice: An IPA study

of Counselling Psychologists’ experiences of making clinical choices.

By

Peter Neil

Submitted in partial fulfilment of the degree of

Practitioner Doctorate in Psychotherapy and Counselling Psychology

School of Psychology

Faculty of Health and Medical Sciences

University of Surrey

September 2017

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Copyright Statement

No aspect of this portfolio may be reproduced in any form without written permission of the author, with the exception of the librarian of the University of Surrey who is authorised to reproduce this work by photocopy or otherwise and lends copies to

those institutions or persons who require them for academic purposes.

© Peter Neil 2017

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Statement of Anonymity and Confidentiality

To preserve the anonymity and confidentiality of all clients, research participants, supervisors, and placements, all names and identifying information in this portfolio

have been omitted or replaced with pseudonyms.

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Acknowledgements

Over the three years of this course I have been supported by many people. Training doesn’t happen in a vacuum and the time and effort required to get people to a professional standard is an arduous task. All of the course team have been available, considerate, patient, dedicated and skilful. That should be enough, but they have also been engaging, thought provoking and challenging. Nearly always with a smile. Elena helped me over the line and I am grateful for her patience and understanding.

I need to acknowledge the supervisors that I had the privilege of training with. It is extraordinary what they give of both their time and counsel. However, the most important people in my clinical training were my clients. They can never read this but I hope I thanked them in the most important way of all, by honouring them as the wonderful people that they are.

Finally, my family. This course has changed our relationships. My partner attended therapy so that she could understand something of my experience. She has given of herself in that way and many, many others. To my children. I count you as five. From the elder Dr Roger, Calum, Grace, Lauren and Sam. Five very good reasons to be the best that I can be.

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Contents

Abstract……………………………...………….……………………………………..6

Introduction to the Research Dossier………..……………………………...………....7

Literature Review: The epistemologies that inform

the ontologies of alliance in psychotherapy and counselling………..………..……….9

Research Report 1: What was it like working with your therapist?

A thematic analysis of the alliance concept from a client’s perspective……....……..39

Research Report 2: Holding the tensions within evidence-based practice:

An IPA study of Counselling Psychologists’ experiences

of making clinical choices.………………………………...………………….…….101

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Abstract

The focus of this research thesis is the therapeutic concept of the ‘alliance’. I

conducted a literature review on key documents from within the American

Psychological Society that sought to establish an evidence-base for psychotherapy

that was methodologically compatible and comparable with pharmacotherapy. The

ontological assumptions that defined and informed an alliance construct derived from

experimental methodology were considered from the perspective of UK Counselling

Psychology.

This was followed by my first research study, which used a qualitative method

to investigate the alliance construct from the clients’ perspective. This was felt to

better reflect the Humanistic assumptions of UK Counselling Psychology and further

explore the alliance construct and its relevance to clinical practice. A further research

project qualitatively investigated Counselling Psychologists experiences of making

clinical choices. It sought to develop the current understanding of Counselling

Psychologists’ dialectical engagement within the UK’s healthcare climate of efficacy

derived practice evidence.

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Introduction to the Research Dossier

This dossier contains a literature review and two qualitative research reports:

one using Thematic Analysis and the other Interpretative Phenomenological Analysis.

Each research question was developed from my understanding of the ‘alliance’

(working/therapeutic) and its implications for how the therapeutic dyad could be

understood and key contemporary Counselling Psychology practice tensions. Each

research report includes my own reflective position within the research and its

contribution to my developing practice.

The literature review explores an historic debate within the American

Psychological Association. It was the genesis of a political movement to introduce an

epistemologically bound evidence-based practice to psychotherapy that would

establish such interventions as efficacious as pharmacology. My position within the

extant literature was to critically explore the methods, epistemologies and subsequent

ontologies of the alliance as a function of the science that rendered it as a theoretical

concept. This highlighted the implications that science has on our practice and the

ways that such concepts can be understood, used and controlled.

My first research project built on my prior literature review by exploring an

understanding of alliance from a client perspective, as it was considered as under-

researched and reflected Counselling Psychology’s Humanistic practice values. The

thematic analysis was experiential in its focus and developed themes that inductively

explored the participants’ interview accounts of their working experience within their

therapy. By exploring the working relationship within the therapeutic dyad, I wanted

to investigate some of the assumptions that had been explored in my literature review.

This I felt was an important valuing of the clients’ voice within research, which is

commensurate with Counselling Psychology’s Humanistic and Existential

epistemology and my own practice stance.

My second research report took my prior research findings and explored what

Counselling Psychologists’ experiences were within the context of an evidence-based

practice climate. My first research project had highlighted to me the relational and

ongoing nature of clients’ needs to participate in what therapy might be for them and

what they would ally with. My intention in this research was to explore the many

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practice tensions that exist between a technical-rational model of evidence-based

practice and Counselling Psychology’s more Humanistic valuing of the ‘other’. By

using Interpretative Phenomenological Analysis I was able to investigate these

practice experiences for something richer and deeper than the ‘tensions’ that were

anticipated.

My personal experience conducting this research has been instrumental in my

development as a practitioner and my practice position within the tensions anticipated

within Counselling Psychology literature. I feel that the nature of qualitative research

is also a key clinical skill that has developed my ability to listen empathically and

critically, to better reflexively consider my interpretations and strengthened my own

commitment to Humanistic practice values. The process was demanding reflexively in

new and novel ways and that has helped me to develop and explore different aspects

of myself. It has given me a much deeper appreciation of the forces at work between

people and the uses and pitfalls of all of our alliances.

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Literature Review: The Epistemologies that inform the ontologiesof alliance in psychotherapy and counselling

Abstract

Bordin (1979) anticipated that a therapy alliance of tasks, bonds and goals

would mean different things to the clinician depending upon their conceptualisation

of therapy practice. I hypothesised that conceptual alliance differences would also

emerge as a function of the epistemological differences within research

methodologies. Therefore, what constituted Bordin’s sub-categories would be

ontologically defined by the methods that were chosen to investigate them.

From a critical realist perspective, divisional task force papers from clinical

and counselling psychology (APA) were reviewed and their epistemological

differences highlighted. Supporting documents that emerged as the debate progressed

and reaction to empirically-validated treatments were also considered. Some research

papers that reflected the disagreement of what constituted evidence were reviewed in

light of findings.

Differences did emerge from the epistemological debate and their effects upon

alliance conceptualisation were characterised in relation to clinical practice.

Bordin’s tasks, bonds and goals of the alliance may well vary across modality,

as he anticipated, but they can be shown to vary according to the epistemological

body of evidence that the practitioner endorses as well. This had been unanticipated

in Bordin’s (1979) original paper when the pan-theoretical concept was proposed.

Keywords: alliance, evidence-based practice, empirically-validated treatment,

counselling psychology

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Introduction

The alliance concept has its roots in the early psychodynamic works of Freud

(Kanzer, 1981). It was defined as the person to person conscious relationship devoid

of transference and unconscious drives, dubbed the analytic pact. Its utility and

investigation has continued at pace with its inclusion, in some form, in virtually all

textbooks and treatment manuals published in recent times (Castonguay, Constantino

and Holtforth, 2006). As a foundational aspect of many therapeutic endeavours with

proponents as integral to modality as Freud, Beck (Emery, Rush & Shaw, 1979),

Rogers (1957a) and psychiatry itself (Heyland, 2012) it would seem to require little

further support within psychotherapy. Constantino, Castonguay and Schut (2002;

p.86) propose that the alliance,

represents interactive, collaborative elements of the relationship (i.e.,

therapist and client abilities to engage in the tasks of therapy and to agree on

the targets of therapy) in the context of an effective bond or positive

attachment.

These three constituent parts of tasks, bonds and goals (Bordin, 1979, 1994) has

formed the basis of a pan-theoretical concept termed the ‘working alliance’. Bordin

(1979) suggested that the working alliance between the therapist and client is key to

the change process. Crucially, for this review, he also proposed that with time and

research resources evidence would emerge that the tripartite aspects of the alliance

would ultimately differ across therapeutic modalities. Differences would be found in

the tasks that are collaboratively agreed and subsequently the goals would diverge by

modality and the attendant bonds that were formed; that ultimately the alliance would

be qualitatively different.

True to Bordin’s view, experimental designs have operationalised this concept

and an example of such a measuring tool is the Working Alliance Inventory (WAI)

(Hovarth and Greenberg, 1987). While the WAI has found much favour within an

experimental methodology it is not uncontentious as a single factor construct. Hovarth

and Greenberg (1989) demonstrated high correlations between the three sub-factors

(tasks, goals and bonds) and only reported adequate validity. Other models have been

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experimentally tested which imply that goals and task may reflect one factor with

confidence and bonds reflecting another (Andrusyna, Tang, DeRubeis and Luborsky,

2001). While the nature of the construct itself may still be contentious, its relevance to

non-specific factors in all therapeutic endeavours has been widely accepted

(Chambless and Ollendick, 2001). However, the recent and accelerating movement

for support within the clinical setting of evidence of treatment efficacy has provoked a

deeper analysis of the alliance: how it can be characterized, what aspects can be

operationalised, its effects upon outcome and potentially the individual differences

that may influence it.

When the American Psychological Association (APA) Division 12 (Clinical

Psychology) Task Force published their ‘Promotion and Dissemination of

Psychological Procedures’ report (American Psychological Association, 1995) it

demonstrated their clear intent of establishing a strong methodological base of

‘evidence’ that supported the work of Clinical Psychology within the US. The

subsequent Task Force responses from other divisions within the APA sought to

challenge many aspects of the report. Such challenges included the methodological

supremacy of randomized control trials (RCT) and meta-analysis, the epistemology of

the medical model, the ontological view of the client/patient and indeed the therapist,

as well as the general assumptions of Psychiatry which the Clinical Psychology Task

Force were thought to compete. The focus of this literature review will seek to take a

critical realist stance within this debate on the nature of ‘relationship’, specifically the

‘common factor’ of ‘alliance’. The purpose and specific focus of this review will be to

potentially render the ontologies of the alliance and its varied conceptualizations from

the material presented as source by Divisions Clinical and Counselling of the APA.

By concept the ‘alliance’ is presented as relatively uncontentious (eg. Cooper, 2008).

However, by definition and therefore an ontology, agreement may be more

problematic. Such a situation arose when broad cross-divisional consensus was

required in the pursuit of therapeutic modality ‘evidence’ of efficacy and

mechanisms-of-change (Bordin, 1979).

This debate has relevance within the context of current UK healthcare and to

Counselling Psychology (CoP). The arena for the literature used as source for this

review was by publication, which set out clear epistemological differences between

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US APA divisions. The documents demonstrated the arguments used to support

differing views on what methodologies might best support evidence of best practice or

if was at all possible to do so. The consequences of defining what best practice

evidence might represent has now gained government interest: in the US as Cochrane

Collaboration (2016), evidence and funding support for a National Institute of Mental

Health, and in the UK as NICE (2014) guidelines. NICE accept and prefer Cochrane

Collaboration evidence which suggests an acceptance of the ramifications of this key

debate. NICE also considers evidence by methodological hierarchy as proposed by the

Cochrane Collaboration. For CoP in the UK, the methodological hierarchy has effects

on what strength types of evidence are perceived to represent. CoP endorses a

pluralist epistemology that rejects the prejudicing of any one knowledge type as more

powerful than another (McAteer, 2010). This debate has resulted in a governmental

and political endorsement of positivist outcome trials at the expense of qualitative

research methods. This weakens CoP’s ability to contribute to the UK debate of what

might represent best evidence-based practice unless it too produces and favours

positivist evidence to support its professional practice philosophy.

Philosophies

I begin with a brief over-view of the philosophies of science and the

assumptions that subsequent knowledge embodies (for a full critical review see

Ponterotto, 2005). At its critical heart, scientific endeavour rests on a psychological

ontology; what can be said of the nature of reality and the forms that it may take and

what can subsequently be known of it? Materialist and idealist ontologies represent

two distinct poles of understanding and neatly conceptualize the positions that

research assumes. Materialist positions assume an underlying structure and a

subsequent realist epistemology of one true reality that is identifiable and therefore

measurable. Such a philosophy is reflected in randomized controlled trials (RCT) as a

suitable positivist methodology (Salvatore, 2011). In contrast is the idealist who

fundamentally believes in multiple realities: constructed, contingent, subjective and

social. The nature of a critical position within the ontology debate is key as it assumes

that all knowledge is positioned and inherently flavoured. Specifically, the defining

shift in psychotherapy towards evidence-based practice (EBP) and the positivist

paradigm of data accumulation has an assumption of knowable and generalizable

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structure that underpins its ‘truth’. While other research possibilities exist they carry

less weight (as valid logic) and therefore less influence (eg. NICE, 2014). Strength of

recommendation puts evidence from meta-analysis of randomised controlled trials as

the strongest empirical support for type of therapeutic treatment intervention.

Descriptive, comparative and correlational studies, case-control studies and clinical

opinion fair worst. What is notable among this hierarchy of evidence is the

supposition of ontology. For our purposes, it poses the question; if the alliance is a

fundamental imperative of therapeutic modalities engaged in the debate on EBP, can

tasks, bonds and goals be defined by the same thing?

I propose that, from a critical realist perspective, the epistemological

differences that underpin the philosophy of clinical and counselling psychology will

inform clinical practice. Therefore, the working alliance that forms the bedrock of the

therapeutic endeavour will ultimately imply different meanings. Rather than the cross-

modality consensus that Cooper (2008) has suggested, under scrutiny they will

diverge and display qualitatively different definitions of the terms tasks, bonds and

goals. By examining the nature of methodologies, epistemologies may be analysed

and potential ontologies (or definitions of what is constituent) extrapolated. Once a

philosophical position is interpreted its implications for the alliance can be rendered.

While any extrapolation must be viewed with caution, it is hoped that these under-

reported scientific philosophies may broaden the scientific debate. The alliance, as a

common therapeutic factor, has implications for all professions in the understanding

of the treatment of human distress.

Clinical Psychology

In 1993, Division 12 (Clinical Psychology) of the APA published the ‘Task

Force on Promotion and Dissemination of Psychological Procedures’ document which

sought to begin a movement within psychotherapy of Empirically Validated

Treatment (EVT). The report further suggested that all psychologist training should

include at least one EVT and that the benefits of EVT should be communicated to

third party payers and the general public as users of psychological services. It is, in

effect, a political movement for methodological primacy within the psychotherapeutic

cohort. The reason for such a change is stated, that without research methodologies

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that can match the double-blind placebo trials that underpin psychiatry treatment then

psychologists will be disadvantaged. They will be unable to support the validity of

their competing psychotherapeutic interventions. It is a requirement of the Federal

Drug Administration in the US since 1980 that all drug applications are supported by

several such methodological enquiries demonstrating its efficacy (Shapiro and

Shapiro, 1997). Crucial in the design is the potential to demonstrate the drug’s

superiority to placebo, thereby logically offering benefits above the psychological

effect of expectation.

The RCT design is one positivist quantitative methodology and Lincoln and

Guba (1985) have summarized the designs inherent assumptions as such; the laws of

explanation and prediction (through hypothetico-deduction) should be the focus of all

scientific inquiry, that concepts are definable as categories, data reflects the laws of

nature, large samples overcome small variations in data and allow the attribution of

cause and effect, and finally, that uniformity exists in nature and that therefore exists

an identifiable reality (Ponterotto, 2005). The post-positivist perspective is also

largely similar, but differs from positivism in that any objective reality will be only

partial and imperfect (Lincoln & Guba, 2000). It dilutes the absolute claims of a

knowable objective reality and assumes that life is inseparable from phenomena

limiting one’s ability to ever fully know what constitutes immutable truth. Both the

positivist and post-positivist positions, while believing that realities exist, differ in the

notion of what they potentially constitute or our ability to fully access and understand

them. The ‘Task Force’ report does not state which epistemological position that it

ultimately takes in the call for EVT. Both positions do (or may) utilise the

methodology of RCT but assumptions could potentially differ influencing how the

knowledge could be utilised to support treatment efficacy and ultimately effect.

The Division 12 Task Force report (1993) asked researchers and practitioners

to accept (largely) one methodology of inquiry at the expense of all others. This was

established by proposing criteria of ‘well-established treatments’ and their

recommended outline follows. The first possibility is two good group design studies,

which can demonstrate efficacy in either comparison to placebo or another treatment.

The second possibility is a large series of single case studies that make comparison

with another treatment intervention. Both categories must use treatment manuals and

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clearly specify the characteristics of the client sample. In a later document addressing

the furore that had broken out among differing divisions of the APA, Chambless and

Ollendick (2001) suggested that for inclusion as an Empirically Supported Treatment

(a noted change in terminology - EST) experiments needed to be conducted with

‘good’ methodology. As such we can begin to build a philosophy of science

underpinning clinical psychology’s Task Force Division 12’s EVT.

The ‘good’ methodology proposed, that might challenge the medical model of

client/patient distress, was necessarily positivist according to Chambless (et al.,

1998). Rather than enter into the ensuing debate about what may or may not advance

the psychotherapeutic endeavour (see Angen, 2000; Lichtenberg and Wampold, 2002;

Wampold, Litchenberg & Waehler, 2005; American Psychological Association, 2005)

I shall focus on the methodological decisions that were considered imperative in the

demand for EVT and the epistemology that Division 12 hoped to build. The

proscription of anything that could not demonstrate bias-free research (RCT), efficacy

specificity (comparison to a control group) and replicability (wo RCTs of similar

focus) was by exclusion deemed not an appropriate psychotherapeutic intervention of

sufficient power to challenge the medical model. Areas highlighted in the Task Force

document were manualised therapy intervention, comparison designs that reflected

placebo or alternative treatment samples and positive efficacy outcomes reflecting

effectiveness. While they were controversially prescriptive (Chambless and

Ollendick, 2001) these ‘conditions’ of EVT were the function of the knowledge that

treatment effectiveness was felt to require for medical validity. I will now address

each of these ‘conditions’ and begin to hypothesise how a realist epistemology may

render the alliance in therapeutic practice.

The first, and possibly most contentious, was the requirement of all validated

research to use manuals, in fact two manuals. In designing any EVT, research had to

demonstrate that the samples within each RCT condition had similar mental health

difficulties otherwise a valid comparison would be extremely difficult (Chambless et

al., 1996). The method that was deemed the only solution was by DSM IV

categorisation by psychiatric diagnosis (American Psychiatric Association, 1994). A

later EVT report notes that though diagnosis may fall short of full acceptance within

psychology and the accepted limitations of such a method of sample control, there is

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no better alternative (Chambless and Ollendick, 2001). Another manual that is also

required for validity within EVT is the manualised treatment guidelines that inform

and constrain therapeutic intervention. Such manuals represented the independent

variable within RCTs and constructed the tasks that therapy would comprise of. As an

alliance construct, tasks of therapy become manualised. Such a constraining of

therapy tasks is a fundamental requirement of ‘good’ research design to facilitate

interpretable positivist results (Chambless et al., 1996, Chambless and Ollendick,

2001). The report asks if anyone can ever know what treatment was actually provided

without manualisation to control experimental bias and therefore therapeutic practice.

This represented a two pronged control of both independent variable (manualised

treatment) and sample group (through DSM diagnosis). It was deemed that without

bias, research could demonstrate the underlying structures that are assumed inherent

within our psychology that were being acted upon during treatment.

EVT however is not uncontested. From papers within the realms of other

epistemologies criticism had focused on the shortcomings of shoe-horning human

distress into a purely RCT model of knowledge acquisition. Principally of note here is

the methodological omissions that may limit what possible validation RCTs in the

psychotherapies may be required to accept. Manualisation of psychotherapeutic

intervention is a proposed control of the tasks of therapy. This would enable the

within-condition variable to be sufficiently similar to allow an assumption of new

realist knowledge. Here, the therapist is considered as a deliverer of treatment and

what therapy constitutes as cause (the tasks of therapy) is the manualised therapy

procedure. However, two factors may ultimately limit these conclusions (Wampold

and Bhati, 2004). The basis of a positivist epistemology is that of the double-blinding

of medical methodology. O’Leary and Berkovec (1978) argue that if genuine

psychotherapeutic placebo were possible it is unlikely that therapists would

administer it in the manner that would be required for experimental control: ethically,

knowingly or practically. This challenge to the ‘inertness’ of placebo in

psychotherapy research is also questioned by Seligman (1995) who suggests that

blinding is impossible as the therapist must be competent, aware and practiced at the

psychotherapy treatment to adhere to the attendant manual. Wampold and Bhati

(2004) also suggest that too little is known of the mechanisms of change to make the

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placebo assumption. The potential active ingredient that is causing change is still

contentious. Any assumption that the theoretical underpinnings of one psychological

treatment against an ‘inert’ other theoretical modality cannot be made with sufficient

validity.

Another contentious methodological assumption that underpins EVT is the

inclusion of DSM IV categorisation for comparison control between experimental

groups, a point acknowledged by Chambless and Ollendick (2001). The inclusion of

DSM criteria suggests that for practitioners to follow EVT evidence for best possible

practice they must also diagnose clients to ascertain if an EVT is suitable. As

diagnosis stems from medical practice the likelihood is that in, a clinical context,

psychologists are unlikely to have sufficient experience to utilize a psychiatric manual

and diagnose. Most psychological specificity is incompatible with psychiatry: that is

the reason EVT seeks to establish validity to challenge the very medical model that

researchers are subsequently bound to accept. Kazdin (2008) also notes from clinical

practice that his position as therapist is not necessarily for the purposes of changing a

client from one category to another but for the process of coping with life. He argues

that the 32,000 possible DSM-IV combinations of conduct disorder seem less relevant

than an assessment of stage of life, marital and family history, gender, ethnicity,

socio-economics etc. This implies that alliance goals are functionally medical due to

RCT methodology proposed that defines participants by medical inclusion criteria.

Brown (2002) suggests that a distinct epistemology exists between psychology and

psychiatry, as exemplified by the DSM, and borrows from evolutionary biology for

insight. That causal epistemology has two spheres of influence: proximate cause and

ultimate cause. The former relates to the mediating factors that explain how

something functions (genotype) and the later explains why something happens

(phenotype) (Mayr, 1988). This is a useful distinction because, as Brown (2002)

points out, they answer different questions. How we do things is a different question

to why. Psychiatric diagnosis is concerned with nosological categorisation and limits

psychological assessment of need as a therapy goal and ‘ultimate’ causal mechanism-

of-change.

The purpose of this piece is not to criticise EVT, but to unpick that which is

implicit. Here the methodology is empiricist, positivist, realist/materialist and borrows

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from medical epistemology. Omissions are evident in the intention to establish realist

structures through contentious controls in the sample population and the independent

variable (the therapy from the therapist) that are evident in the accepted methodology

of EVT. Critically, the assumptions that underpin methods and epistemologies

become conceptually important when assessing the persuasiveness of evidence

critically. The ontological assumption that allows a treatment to be validated is the

objective knowing of the structures that are reflected in the hypothetical experimental

premise. Researcher and therapist bias, through the inability to double-blind trials, is

ignored in the pursuit of a gold standard that can compete with pharmacology. That

biases may still exist is a matter of continuing research and debate but EVT validation

can be said to have been established and treatment purported to be of sufficient

experimental rigour (Task Force on Promotion and Dissemination of Psychological

Procedures, 1995). EVT methodology can also be shown to methodologically control

alliance tasks and goals. This methodological effect may be unintentional but the

move to challenge pharmacological interventions with psychological EVT has

potentially redefined what therapists might do in therapy and what clients might hope

to achieve.

The alliance, an EVT ontology

To return to the alliance as an ontology we began by proposing Bordin’s

(1979) single factor, three sub-factor model; tasks, bonds and goals. What

implications, if any, would manualised diagnosis and treatment have on our

understanding of what the tripartite factors may mean to the clinician? Firstly, the

agreement on treatments goals would be impacted by the prescriptive nature of

diagnosis by DSM. Goals that do not include reduction in symptoms that comply with

diagnosis category would not be possible without departure from EVT. While clinical

judgement may facilitate any evolving client demand for goals to be re-assessed, EVT

adherence would view this as a departure into clinical judgement without empirical

support. Similarly, goals must remain fixed and specific for the duration of treatment

as that would also depart from the clinical treatment into a new EVT or a category

where no EVT exists to inform the therapist. Bordin’s second alliance component is

the agreement on the tasks to achieve the stated goals. Treatment manuals define the

tasks of therapy usually by theoretical mechanism of change (eg. attending to and

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challenging distorted thoughts in Cognitive Therapy). EVT decries the lack of

specificity in most clinical practice because it is deemed without empirical support.

This suggests that the brand names of therapy are not the identifiers, the manual is

(Chambless et al., 1996). Working Alliance ‘tasks’ are therefore specified by manual

and agreed upon before treatment begins. To provide EVT, the clinician and the client

must therefore agree upon the tasks, specified in the treatment manual, that

correspond with diagnosis category. Failure to follow this procedure would represent

a departure from the independent variable and limit the empirical support for

treatment efficacy. The third alliance component is the client-therapist bond.

Chambless (et al., 1996) suggests that the bond and the subsequent relationship

between client and therapist may be impacted by client personality factors; reactance

and impulsivity/low socialisation and ultimately may rest on three of four factors.

This represents another layer of alliance influence as client personality categorisation

would be required to facilitate varying manualisation by client ‘type’. What bonds the

manualised therapist can create with a diagnosed and personality-tested client may

ultimately rest upon flexible clinical skill and style, something which is assumed will

be achieved by EVT protocols.

Another methodological premise, outlined previously, of EVT is the need to

demonstrate comparative validity; either to placebo or another established treatment

(Task Force on Dissemination of Psychological Procedures, 1995). This is usually

controlled by a pre-test post-test outcome measure (eg. Beck Depression Inventory)

and the resultant statistical analysis can demonstrate the measure of change. Then by

comparison between experimental groups the amount of change can be ascertained.

Kazdin (2008) makes two key points. The first is that this methodology of

comparative evaluation may demonstrate experimentally that one treatment

outperforms another, but provides little information on the mechanism-of-change.

Secondly, that real client change must reflect something more than ‘arbitrary metrics’

of quantitative measure without reference to something that is meaningful to the client

(Blanton and Jaccard, 2006). This has two-fold implications for the psychotherapist. If

departure from EVT protocol is required through clinical judgement then little

empirical information is available to inform best practice of how to be flexible and

use the mechanism-of-change creatively for the benefit of attaining treatment goals.

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Secondly, that EVT change is judged as metrically important. What that represents to

the client is not regarded specifically, but is assumed to be satisfactory. This may

indeed be the case but it has implications for the alliance.

EVT methodology, that validates treatment protocols through comparative

design, also has implications for clinical practice. The tasks of the alliance are

impacted by the validation of efficacy without the mechanism-of-change being

validated. If flexibility is required (eg. to accommodate changing goals, rupture or

discontent) the psychotherapist has to rely upon theoretical constructs rather than an

established mechanism-of-change (from an EVT perspective). The tasks of therapy

then become integrative or eclectic as without specification treatment lapses into

‘brand name’ therapy (which, in itself, is neither good nor bad but not necessarily

empirically validated). Also, the bonds of any alliance must inherently rest on trust

(Bordin, 1979). The ability to demonstrate one treatment style of efficacy over

another may impact upon confidence in the therapist and possibly the client, or the

therapy itself. How this could play itself out in the alliance is potentially as variable as

all relationships. It is worth noting that it loads the alliance with an external influence:

therapist as purveyor of validated scientific knowledge (or therapist without empirical

support) or distributor of constrained patient choice (Kazdin, 2008). In a Presidential

Task Force report, Levant (American Psychological Association, 2005) makes this

very point, that recognition of EVT increased among the public, training programs

and policy-makers following dissemination. The bonds of alliance, as a function of

trust in an expert/non-expert or institution, may also be influenced. Finally, the

alliance tri-partite component of goals would seem to suggest that goals that comply

with EVT goals are the most appropriate for the diagnosis that the client has received.

If they have delivered a comparative advantage over another theoretical possibility,

has the client really been offered an informed choice? Especially if they cannot

understand the limitations of EVT methodology and the lack of evidence regarding

mechanisms-of-change? The Division 12 Task Force does accept that informed

consent is fundamental (Chambless et al., 1996), but can we expect clients to

understand the fundamental methodological issues regarding the empirical

epistemology that underpins RCT methodology?

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This aspect of the debate remains relevant to the UK and UK Counselling

Psychology today. It is an ethical concern as much as a methodological issue.

Treatment choice is enshrined in NICE guidelines (2011) as a fundamental service-

user right to informed choice from all available treatment possibilities. For CoP, it is

also a humanistic value that is mandated by the professional body as a promotion of

and valuing personal responsibility (BPS, 2014). The ethics of the EVT movement

philosophy is to improve access to psychological therapies as an alternative to

pharmacological solutions. Yet the consequences on the ethics of treatment choice are

perhaps unintended and represent a challenge to the professional ethics of UK CoP.

Moreover, what implications are the constraints on treatment choice to EVT and any

alliance that may be left undefined by its methodology?

An Empirically Validated Treatment

The first ‘well established treatment’ listed as EVT is Beck’s cognitive therapy

for depression (Task Force on Promotion and Dissemination of Psychological

Procedures, 1995). A review of this research may demonstrate the nature of empirical

validation and the implications that it can have on how the clinical interpretation of

the alliance might be rendered. The citation for efficacy evidence is a meta-analysis

(Dobson, 1989). The report suggests that previous meta-analysis had lacked

specificity of treatment and so only studies that used or cited the work of Beck and his

associates (Beck, Rush, Shaw & Emery, 1979) were included. The analysis also only

reported on those studies that used the Beck Depression Inventory (BDI) and no

assessment criteria for depression was considered necessary to report. Several

statistical analyses are worth noting and all effect sizes as per Cohen (1977, cited in

Dobson, 1989). Those clients that received cognitive therapy did significantly better

than wait-list and no-treatment groups (2.15). Cognitive Therapy was more

efficacious than pharmacotherapy (0.53, range = 0.42 to 1.74) and ‘other

psychotherapy clients’ (0.54, range = 0.32 to 0.90). The number of weeks of

treatment did not relate to the amount of BDI change (0.28). Based on these results

the report suggests a reliable conclusion that, by assessed changes in the BDI,

cognitive therapy is more effective than no-treatment, wait list, pharmacotherapy and

other forms of therapy.

21

What implications might these EVT findings have in the clinical setting on the

alliance tasks between the therapist and client? Two areas highlighted previously in

the methodological review of EVT was the impact of manualisation and the

comparison between groups on the alliance. Dobson (1989) discusses the time effects,

as weeks of treatment, within the trial that had little impact upon outcome in the

Cognitive Therapy condition (0.28). He proposed more research to establish if the

cognitive elements were the specific mechanism-of-change or the behavioural

elements which feature in the early phases of cognitive therapy, as per manualised

protocol. If there is little evidence to support continued improvement beyond the early

stages of treatment, what can the clinician make of the alliance tasks if improvement

is disrupted, rupture ensues or the client attends to cognitive tasks but cannot or will

not attend to behavioural. Without the evidence of specificity that comparative

efficacy trials largely ignore, the departure from EVT protocol would seem likely

unless adherence to tasks were mandated. The clinician has limited flexibility as the

alliance tasks, as prescribed by EVT, are manualised. This inflexibility of treatment,

that is a function of manualised treatment, is noted by Chambless and Ollendick

(2001) and they conclude that the small amount of research that they can draw to

determine appropriate clinical action is equivocal.

The alliance bonds are also impacted by the inherent methodological

assumptions of EVT. Beck’s (et al., 1979) manual devotes a chapter to the nature of

the relationship that is required to facilitate cognitive therapy: accurate empathy,

genuineness, trust and rapport. Within the Dobson (1989) meta-analysis that

established EVT, no measure was reported of the strength of alliance bond and, as

such, an assumption was made that bonds existed and were effective, or that they

were not a variable. The cognitive manual of depression protocol begins with a

relationship, suggesting that interpersonal characteristics “are necessary but not

sufficient to produce an optimum therapeutic effect” (Beck et al., 1979, p 45). Given

the variance of personality style that has been highlighted by Chambless (et al., 1996)

as potentially influential on treatment efficacy previously, the lack of relational data

included within this meta-analysis (Dobson, 1989) is consistent with the analysis that

it is assumed that sufficient relational quality, management of rupture, adherence to

tasks and goals has been achieved as per manual protocol. The comparative nature of

22

EVT also has implications for alliance bonds as demonstrated by the evidence of

efficacy for depression of cognitive therapy. Dobson (1989) concludes that limitations

exist in the outcome measure reported in the tests used for analysis. While he accepts

that drop-outs are seldom reported by empirical reports it is one possibility that, for

some, the bonds of alliance lacked the requisite strength. An analysis of this feature of

the data (or lack of such) would be required if we are to understand what implications

can be drawn in regard to the alliance. But the status of the EVT of cognitive therapy

of depression is that of a “well established treatment” (Task Force on the Promotion

and Dissemination of Psychological Procedures, 1995, p 11) despite the bonds of

alliance being assumed, unexamined yet potentially significant with regard to client

drop-out rates.

Alliance goals can also be better understood from the research that underpins

its status. Dobson’s (1989) meta-analysis only chose research that utilised the BDI as

an outcome measure. The implication is that the BDI reliably and consistently reflects

all of the therapeutic goals that the successful therapy of depression encompasses, at

least enough of the goals necessary to imply that the meta-analysis has demonstrated

sufficient power to make a claim of empirical validation. Beck (et al., 1979) gives

clues to the modalities approach to the collaboration. That the ‘collaboration’ is the

basis of making goal decisions and that the BDI is a useful tool when goals are

considered, however, suggests that goals are ultimately dictated by the manual of

treatment onto target symptoms (and the BDI). The purpose of this review is to

establish what implications different approaches to assessing evidence may have on

the alliance. Kazdin (2008) asks if treatment efficacy actually means anything in the

clinical context. On the question of goals he points out that his practitioner role has

goals often defined as something quite different to that specified by the BDI. As such,

EVT evidence ignores this crucial debate and assumes that its power has been

sufficient to establish clinical utility. Cognitive therapy may be the most effective way

to treat clients with depression. However, it does suggest that the pan-theoretical

agreement on the working alliance, as suggested by Cooper (2008), may not be the

case at all. Indeed, it is more in line with Bordin’s (1979) contention that the alliance

would vary by modality and it would also seem to be influenced by the epistemology

of evidence.

23

Counselling Psychology

We move now to the counter-production of knowledge. An assessment of

Division 17 of the APA (Counselling Psychology) response to EVT also suggests

impacts on how the alliance might be understood. Counselling Psychology in the US

began in the early 20th century and chief among its practice was vocational guidance,

helping young people navigate the educational transition into work (Schmidt, 2000).

Psychometric measurement was utilised during the Second World War and a growing

emphasis on intelligence testing further expanded the role beyond the purely

vocational nature of early work. Divisional APA recognition followed in the early

1940’s and the work of Carl Rogers (1951/2003; 1957b) became highly influential as

it offered new accounts of people and their problems distinct from the behavioural

paradigm so prevalent at that time. Both in the US and the UK the profession is

practice led and focuses on the subjective truth of little narratives rather than the large

over-arching natural laws of modernist science (Strawbridge & Woolfe, 2010). As a

post-modernist venture, knowledge is viewed as subjectively embedded in culture and

the focus on the person rather than the individual emphasises how psychotherapeutic

change occurs rather than a pathological focus on what needs to change. Counselling

Psychology is epistemologically critical and views the philosophy of science as

centrally as the science itself.

The EVT movement that emerged from Division 12, Clinical Psychology,

within the APA embodied a distinct epistemological position that ran contra to the

stated ethos of Counselling Psychology. Principles for Empirically Supported

Interventions (ESI) followed (Wampold, Litchenberg & Waehler, 2002) after two

prior documents that set out Counselling Psychology’s criticism of the EVT

movement (Waehler et al., 2000; Litchenberg & Wampold, 2002). The principles of

ESI was a change in direction for Division 17 as it sought to establish what empirical

support might entail rather than what it was not. It outlined seven principles in total

but also included the rationale for such principles to better facilitate a transparent

dialogue between service providers, divisions and practitioners. This rationale, in

itself, is consistent with a humanistic perspective of knowledge creation (both the US

and the UK) that is embedded in an historical, cultural and social context (Corrie,

2010). Deriving from a critical perspective, it suggests that all knowledge is but a

24

piece in a complex puzzle and that an objective realist epistemology is incompatible

with Counselling Psychology’s inherent subjective ‘truths’. We will address each of

the seven principles, drawing upon research where appropriate, that have supported

Division 17 rationale for evidence-based practice (EBP) noting its contrasting

epistemology with EVT. This material is significantly US based. The debate that has

been focused on in this document is around response and counter-response of APA

divisional debate. Its effects are felt and, to a large degree, influence health care

policy within the UK (NICE, 2014). The opportunity to critically analyse what

ramifications the scientific philosophy, that underpins what constitutes knowledge

that has been evident within these Divisional papers, remains accessible. The alliance

between therapist and client that may emerge is fundamental to psychotherapeutic

practice and CoP in the UK.

The first principle (Wampold, Litchenberg & Waehler, 2002) is that

specificity should be a consideration in any evaluation of outcome efficacy and

effectiveness. Four levels are proposed; from the broadest systemic sphere of general

categories of action to the lowest which includes the nature of the clients presenting

problems and the intervention which considers personal risk factors and cultural

characteristics. The rationale for this proposal is that empirical evidence should not be

limited to any one level of specificity. This emphasis upon levels of specificity

highlights the unintended consequences of EVT research, as noted by Chambless

(2002). Her stated intention was, in the case of psychotherapy, to engage support for

clinical psychology at level three specificity (major approaches applied to specific

populations) with aspirations for level four. The subsequent use of EVT that

prescribes activity at level four however assumes that populations are of sufficient

specificity for national introduction (in the UK, IAPT is one such example). Here is

the dilemma for Counselling Psychologists and its implications for any alliance within

psychotherapy. The little subjective truths of the person (level four) are potentially at

odds with the categorical nature of EVT (level three). A methodological hierarchy

however weights the systemic influence against level four evidence from being with

the person. Practice no longer becomes the practitioner looking into research for

utility. Rather, tasks and goals become global and systemically politicized as service

provision (level two and three).

25

Within the UK, IAPT provides some effectiveness research that can

demonstrate this impact (Radhakrishnan et al., 2013). While reporting a cost/benefit

analysis of IAPT, a better than 50% recovery rate for depression was recorded for

those that completed treatment, with a 30% natural recovery rate reported nationally.

One suggestion offered for improving efficiency was the increased use of “telephone

mediated interventions” (Radhakrishnan et al., 2013, p 44). Here is the sharp end of a

very big epistemological stick. Cost analysis of IAPT has the reduction of the alliance

(telephone contact only) and the increase in treatment specificity as the most

advantageous improvement to service. For Counselling Psychology, Bordin’s (1979)

bonds of alliance are a fundamental aspect of therapeutic change through being in

relation with the person (Strawbridge & Woolfe, 2010) and are reflected in the focus

of level four specificity. More importantly, the epistemological differences between

the Divisions results in an alliance as something that is assumed can be

accommodated whatever the context or an alliance of being in relation and wholly

contextual.

The second principle relates to goals of alliance in the proposed move away

from DSM diagnosis in psychotherapy efficacy trials (Wampold, Litchenberg &

Waehler, 2002). Humanistic values suggest that clients, as ‘variables’, are difficult to

group and encompass more than psychopathology but inherently include ethnicity,

gender, values, culture, choice and complexity of presenting problems. The rationale

is Counselling Psychology’s focus upon health, diversity and respect rather than

pathology. This principle is key as it suggests that, epistemologically, criteria for

intervention is founded on the needs of the person rather than categories of

individuals. Alliance goals are reflected in assessment of all that constitutes need

rather than symptomology alone. Principle six follows from this premise, that

outcome should be assessed broadly by perspective and general life functioning. The

rationale is that quality of the person’s life has more utility as an outcome measure

rather than those targeted by specified intervention. Outcome is therefore a personal

construct rather than a generalizable measure (eg. BDI). This presents methodological

issues for the values of CoP. If EVT requires consistent variable groups and outcome

measures then RCTs become problematic for CoP research evidence. The scientist-

practitioner, in and of itself, suggests a mix of epistemologies which necessitates the

26

CoP to be critically integrative (Manafi, 2005). Politically, CoP is devoid of the power

to claim objective truth by virtue of its holistic epistemology which is a potential

dilution of what human science can contribute to a debate framed by the positivist

economics of health care. Principle seven highlights the intrinsic nature of practice at

level four, with the person. Outcomes should be assessed locally, regardless of

evidence at level three. This is the notion of judgement from a science informed

practitioner, which from a humanistic perspective is holistic, embedded and culturally,

ethnically and gender sensitive. Counselling Psychotherapy is a function of being in

relation with a person in context. The tasks, bonds and goals of alliance are led by the

person’s need, not from a treatment protocol informed by diagnosis. This difference is

key as it highlights something unanticipated by Bordin (1979). The alliance may

differ across modality as proposed but there would also seem to be key alliance

differences between scientific philosophies.

The final three principles relate to methodology and the epistemological

claims that can be made from findings (Wampold, Litchenberg & Waehler, 2002).

They provide little immediate insight to the alliance, but I list them here for

completeness. Principle three states that examination of evidence needs to include

effect sizes and be aggregated by meta-analysis. Principle four, that many factors may

need to be considered as well as efficacy, notably patient choice when two contrasting

treatments are of similar power. This is an ethical consideration that has been

highlighted previously. Principle five, that claims of efficacy of ‘unique ingredients’

must be accompanied by verifying a psychological process. It is felt that a focus on

demonstrated efficacy may have ignored a key common-factors approach, as opposed

to a specific-ingredient model of psychological change. Perhaps this principle

emphasises the differing approach proposed by Division 17, that for level four

specificity to be effective it requires a practice led approach that looks into scientific

research to fit interventions to the client based upon the embedded contextual

relationship and the alliance between the therapist and client. As such, it places the

alliance as the pivot upon which therapy can begin to effect change and not an

alliance as a function of a prescriptive intervention.

27

The Alliance, research epistemologies

Research that might support the alliance, as a non-specific factor in therapy

outcome, is in ready abundance as it has become the most studied process of change

(Castonguay, Constantino & Holtforth, 2006). Outcome research has begun to emerge

from an epistemology that supports a contextual view of the client in relation. Before

offering a brief review of two poignant research conclusions, it is worth noting the

entrenched epistemological positions that characterise the debate. In that vein, I will

use the debate as a structure to provide a brief overview of what implications the

realist and contextual view of therapeutic intervention might have for the alliance in

clinical practice. Within the UK, the dissemination of CBT has, to a greater degree,

been through the social care model of IAPT. In a paper by Clark (2011) he offers an

analysis of effectiveness of depression and anxiety by reported patient outcome after

two and a half years of IAPT service and over 400,000 patients seen. He concludes

that there were no differences in the recovery rates of counselling (of non-reported

modality) and CBT with clients assessed with depression. While these reported

figures may not be the product of randomised trial and no controls were reported for

the selection of treatment modality it does utilise real world figures on a very large

scale. If we ignore the implications of diagnosis/treatment/outcome intervention

practice of IAPT we are still left with two differing treatment modalities, ontologies

and process/outcome epistemologies that have, within IAPT, been equally effective (it

is worth noting that the same was not true of anxiety). Despite such large scale

evidence that treatment protocol was not more effective the author’s conclusion called

for greater dissemination of CBT. Evidence-based practice may have acquired a

political edge within UK healthcare provision. Many political movements exist,

however, the politics of treatment superiority has an alliance consequence. Other

research has sharpened this political edge.

DeRubeis (et al., 2005) conducted a large RCT (n=240) comparing CBT and a

medication condition with moderate to severe patient depression (with some elements

of blinding in the medication/placebo condition). Findings were that CBT varied

across sites and that the recently qualified CBT practitioners did less well than their

more experienced counterparts. In a review, Shafran (et al., 2009) concluded that

efficacy must therefore be predicated on the more experienced therapists adhering to

28

protocol. The epistemological assumption underpinning EVT is that alliance sub-

factors can be largely mandated and would not also be influenced by therapist

qualities, apart from adherence to treatment. Can such a fundamental claim of

mechanism-of-change be made from the evidence of six therapists (four experienced,

two less experienced) all who had been approved as competent by the Beck Institute

for Cognitive Therapy? A further conclusion was that alliance is a function of

symptom improvement. It was argued that protocolised treatment remained the only

conclusive mechanism-of-change and cites Feeley, DeRubeis and Gelfland (1999) as

evidence. This research was a replication of a previous study that had found a small

effect size for predictor of outcome from alliance measure at an early stage of

treatment (CBT - session 2), but had also found a larger effect size for treatment

adherence as a predictor of outcome in depression (DeRubeis & Feeley, 1990). Both

studies had small samples (N <30) and the later paper reported a change from a small

effect size of alliance as predictor to none. Notable in the design was that temporal

effects were studied and that symptom reduction occurred (by BDI measure) earlier

than alliance being established. Alliance measure was by observation using

undergraduate students who had received 30 hours of training. The conclusion was

that the non-specific factor of alliance lacked any power of prediction and therefore

the mechanism-of-change (cognitive modality) was responsible. This had been cited

as an example of how IAPT in the UK has been failing to fully utilise the strong

evidence base for protocolised treatment (Shafran, et al., 2009). The message would

seem to concur with my earlier review of EVT, that specific protocolised treatment

mandates alliance bonds that are done, tasks and goals are as per modality and it has

minimum utility as efficacy rests upon the protocol. Taken at face value, Shafran (et

al., 2009) have left us in little doubt of his epistemology. However, other conclusions

on alliance as mechanism of change have been proposed.

Falkenström, Granström & Holmqvist (2013) review preceding research in

their alliance study and note the five papers that report the seeming ineffectiveness of

alliance predicting outcome (for a full review see Constantino, Castonguay & Schut,

2002). Four, they concluded, were by the same research group (including the two

previously reviewed) and utilized observed measure of alliance by researcher. Two

problems are highlighted by these negative alliance research findings. The first, is that

29

no control or consideration was made for between-patient and within-patient effects

arguing that it is a logical fallacy to draw general conclusions about people from

between-person effects. Secondly, that statistical modelling of time-varying predictors

must assume stationarity (that joint probability distribution will not change over time)

and that statistical models of outcome prediction of within-patient effects must

separate out the recorded session’s measures from the overall trajectory. This study

represents a more sophisticated statistical design than previous alliance research trials

and potentially overcomes some limitations. The sample included over 1,000 patients

in Sweden who were treated in an out-patient context by 83 therapists (62% social

workers, 28% psychologists). Number of treatment sessions was predominantly short

(mean 4.6 sessions), but a small portion of participants received greater than 30 across

many therapeutic modalities. Results showed that 45% of variance to outcome was

within-patient variation, which may explain previous negative findings. These

measures are a key difference in the research designs; patient reporting in this

instance, under-graduate students observing alliance outcome in the other (DeRubeis

& Feeley, 1990). Findings were that an effect of within-patient variation of alliance

impacted on symptom change session by session. Importantly, conclusions were that

the alliance is a fluctuating process reflecting the contextual interaction between

therapist and patient (level four specificity). The present study was able to show that

the within-patient effect of the alliance upon symptom change was independent of the

reverse causation effects of immediately preceding symptom change.

It can be conclusively drawn from the research regarding the alliance that

there is still much that is contested empirically. The differing epistemologies of EVT

and ESI, as outlined by their appropriate Task Force documents, challenge each other

to accept a particular view of the person, science, evidence, practice and ultimately

philosophical view of the nature of the world. Fundamentally, both have demonstrated

their realist and contextual epistemological positions by outlining what they accept as

evidence for therapeutic efficacy and what they believe to be most appropriate in

guiding clinical practice. The alliance is also a function of those beliefs, not only what

it is but also what it can be as the contact point between two people in a helping

relationship.

30

Reaction to the debate has also had implications for practice. The APA

Presidential report on EBP (American Psychological Association, 2005) proposed

evidence-based practice in psychology (EBPP) in line with current medical concepts

of best practice. This included a broader range of clinical activities; the integration of

best available research combined with expertise and patient considerations of culture,

choice and characteristics. The APA also endorsed a broad range of methodologies, a

notable exception in the current debate around EVT (now EST) and ESI. As such, it

represents a call for practitioner autonomy away from a prescriptive medical model of

treatment intervention and supports the Division 17 call for a broader concept of EBP.

For the alliance it also offers the hope of a flexible return to clinical expertise and the

client choice of tasks, bonds and goals in collaboration with the therapist. Within the

UK, the restrictive nature of EVT upon clinic practice has been noted by such

organisations as the Centre for Social Justice (Centre for social justice, 2014). They

argue that the £400 million pound funding for NICE approved talking therapies is not

justified by the recovery rate of 15%. The restrictive nature of NICE approved talking

therapies is limiting patients’ ability to receive affective treatment from those

modalities that do not currently have the resources to attain EVT/EST. Perhaps,

within the UK, we can hope that the debate about evidence can begin to put a level of

criticality back into the scientific arena. Alliance conceptualization, investigation and

utility is poorer for being marginalized, mandated and prescribed by EVT despite the

evidence that continues to support its coalescence with mechanisms-of-change.

Conclusion

In conclusion, documents that outlined the differing perspectives of evidence

that underpin efficacy of therapeutic treatment were reviewed along with supporting

and contrasting comment and research. From the epistemologies that emerged from

the debate the impacts upon Bordin’s (1979) tripartite sub-factor model of the alliance

were discussed. While some agreement upon a definition of the alliance might be

possible, what each of the sub-factors represents, its utility, how it can be investigated

and its centrality as a mechanism-of-change are influenced by the scientific

philosophical stance that different Division of the APA subscribed to. While Bordin

had anticipated that different sub-factors may feature in varying strengths depending

31

on modality, the movements of EVT/EST and ESI/EBPP have implications on the

alliance of a greater magnitude than he had anticipated.

32

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Appendix A

Counselling Psychology ReviewCounselling Psychology Review is the Division of Counselling Psychology’s quarterly peer-reviewed researchpublication. It brings together high quality research pertinent to the work of counselling psychologists.It primarily focuses upon work being undertaken in the UK but it is also likely to be of interest tointernational colleagues and those in related therapeutic disciplines. The content is pluralist in nature,with its focus being on excellent work rather than methodological or paradigmatic preference, andsubmissions are invited in the following areas:l papers reporting original empirical investigations (qualitative, quantitative or mixed methods);l case studies, provided these are presented within a research frame;l theoretical papers, provided that these provide original insights that are rigorously based in theempirical and/or theoretical literature;l systematic review articles;l methodological papers related to the work of counselling psychologists.For more information about the peer review process for this publication please contact the Editor.Notes for Contributors1. Length:Papers should normally be no more than 5000 words (including abstract, reference list, tables and figures),although the Editor retains discretion to publish papers beyond this length in cases where the clear andconcise expression of the scientific content requires greater length.2. Manuscript requirements:l The front page (which will be removed prior to anonymous review) should give the author(s)’s name,current professional/training affiliation and contact details. One author should be identified as theauthor responsible for correspondence. A statement should be included to state that the paper has notbeen published elsewhere and is not under consideration elsewhere. Contact details will be published ifthe paper is accepted.l Apart from the front page, the document should be free of information identifying the author(s).l Authors should follow the Society’s guidelines for the use of non-sexist language and all referencesmust be presented in the Society’s style, which is similar to APA style. For an electronic copy of theSociety’s Style Guide, go to the Publications page of www.bps.org.uk and then click on Policy andguidelines/General guidelines and policy documents and choose Society Editorial Style Guide from thelist of documents).l For articles containing original research, a structured abstract of up to 250 words should be includedwith the headings: Background/Aims/Objectives, Methodology/Methods, Results/Findings,Discussion/Conclusions. Review articles should use these headings: Purpose, Methods, Results/Findings,Discussion/Conclusions.l Approximately five keywords should be provided for each paper.l Authors are responsible for acquiring written permission to publish lengthy quotations, illustrations,etc., for which they do not own copyright.l Graphs, diagrams, etc., must have titles.

38

l Submissions should be sent as email attachments. Word document attachments should be saved underan abbreviated title of your submission. Include no author names in the title. Please add‘CPR Submission’ in the email subject bar. Please expect an email acknowledgment of your submission.l Proofs of accepted papers will be sent to authors as email attachments for minor corrections only.These will need to be returned promptly.3. Submissions and enquiries should be e-mailed to:

Dr Terry Hanley. Email: terry.hanley@manchester.ac.uk

Research Report 1: What was it like working with your therapist?

A thematic analysis of the alliance concept from a client’s perspective

Abstract

The ‘alliance’ concept is considered by some to be central to Counselling Psychology practice, as a Humanistic valuing of empowerment, personal choice and agency within the therapy context. Yet the concept is utilised in differing ways when understood within a relational epistemology. It is argued that a focus on a client account of alliance is under-researched and reflects both Counselling Psychology’s practice-led research ethos and its Humanistic value base. This research aims to explore the alliance representations and responses from participants’ accounts of working with their therapist.

A thematic analysis method (Braun & Clarke, 2013), informed by the researcher’s critical realist position, allowed an inductive experiential analysis of the alliance concept grounded in the participants’ accounts. Semi-structured interviews with eight participants were analysed and reported. Inclusion criteria was that participants had completed therapy as per their initial contracting and had not sought further professional help for a full year.

Findings were represented by four major themes: “Preconceptions of what therapy might be”, “Is it me, therapy, or the therapist?”, “Connecting the dots”, and “The unequal relationship”. The final theme was not presented, as such an experiential theme was anticipated within the relational epistemology of Counselling Psychology. The themes were interpreted as reflecting the participants’ experiences of an ongoing and dynamic nature, both between what their preconceptions might have been of the therapy and the relevance of their experiences to their everyday lives, within multiple relationships as a constant interpretative and dynamic act.

39

Conclusion were that the fluid and ongoing nature of the participants’ experiences suggested that an alliance of agreement, collaboration or contract may not be fully representative of the clients’ perspective of alliance. Potential impacts of these findings is the support of Counselling Psychology’s pluralistic therapeutic stance, an ethical valuing of client choice and an emphasis within the dyad of the potential client therapeutic needs transitioning throughout the therapy.

Keywords:Alliance, Psychotherapy, Tasks, Goals, Thematic-Analysis.

Introduction

The Alliance

Within psychotherapy, the ‘alliance’ concept has been much utilized to

describe key aspects of the therapeutic encounter. Such a construct encompasses the

“partnership and mutual collaboration between therapist and client” (Norcross &

Lambert, 2011, p.28). Norcross (2011) also concluded that the alliance is not the same

as a therapeutic relationship. Rather, it is a way of understanding what was achieved

as an inseparable part of everything that occurred in the therapy.

The centrality of the alliance concept remains common to many forms of

mainstream therapeutic intervention (Norcross & Lambert, 2011). From its early

psychodynamic roots, the alliance was understood as a conscious positive transference

relationship (Freud, 1913/1940). Freud considered this analytic pact as a key quality

that enabled the analysand to remain in therapy in spite of their unconscious fears and

defences. Later, Luborsky (1976) proposed two distinct phases of alliance in therapy.

An early alliance (Type I) of secure holding of the analysand by the analyst was

followed by an alliance (Type II) of the analysand’s faith in the therapeutic process.

Bordin (1979) developed the construct further and proposed tripartite ‘working

alliance’ sub-factors; the tasks undertaken in therapy, the goals that the dyad works

towards, and the bonds that exist between therapist and client. Norcross (2011)

suggests that both Bordin and Luborsky sought to offer an alliance account that was

40

separate from its psychodynamic history and more compatible with other theoretical

approaches. However, each alliance construct lacked a clear definition of how it might

relate to (or be distinct from) other existing conceptualisations and parts of the

therapeutic relationship.

Despite this lack of pan-theoretical definition (Castonguay, Constantino &

Holtforth, 2006) more than 24 alliance measurement instruments currently exist for

quantitative research and clinical purposes (Horvath & Bedi, 2002). Such tools satisfy

a desire to operationalise and control for aspects of the therapy dyad. However, such

an operationalisation of the construct also defines it in a way that enables categorical

answers taken at points in time. This assumes that the measure accurately reflects the

client’s and therapist’s understanding of their alliance (Horvath, Del Re, Fluckiger &

Symonds, 2011). In effect, alliance measurement tools define alliance processes by

proxy as those things that were measured.

One such measure that is frequently utilised in research trials is the Working

Alliance Inventory (WAI). It uses Bordin’s (1979) sub-factors as a basis for

questionnaire and Likert style answer and has received cautious validation (Horvath &

Greenberg, 1989). Conclusions from this validation research suggested high co-

variance between the three sub-factors and that they may not represent discrete

alliance sub-categories. From a positivist perspective, the WAI is therefore assumed a

valid measure of alliance processes with some sub-category co-variance. Perhaps

these findings of co-variance reflect a wider epistemological question. Co-variance

both suggests that aspects of the quantitative measure may not reflect discrete variable

categorical constructs, or that the constructs have been transformed by the

methodological demands of a quantitative natural science paradigm (Spinelli, 2006).

Are quantitative measures able to represent the underlying alliance conceptualisation

upon which it was constructed? If not, does the construct still capture the reality for

the therapist and the client and what are the impacts of such a construct on

Counselling Psychologist’s (CPs) practice?

Conceptual differences and influences

Despite this seeming lack of definitional consensus, the alliance concept

endures under various guises. One such variation is Cognitive Behavioural Therapy’s

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(CBT) “therapeutic relationship as a working alliance” (Westbrook, Kennerley &

Kirk, 2011, p.41) that enabled those in therapy to overcome negative expectations and

fostered therapeutic possibilities (Beck, Rush, Shaw & Emery, 1979). Such a

definition shares aspects of Freud’s (1913/1940) reality-based collaboration that he

suggested enabled the analysands to sustain themselves despite the rigours of therapy.

Yet each alliance concept differs significantly, principally in what is not considered

part of the alliance concept (eg. unconscious transference processes). For CBT, an

alliance of collaboration might be understood as a relational act in totality (a

therapeutic relationship); from a psychodynamic perspective the alliance is part of

interaction in spite of the unconscious transference/counter-transference relationship.

From a critical perspective, each alliance conceptualisation is potentially

construed by the epistemology from which it emerges. However, alliance

conceptualisations and research are also influenced by the politics of health care, both

here in the UK and in the US which dominates with large funded programmes of

research. In a prior review of the literature surrounding the genesis of the evidence-

based practice movement in the U.S., key differences were apparent within divisions

of psychology (Neil, 2014, unpublished). Firstly, that positivist evidence derived from

randomised controlled trials (RCT) was considered the only methodology to compete

with dominant pharmacotherapy (Chambless & Ollendick, 2001). Secondly, that

alliance tasks were required to be operationalised for outcome efficacy to be

established. Finally, that alliance goals were required to be homogeneous to compare

treatment outcomes. Such methodology has facilitated treatment comparison and is

now a feature of the UK’s National Health Service landscape in the form of NICE

guidelines on psychotherapy interventions (NICE, 2014). Within this political context,

alliance tasks and goals are now frequently manualised and guidelines inform their

implementation across national services. From one perspective, what we do and what

we expect clients to achieve in therapy is largely an alliance with service provision

(Vermes, 2017) which favours positivist scientific outcome evidence, and is assumed

measurable. Whatever theoretical debates surround the construct, alliance is

increasingly defined within the UK national healthcare sector as protocolised tasks

and medically defined goals of symptom reduction.

Alliance and Counselling Psychology

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This situation is problematic for the UK Counselling Psychology (CoP)

profession on many levels. Philosophically, an alliance based on diagnosis leading to

a treatment protocol assumes the legitimacy of diagnosis which is contested (Milton,

Craven & Coyle, 2010) but also ignores CoP’s stated focus on well-being as an

equally valid therapeutic stance (BPS, 2014a). It also assumes that RCT-based

efficacy knowledge has validity in every therapeutic context. The notable loss is the

person’s agency: to participate in how their distress is understood, to choose what

might help them, and to be heard as an expert in their own recovery. The notion of

collaborative alliance is limited within an epistemology of power and expertise

(Woolfe, 2016). The notion of relationship is also lost beyond what can be

experimentally represented in variables and data (Bennett-Levy & Thwaites, 2009).

Norcross’ (2011) fear that current alliance constructs lack clarity and fail to

accommodate post-modern relational concepts would seem to be born out. Politically,

this too is problematic. For CoP to be deemed contemporary, it must engage within a

best-practice climate of RCT evidence and alliance/relationship conceptualisations

represented in such evidence. Yet, the biggest challenge that such alliance constructs

represent is to the ethical values that CoP adheres to. The Humanistic notions of

social-justice and agency aren’t reflected in the medical diagnostic and symptom

reduction climate that is characterized by the positivist evidence-base of best practice.

Indeed, recent research on the value of NICE guidelines and their relevance to

practice has also been questioned within Clinical Psychology in the UK too (Court,

Cooke & Scrivener, 2016). Ethically, CoP must seek to forge an alliance construct

that is commensurate with those values. It is a challenge to the dominant scientific

paradigm informing practice.

What position does UK CoP take with the alliance concept? Certainly,

contemporary UK CoP literature extolls the “emphasis on the therapeutic alliance,

meaning-making and competence in several therapeutic models” (Milton, 2010,

p.191; Hession, 2010). Campiao (2012) summarized the alliance as it is

conceptualized in literature along three potential construct properties; alliance as a

component of therapeutic relationship, alliance as relational equivalence, and alliance

as one of many therapeutic relationships. Within the handbook of Counselling

Psychology (Woolfe, Strawbridge, Douglas & Dryden, 2010; Douglas, Woolfe,

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Strawbridge, Kasket & Galbraith, 2016) each of these three approaches are evident.

Examples of these approaches are: as a relational component of dialogical “being

with” (du Plock, 2010, p.131), alliance as a relational equivalence of “core conditions

that form the basis of an effective therapeutic alliance” (Parritt, 2016, p.200), and

alliance as one of “five types of relationship” (Jordan, 2010, p.252).

From a perspective of pluralism, CoP locates its own epistemology within

ideographic narratives and, at best, fragments of understanding (Strawbridge &

Woolfe, 2010). In one sense, the alliance constructs used within CoP would seem to

reflect such a philosophy. Yet, such a pluralistic notion of alliance and its place within

relational knowledge seems at odds with professional practice guidelines. These

suggest a “firm value base grounded in the primacy of the counselling and therapeutic

relationship” (BPS, 2014a, p.1). From this perspective (and it is an important

professional one), the therapeutic relationship is understood within a two-person

psychology (Campiao, 2012) as intersubjective and dialogical.

Such a position, applied to the variety of alliance constructs differs from the

notion of alliance as outside a relationship, or alliance as a relationship in its totality.

Yet under political pressure to conform to a medical model of treatment (Milton,

Craven & Coyle, 2010) and with a multitude of alliance conceptualisations at work

within CoP literature, how CoP’s work with clients and what they hope to achieve has

become an increasingly taut thread connecting evidence-based practice with the

professions humanistic values. How we define ‘alliance’ may no longer reflect the

voices of those that matter most, our clients’. How do clients ally what they do in

therapy and its therapeutic implications?

Existing empirical knowledge

Alliance has been frequently investigated as one common therapy factor.

Meta-analysis suggests that alliance is correlated with outcome positively (Horvath &

Bedi, 2002; Horvath, Del Re, Fluckinger & Symonds, 2011). Another common-factor

hypothesis was demonstrated by meta-analysis of clients matched to their treatment of

choice and found a small but significant effect size for positive outcomes (Swift &

Callahan, 2009). The stand-out finding, however, was that clients matched to a

treatment of choice also had half the drop-out rate from those clients who were not

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offered treatment choice. From a contextualist perspective it may say little of the

actual client’s alliance with the therapist. However, it does point to the possible

population effects of politically pursuing treatment protocols based on diagnosis:

clients may leave therapy. It also questions the alliance construct within such an

evidence-based context. Responding to clients’ choices and their power to affect that

change matters. Crucially, it matters at a population service level and at a personal

level. Alliance as a concept seems to have robust positivist evidence to support its

inclusion in the broader scientific discourse.

Other methodological enquiries have highlighted potential clinical limits of

such positivist alliance understandings. In the US, Batchelor (1995) provoked a raft of

new research when she reported key differences between client understandings of

alliance processes. Using phenomenological inductive content analysis based on client

reports (n=34) within the early stages of therapy, Batchelor described three distinct

client experiences of relational qualities and characteristics: nurturant (46% of client

reports), insight-oriented (39%) and collaborative (15%). Notable here is the view of

relationship and alliance being offered. Batchelor points out that many aspects of

relational qualities were reported but that such qualities were not deemed the most

salient in developing an involved relationship. The study focused on early alliance

processes (pre-therapy to mid-therapy) with inclusion criteria of a positive account of

relationship with the therapist. While such a method may not claim to be

representative of all therapy experiences, it did provoke further alliance inquiries from

the client perspective (Bedi, Davis and Williams, 2005; Bedi, 2006, Duff & Bedi,

2010; Bedi & Duff, 2014; Baylis, Collins & Coleman, 2011; Bedi & Richards, 2011).

It is notable in these studies that the focus has been on early alliance formation

(possibly due to correlational findings linking early alliance formation to outcome)

and the research aims of identifying potential experimental variables.

Rationale for the current project and research question

Taken together, key limitations in the alliance construct represent a challenge

to pluralist CoP practice. Its lack of definition within a relational epistemology has

left the construct largely defined by an experimental methodology. CoP discourse has

also blurred the concept further by using the term in a myriad of contrasting relational

45

conceptualisations. Politically, forces within the UK healthcare sector have

marginalised relational understandings of alliance processes and have promoted

working practices akin to medical treatment protocols. This has impacted on the

therapeutic dyad by limiting practitioners working practices to that which can be

evidenced through an RCT method; and alliance as a measurable construct that is

contracted. Yet, evidence does exist for the positive impacts that a good alliance

within the dyad has on outcomes. Also, further recent evidence exists for alliance

processes (or differing conceptualisations) which challenge the standard model of

alliance represented in RCT methods. That client-based research has demonstrated the

multitude of alliance styles and qualities suggests a significant divide between what is

theoretically understood and what is the experience of the client. This is compounded

by the evidence that suggests that therapy consists of ongoing communication and

negotiation. For the alliance in a clinical setting, a difference would seem to exist

between the theoretical construct that underpins efficacy evidence and the evidence of

client choice impacting alliance, differing client alliance needs and the ongoing nature

of these communications.

Perhaps the difficulty for CoP lies with a relational epistemology that

collapses alliance processes into a two-person psychology of intersubjectivity and

relatedness (Spinelli, 2015). Yet, the alliance concept remains central to CoP practice

(Milton, 2010) as a humanistic valuing of personal choice. From a personal

perspective, I value the practice lead research findings which explore how I might

work with clients more effectively. Within CoP, the humanistic emphasis on a therapy

relationship which clients find the most facilitative is largely ignored by RCT efficacy

trials and potentially limits my ability to respond to client needs flexibly. If the

theoretical concept of alliance is problematic, then CoP might be served by

demonstrating other possibilities; “allow(ing) the meaning of the term to evolve”

(Safran & Muran, 2006, p.290). Within a CoP epistemology, humanistic valuing of

the clients’ own subjective account would seem the most appropriate place to begin-

again and one which CoP has been criticized for not pursuing extensively (Vermes,

2017). The need for further exploratory research within subjective accounts was

highlighted by Papayianni and Cooper (2017). Building research that potentially

demonstrates the value of an alliance construct that reflects the intersubjectivity of the

46

therapeutic dyad has the potential to support clients more effectively (and ethically).

Rather than a challenge to the theoretical accounts of the alliance construct, a

subjective client-centred viewpoint might allow a richer account of what clients

consider important to foster their sense of being allied within the therapy.

This research aims to explore the alliance representations and responses from

participants’ accounts of working with their therapist. By exploring alliance from the

perspective of clients it is hoped to support prior research findings that have

demonstrated a more complex understanding of alliance processes than current

theoretical conceptualisations. Most existing alliance research has also investigated

the early stages of therapy only as a theoretical construct of alliance formation. This

study will take an exploratory perspective and seek to include participants who have

completed a full course of therapy to conclusion, of both positive and negative

therapy experiences, in the south-east of England.

Method

Much of the research that has been undertaken to investigate the alliance

concept has been positivist in nature. However, some research findings have

introduced doubt regarding relevance to clients’ own understanding of their alliances

in therapy (see Batchelor, 1995). While this could be addressed by conducting

positivist research using client-derived data, such a research endeavour would also

rest on the theoretical construct assumptions that have been utilised to define the

alliance (eg. WAI). What was notable from Batchelor’s research was its inductive

nature which focused on the perspective from the client. Critically, each epistemology

may contribute something to a clinical understanding of alliance processes at work

within the therapeutic dyad. Yet, from humanistic and phenomenological

perspectives, positivism potentially misses the nuance and richness of individual

subjectivity (Strawbridge, 2016). As the research question seeks to explore alliance

representations and responses from participants’ accounts, a methodology reflecting

the clients’ perspective would seem the most compatible with the research aims. Such

a focus on subjective accounts would suit a qualitative methodology (Willig, 2013).

47

Thematic analysis (TA) serves as a “foundational method” (Braun & Clarke,

2006, p.4) in many qualitative approaches. What distinguishes TA from others is its

methodological flexibility lending itself to a variety of epistemological stances within

each method. While this has been a criticism of TA, as a method in its own right, this

flexibility would enable me (the researcher) to take an appropriate epistemological

stance that is compatible with the research question (Braun and Clarke, 2006). The

theoretical framework of this research was to take a critical realist position. This was

anticipated to be grounded in the subjective experiential accounts of the participants’

representations and responses while also allowing a critical and contextualised

analysis of their language and meaning (Terry, 2015). Themes were data-driven as an

inductive bottom-up approach. Yet the deductive nature of an alliance construct is

also acknowledged and while the existing constructs did not inform the themes, they

were inevitably considered from this deductive position as previous alliance research

had been conducted during the literature review process. This is a common approach

within TA methods (Braun & Clarke, 2013) and aims to offer a rich and complex

analysis anticipated by the research question. The coding focus was at a semantic

level to reflect an analysis grounded in the participants’ own representations. Such a

TA method allowed me to organise the patterns in the participant data for its content

and meaning, with a humanistic emphasis on the validity of subjective experience that

is compatible with a CoP epistemology (Strawbridge, 2016, BPS, 2014a).

Recruitment and participants

Participants in this study were ‘convenience’ recruited through direct contact

with people known to the researcher and by ‘snowballing’ through indirect word of

mouth recruitment from those that had been approached. Potential participants who

expressed an interest in further information were contacted by telephone or email to

enquire if they would like to contribute. If interested, they were forwarded a

participant information sheet and consent form to review (Appendix B & C). Further

telephone contact established the intention to participate, inclusion criteria being met

and appropriate arrangements made for the researcher to attend the participants own

home at a suitable time. Stratification sampling also developed the participant pool to

include male and some ethnic-minority participants. Such a recruitment strategy was

inevitably a reflection of the researcher’s own social group. The aim of recruitment

48

was to capture a broad range of therapy experiences, both positive, negative, singular

and multiple therapy interventions. A limited representation of gender, ethnic

diversity and differing therapy outcome experiences was achieved. The small sample

pool of participants cannot be considered representative of the differences and

diversity in the wider UK population. Findings must be viewed through this limitation

reflected in the recruitment strategy.

Eight participants who had completed an individual therapy process and

hadn’t further therapy for a full year were recruited. All were known to the researcher

or were known to friends or acquaintances. This recruitment method introduced the

possibility of a dual-role for the participants and myself as researcher. Two key

aspects of the dual role were considered by myself reflexively and actively with the

participants. Firstly, in accordance with ethical research guidelines (BPS, 2014) the

nature of any dual-role conflict and its potential for harm was discussed with

participants during recruitment, interview procedure and during disclosure of research

findings to the participants. Secondly, the influences of shared personal history and

prior knowledge of the participants was a potential constraint on participants’

interview experience and my subsequent analysis. During each contact stage I

initiated a discussion regarding the participants thoughts and experiences regarding

their dual-role and its potential limitations. This also aided my own insights supported

by reflexive journal entries. Despite potential limitations, it was felt that convenience

and snowballing recruitment increased the possibility of capturing a broader range of

therapy outcome experiences beyond solely positive accounts. Demographically the

participants ranged in age from 21 to 52, two identified as male and six as female, two

were British-Asian, two White-European and four were White-British.

Table 1: Participant information

Pseudonym Gender AgeCultural

Background

Modality or

Profession

Service

contextOutcome

John Male 33British

AsianUnknown

Work-

related

service

Positive

Mary FemaleWhite

BritishUnknown

Private

PractitionerNegative

49

Fiona FemaleWhite

European

CBT,

Unknown

NHS

NHS

Negative

Negative

Margaret Female 49White

EuropeanUnknown

Trauma

CharityPositive

Jade Female 21White

British

Unknown

CBT

NHS

NHS

Positive

Negative

Liz Female 31British

Asian

Psychodynamic,

Phd

Private

PractitionerPositive

Robert Male 52White

BritishUnknown NHS Negative

Alison Female 41White

BritishUnknown

Counselling

CharityPositive

The modality of therapy and professional qualifications of the participants’

practitioner was frequently reported as unknown. However, participants were

unequivocal regarding the help that they derived from their therapy experiences (as

good or bad). Several participants had multiple therapy experiences which were

deemed a valuable variation in the data-set. The presenting issues that clients had

attended therapy for was not sought for ethical reasons as a safeguard of the

participants and the researcher’s potential dual-role and that such a disclosure was

deemed not necessary to fully explore the research aims.

Design

The design method of this research project used semi-structured interviews.

This method allowed a focus on participants’ individual voices potentially facilitating

a richer holistic understanding of the research question. Semi-structured interviews

offered a flexibility in the interview schedule allowing the researcher to be responsive

while minimising any potential reduction of the discursive account that participants

shared (Willig, 2013).

Before the semi-structured one-to-one interview began, the right to withdraw

at any time (including during the interview) and the right to have all interview

recordings erased if consent was withdrawn was discussed and emphasised.

50

Participants were given the Participant Sheet (Appendix B) and asked if they wished

to reread the document. A brief verbal overview of the project was given to confirm

the research aims and the expectation on the part of the participant and informed

consent sought and signed (Appendix C). Demographic information and details of

what was known or recalled by the participants was then explored; therapy modality,

when therapy had ended and the number of sessions, what was known of the

professionals’ credentials and training and the service context. Such information was

frequently unknown (as per piloting of the initial interview schedule) and it was

anticipated that more information could be facilitated through conversation than

questionnaire. It was also hoped that such a conversation would provide an orienting

experience to foster an early trusting experience before the recording commenced.

When the participant and researcher had established what information was known (or

was willing to be shared) audio recording began and the interview commenced

following the prepared interview schedule (Appendix D). The interviews lasted

approximately 60 minutes and were recorded using a portable digital recorder. On

returning to my own place of residence, the recordings were encrypted and transferred

to a password protected personal computer with no external identifying information.

(Great Britain, 1998).

Questions were of a broad and non-theoretical nature, in line with the aims of

the project to capture clients’ experiences without imposing or constraining the

discourse with pre-existing theoretical conceptualisations. Limited use of theoretical

psychological concepts, such as alliance or relationship, was anticipated to allow

participants the flexibility and space to explore their own experiences and to minimise

imposing a pre-defined understanding of such concepts.

Ethical Considerations

This research procedure was conducted after receiving favourable ethical

opinion from the FAHS Ethics Committee (Appendix A). It also adhered to three

external professional regulatory frameworks. Professional and ethical conduct and

research practice was in accordance with the Health Care Professionals Council

(2015), the British Psychological Society’s professional practice guidelines

(2014a) and the BPS code of human research ethics guidelines (2014).

51

These guidelines informed and guided every aspect of the research

procedure, analysis and subsequent report. The research was conducted with full

disclosure; explicit participant information sheets outlining the studies aims,

subject matter and research requirements. As participants were being interviewed

about their therapy experience it was assumed that assessment of their potential for

personal distress was an on-going ethical requirement (Guillemin & Gillam, 2004),

irrespective of the stability indicated by the inclusion criteria of one year post-

therapy. This was also considered from the perspective of the dual personal roles

that the recruitment procedure created. This was explicitly considered at

recruitment, pre-interview, interview and debrief. Such a process of exploring the

sensitive nature of the subject matter and the nature of the dual-role relationship

were considered together before the interview took place. This was anticipated to

make any possible difficulties easier for the participant by encouraging and valuing

their power within the interview process and their ethical right to exercise control

of the procedure. This included the right to withdraw at any time, written and on-

going consent and, in the event of uncertainty, the intention to consider how best to

proceed.

Confidentiality of participants was maintained throughout the research

process. Names were pseudonymised and identifying details were not recorded in

transcripts. All details of participants not ultimately recruited were destroyed and

all recordings erased as per the Data Protection Act (Great Britain, 1998). All other

material was stored as one copy on a password locked computer as encrypted files.

All such procedures were discussed and confirmed prior to written consent.

The location of each interview was within the participant’s own home and

University of Surrey protocol was followed to safeguard the researcher (University of

Surrey, 2015).

Analytic Procedure

For a complete account of the analytic procedure and thematic findings I

would direct the reader to Appendix E (and a graphical account of the themes and

sub-themes appears as Appendix I).

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Credibility

The data and analysis of this study was informed by Yardley’s (2000)

guidelines in ‘Dilemmas in qualitative health research’. Yardley argues that credibility

is key to qualitative research as it lacks the often punitive rigour of quantitative

methodologies. The interview method sought to explore the participants’ experiences

in a context that was familiar and in which they could maintain a sense of control in

relation to the researcher. The interview protocol, and subsequent further exploration

of the interview material, explored the research question in language that was familiar

and as theoretically free as possible for participants. It focused upon participants’

private experiences and emphasised the personal and individual nature of the material

discussed. This consideration of power within the research paradigm was also key to

the nature of the dual-role of familiarity that the researcher had with participants (both

first and second-hand). Data was understood to be a co-construction, but that power to

construct was considered during the recruitment phase by making it explicit;

consideration of location, the researcher’s sensitivity to the dilemma of power,

checking during interview, and an account of this aspect of experience during debrief.

A full journal of the researcher’s experiences and possible conflicts was kept and

reflected upon during protocol construction, analysis and reporting (and a personal

reflective statement of my own response to the research process drawn from these

journal entries is contained within the discussion section of this report). These finding

were also followed up with a brief email outlining the study’s main conclusions and

the invitation for participants to comment on the findings.

Analysis

Table 2: Table of themes

Themes Sub-themes

Preconceptions of what therapy might be Therapy as “extra to life”

“You’re the mechanic”

Is it me, therapy, or the therapist? “Negotiating in the moment”

“Should I be saying this?”

“Figuring it out myself”

Connecting the dots “Going somewhere else”

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“Nobody really knows what they are trying to achieve”

The unequal relationship Separateness and relatedness

The power in differing roles

The analysis was considered as four key perspectives of alliance

representations and responses from participants’ accounts of working with their

therapist (Table 2). Due to limitations imposed on the size of this report I will present

in detail the first three themes. These first three themes offered something distinct

from the final theme (the unequal relationship) which addressed participants’ reports

of their relationship representations with their therapist. While significant in their

accounts, it was understood to also be representative of some aspects of the

therapeutic dyad that are well understood and anticipated by existing CoP knowledge.

In the current CoP Handbook, the sub-theme ‘the power in differing roles’ is

addressed by Woolfe (2016) and the phenomenological understanding of relatedness

and the experiences of separateness are considered by Milton (2016). While the

analysis retained its experiential focus, the CoP concepts of ‘relationship’ and ‘power’

were inevitably deductive given my own training background. As such, the report’s

focus remained on the first three themes as it was felt that they offered an account of

the data-set that retained an inductive focus and a novel insight into the research

question. Here, I will provide an overview of the first three major-themes and their

sub-themes to orient the reader before offering an in-depth account with supporting

excerpts.

The first theme (preconceptions of what therapy might be) was analysed to

capture the participants’ reflexive use of their own pre-therapy representations. While

the theme did reflect some aspects of expectation (be that met or misjudged), it was

understood as the participants’ concepts of therapy as a preceding representation that

was used as a present sense-making experience. It is important to reflect that myself,

as a trainee CoP, and my broader cohort may also have preconceptions of what might

be valued and understood by a more-privileged access to British society’s repertoire

of helping professions. I would urge the reader to also consider findings from other

potential sources of socio-economic and cultural diversity as this participant pool is

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neither representative nor comprehensive of British society. While this theme is likely

influenced by the recruitment strategy, the exploratory research aims remain a useful

insight into a narrow demographic within British society and the impacts of these

discourses.

Within the first sub-theme (therapy as extra to life), the participants’ therapy

was represented as something that was outside of life as an extra to their day-to-day

lives. From this vantage point, therapy was frequently conceived to be pursued in a

manner not commensurate with their everyday understandings of interaction with

others and allowed a meaning of their actual therapy experiences. The second sub-

theme analysis suggested that therapists were represented as professionals with skilful

capabilities; possibly as mechanics of the mind (you’re the mechanic) or imbued with

extra-ordinary insights. It was the notion of therapy’s transcendence of life and their

assumption of capability as an exacting professional standard that drew the

participants into therapy. As a contribution to an alliance construct commensurate

with a CoP epistemology, the theme captured an everyday and personal representation

that therapists would meet, negotiate and overcome if therapy was to be useful for the

participants.

The second theme (is it me, therapy or the therapist?) was understood to

represent the fluidity of therapy among the multiple relationships that participants

were confronted with. The theme title was an excerpt that succinctly pinpoints three

relationships that the participants reported negotiating and the questioning stance

often taken within that experience. As a contribution to an understanding of alliance it

emphasises the work that was required on the part of the participants to manage,

negotiate and find the confidence to proceed: with their distress, in their therapy, with

an other. For the participants, whatever else may have represented their therapy, it

was largely constructed together in these moment-to-moment experiences across the

three relational representations. The first sub-theme (negotiating in the moment)

captured this moment-to-moment concept as an on-going felt consensual sense. It was

also analysed as an implicit negotiation of the therapy space and how their needs were

met by the therapist. The second sub-theme (should I be saying this?) was represented

as an on-going coming to terms with a space and context frequently in conflict with

their preconceptions. The third sub-theme (figuring it out myself) represented the

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struggle to find the confidence in all of the key relationships that participants reported.

As an insight into participants’ alliance processes, this theme suggested that what

therapy might be was expressed by their felt sense of moment-to-moment

participation.

The third theme (connecting the dots) was understood to reflect the

participants’ reports of their on-going search for the relevance in each therapy

interaction and its connection with a therapeutic change in their daily lives. While this

theme could be understood as a function of outcome, such an outcome concept was

frequently reported as being inaccurate and a function of participants’ therapy

preconceptions as a ’fix’. Rather, a process of ongoing personal connection with what

was done in therapy with what might represent a useful purpose of therapy was

understood (as the two sub-themes – ‘going somewhere else’ and ‘nobody really

knows what they are trying to achieve’). Each sub-theme was interconnected, yet each

was also considered for relevance and the ways that such experiences were connected.

As an alliance concept, finding that relevance (or not) in everything that was done in

therapy together was expressed as helpful or frustrating (depending on the ultimate

perceived view of the therapy’s effectiveness). Rather than an account of their

outcome, this sub-theme was frequently expressed as a felt transformation from their

previously expressed preconceptions, acceptance rather than a ‘fix’ or insight rather

than change.

Preconceptions of what therapy might be

I have briefly outlined (above) what this theme was analysed to represent in

the participants’ accounts of their therapy. This theme was understood to be

something more than a mere temporal account of participants’ mind-sets before

entering therapy. The theme’s significance rests with its interaction with other themes

as the participants’ notion of transformation from this pre-existing conceptualisation

was explored throughout their therapy. Notable here is the differing experiences of

participants depending on their assessment of therapy’s effectiveness and its role in

their subsequent lives.

Therapy as extra to life

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I guess I just thought of it as extra to life. Sort of above what was happening in a way. (Robert)

Robert’s statement was invoked as a retrospective sentiment and was chosen

to represent the participants’ preconceived views on what therapy would be: extra or

above real life. This sentiment was empathically analysed, not as a supernatural

phenomenon, but as a sense that the participants would be taking their distress

experiences to something that transcended the everyday. Robert suggested that his

hope of therapy would be beyond his realm of real-life and that preconceived his

notion of what therapy would be. “Everybody else had a biased opinion” was John’s

account of the same sentiment. It is notable for what it doesn’t say – therapy

represented something that would transcend his everyday experiences. Yet, for the

participants, their therapy experiences were of shared human experiences of

frustration, fear, misunderstanding and felt bias rather than a transcendence of their

lives. Their accounts made sense of their preconceptions that therapy might be

separate or above those experiences.

She’s not like your friend… They’re like a third party. Someone on the outside and that felt really helpful. So I thought I’d go along… (Jade)

Jade reflects on what had drawn her to seek help through therapy. Her

understanding of what therapy might represent is expressed as outside of her

friendships as a separate ‘other’ to her relationships as a third party. For Jade, this

notion of therapy as an outside is expressed as a helpful concept and was understood

as facilitative of her seeking help. Jade’s positive therapy experience may well be

reflected in her preconceptions being met. This sub-theme was also expressed in other

ways.

So there was fear, but I didn’t think I was going to… be taken to anywhere that was more horrendous than I could manage… (Fiona)

Fiona’s excerpt was interpreted as having an extra-to-life quality in that her

preconception was that she wouldn’t be overwhelmed in therapy by the things that

had been so overwhelming in her life. It was analysed to have expressed a faith in

therapy and a therapist as a concept, despite her sense of fear and trepidation. Upon

entering her therapy, Fiona’s thoughts were of manageable safety despite her fear of

what she could not bear. Fiona’s interview featured many honest accounts of the upset

57

that therapy provoked (“I would just cry and cry”). Such a preconception of therapy as

being emotionally manageable were challenged by her experiences but the belief that

she would be protected from what she couldn’t manage had been facilitative. Fiona

reported a positive experience and a deep connection with her therapist, possibly as a

trust, allowing her to feel the safety that she sought. Both Jade and Fiona would seem

to have had their preconceptions met and they reported positive therapy experiences.

For these two participants, what therapy represented may or may not be transformed

by the experience. Perhaps this depended upon how closely their expectations and the

reality of therapy correlated.

…it was strange at first because I had never done anything like that and I didn’t know what to expect. (Mary)

This response from Mary was also analysed from the greater context of her

interview account. Her therapy experience had been frustrating and she reported

feelings of anger towards her therapist. Her frustration was that therapy was “just

talk” and that her expectation was that it would be something more than another

person-to-person experience, as a human encounter that she couldn’t imagine.

Something extra had been her preconception. Unfortunately for Mary, therapy had

remained nothing more than “what I could have done with my mother” (Mary) and

was reported as unsuccessful.

Taken together, this sub-theme was analysed to represent the participant’s

preconceptions of therapy and the hope that it offered of something extra in unique

and novel ways. Transcending clients’ lives is possibly an unenviable task for

therapists, especially when their hope is inevitably met with another human being. For

the participants, these preconceptions also represented a baseline from which their

actual therapy would be understood as they navigated the meaning of being in therapy

and what therapy might ultimately provide for them.

You’re the mechanic

…it feels like going to a car mechanic and you spend an hour with them and the cars still not working and they say ‘so, eh, what do you think the problem might be?’ and I’m like, ‘you’re the mechanic’. (Margaret)

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This sub-theme was understood to represent the participants’ hope of being

met with the knowing skilled professional of the therapist. The excerpt was a response

to a clarification that I had asked for during the interview regarding Margaret’s’ stated

belief that therapy would help her. She provided an example and it was a common

sentiment among the participants’ accounts. For Margaret, her belief in therapy

(before her experience of therapy) was mechanical and problems were fixed by the

depersonalised expert. Participants also reported that their preconceptions of their

therapist were likened to a “dentist”, “a driver” and a “chef”. The key shared quality

that the participants reported was the anticipation of a level of skilful mastery in the

therapist.

I think I was probably quite… unfairly imagining him to know straight away what my issue was... That’s what I expected a therapist to do…He was the professional, not me. (Mary)

Mary’s negative therapy experience is perhaps laid bare in this excerpt. Her

disappointment at not having her preconceptions met is indicated by the unfairness

that she expresses. Yet she maintains that her therapist’s professional role is to know

her issue and alleviate her distress no matter how unfair. This perception of stratum of

professional skill to understand and correct was also evident in other excerpts.

…every time I got referred it was, you know, that one person was more qualified or better or whatever. And every time I got really hopeful… (Jade)

Jade describes the experience of being referred within the stepped tiered model

of the NHS (NICE, 2014). Perhaps the participants’ experiences of expectation are

derived from such a readily available discourse. It also potentially says something of

this analysis and my own opposition to the notion of a mental-health “expert”. What

is notable in Jade’s account is the depersonalisation of the therapist as her hope

increases. Her preconception is of the skill to meet her needs as a structure of

professional capability and a hoped for expectation of a hierarchy of skill, rather than

a relational process of fit.

John provided a succinct account of why such a preconception of assumed

professional ability may have influenced his experiences.

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If it’s gonna’ be sold to me as, you know, you, you go and talk to this person you’ll feel better after a few weeks… I wouldn’t have taken it seriously. (John)

As an excerpt, it offers an insight into the value system that professional service is

assumed to offer. “Talk” as a therapy for distress isn’t understood as seriously

professional. John’s therapy experiences were considered positive and helpful and his

description contains the irony that what he mocked was precisely his positive therapy

experience. John’s account of his therapy was as much about his experience of a

transforming understanding of therapy and himself as evidenced by his post-hoc

assessment of his own preconception. The analysis here is focused on his sense of

what he would be meeting. It was something that remained active in his therapy, both

as a hoped-for preconception of professional ability and as a way of understanding

what his therapy became.

From an alliance perspective, meeting clients’ expectations of what therapy

might be was understood to be significant for the participants. Not just as a moment in

time when therapy began but also a representation that they used throughout the

therapy process; as hope and expectation. As such, it subtly overlaps with all of the

other themes, not as a discrete early therapy experience, but also throughout therapy

as a baseline to make sense of the change process (or lack thereof). CoP, as a post-

modern scientific epistemology (Vermes, 2017), is well placed to recognise the power

of socially available discourses and the impacts that such processes might have on the

therapeutic alliance. While we all have preconceptions, the nature of the sub-themes

analysed here speak of the therapy space as something largely unreal, misconstrued

and within a hoped-for meeting of professional mastery. As a response to the research

question, analysis of the data reflected the participants’ powerful preconceptions and

their therapy representations. Alliance, as a construct, would seem likely be

represented in the participants’ contextual understanding of what their preconceptions

might be.

Is it me, therapy, or the therapist?

This theme represented three key relationship experiences that were

understood to be expressed in the participants’ accounts and was taken from a

participant excerpt. ‘Is it me, therapy, or the therapist?’ suggested that three dynamics

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were represented; a relationship with distress and a sense of self, a relationship with

the therapist in whatever guise they understood this relationship, and a relationship

with the therapy space. Rather than a confusion on the part of the participants, a

critical understanding of such accounts might understand the depth of their insight

into the relational complexity that therapy might represent (and my own critical realist

position). While the theme was understood as one of multiple relationships, the sub-

themes represented distinct responses to the experience of multiple relationships. This

theme also overlapped with each of the other themes as a central present organising

experience. It’s moment-to-moment quality was analysed as a constant state of

judgement, evaluation and valanced experience around the sub-themes. Its

contribution to an understanding of alliance is the qualities expressed contributing to

the participants’ struggle to maintain the multiple relationships evidenced in their

accounts.

Negotiating in the moment

What’s different is that it’s not concrete. It’s kind of negotiating in the moment. (Liz)

This sub-theme was analysed to reflect the participants’ experiences of

negotiation as an ongoing act that was frequently expressed as part of everything that

was done together. As an empathetic interpretation it was felt to represent a form of

consensus around what the participants felt they needed to participate in the therapy.

Here, Liz’s therapy contract could be better understood as a therapy experience where

consensus is never achieved but remains ongoing as a negotiation in the present tense

as a moment-to-moment experience. Such a consensus was also evident in the

relationship with the therapist.

There was a trust and then it would be proven… it wouldn’t take very long to know that, that it was, you know, it was ok. (Margaret)

Margaret gives an insight into her experience of trusting her relationship with

her therapist and the anxiety that revealing herself entails. While nothing seems to be

said to her therapist, she describes withholding her consensus until faith in her trusting

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relationship is “proven” to her. Not everybody was as able to negotiate their

relationships in this way.

I sometimes wondered why we were talking about things, certain thing, and if it made sense… I just didn’t know how to ask. (Alison)

Alison’s excerpt was coded in several ways as it reflected more than one of the

sub-themes (also ‘going somewhere else’). The focus within this sub-theme was the

experience of her own inability to negotiate and expressed it as a personal sentiment.

Her sense that her inability was construed as consensus is matched by her

disappointment that she felt ill-equipped to participate in that part of her therapy. It

represents a relationship with her own sense of loss through what she cannot do. The

account of participants offered here is that multiple relationships are negotiated in the

moment. While a failure in one might be contra-reflected in the sufficiency of another,

we cannot know with certainty (nor may we want to).

The approach of the therapist seemed to, in my experience, was always quite consistent. It was that… that approach didn’t fit with what I needed. ( Fiona)

Fiona’s desperate plight with therapy failure is expressed as a consistent

ongoing frustration that stifles her ability to negotiate. Telling here is the three

relationships that are invoked as requiring negotiation. Therapy is represented as an

approach, the therapist as consistently unmoving from that stance, and Fiona’s needs.

For each of the participants, negotiating their relationships within the therapy was not

always reported as an explicit act with their therapist. However, it was frequently

reported as implicit, ongoing, embedded in interaction, and important to their sense of

participation. As an insight into an alliance construct, participants’ accounts expressed

many shared elements of current alliance constructs (eg. contract agreement, consent,

psychometrics such as the WAI). Yet, the analysis presented in this sub-theme

suggests that their experiences were of something more complex than a pre-

agreement, observable and shared. ‘Negotiating in the moment’ reflected multiple

relationships that were negotiated and the complex interplay between them.

Should I be saying this?

I am saying things I am not sure I should be saying and then should I be saying them. (Mary)

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…do you need to know this, this, or this? They have an idea, because you all have different theories don’t you… (Robert)

This sub-theme title is taken from Mary’s excerpt, yet it could have also come

from several others. Both Mary’s and Robert’s excerpts reflected the sub-themes

definition of participants’ representations of an undefined therapy space. Both

participants (above) reported that their therapy had been negative and unhelpful. Yet

their dilemma of meeting such an undefined space as an uncertain experience and was

also shared by other participants who reported positive experiences. The analysis was

that participants were reporting their experiences of uncertainty across multiple

relationships. For Mary her uncertainty was what to “give him” and the dilemma of

her relationship with her own distressing experiences. Robert’s uncertainty was which

parts to share but also within the relational backdrop with his therapist within a broad

cohort of therapists. However, other participants’ were able to use the undefined

nature of the therapy space productively.

Yeah, it felt like chatting, except she seemed to have a very, very clever way of chatting… (Margaret)

So it was kinda’ from the get-go it was just very, very open. And I think because it was… so open it allowed me to be open. (Liz)

These two excerpts were selected because they offered differing responses to

the nature of the sub-theme while highlighting the feature of their experiences that

was also shared. While all of the participants offered some account of their therapy

space as undefined, how they responded to the context was often quite personal. Here

Margaret recalls her trust that such a relaxed, informal directionless chat is

compensated by her belief in her therapist relationship to make sure they were doing

therapy, effectively compensating one relationship with another. For Liz, the openness

was understood as an invitation to follow suit and that such an experience was

facilitative. My reflexive position is that such an analysis is crucially insightful to an

account of participants’ alliance experiences. The differing experience of such a

context highlights the possibilities of co-defining what therapy will be, not just as a

modality or a personal dyadic relationship. But across multiple relationships, each

which is felt and was used by the participants to ally themselves within their

experiences of therapy.

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Figuring it out myself

No, I think before I would have been too much of a pussy to go ahead… you’re just going to leave it to me then (both laugh)… Yeah, I needed to figure it out myself what I was gonna’ do… (John)

This sub-theme was understood to represent the confidence that participants

felt across all aspects of their therapy. John’s response is that his own sense of self is

judged insufficient to allow his involvement in what his therapy might be, with his

therapist (“you’re just going to leave it with me”). The confidence to take that mantle

within the therapy is indicated as a growing experience and was empathically

understood as his confidence in his relationships. This despite reporting an “instant

rapport” with his therapist yet his confidence with his own abilities clearly grew from

an initial low point. This growth in confidence however wasn’t universal.

There was no sort of guidance, there was no sort of questioning about certain things. I think it… and that didn’t give me the confidence. (Mary)

Mary is clear that the experience of confidence was a crucial issue in her

therapy. This excerpt was empathically understood as Mary’s unhappiness that she

had been left to figure it out herself. It highlights the ongoing judgements made across

the multiple relationships within the therapy. For Mary and John, confidence was a

key determinant.

I did my part by talking about it, you know… And she… made me want to… get those goals of being a stronger person. (Jade)

Confidence here is diffused, as a “want”, yet the energy from Jade’s excerpt is

of being made strong enough to figure out personal on-going goals in her life. It

speaks of achievement and purpose in her relationship with herself through her

relationship with her therapist.

Notable in the excerpts presented here is the notion of therapy purpose for the

participants. Its fit with the theme (is it me, therapy, or the therapist?) is the sense that

what is done in therapy is linked by the relationships that the participants identified

and how that relates to themselves, both as a relationship with the presenting problem

and what a change might represent to them. All of the participants reported a strong

sense-making experience; active, valenced and ongoing. ‘Figuring it out myself’ was

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felt to reflect the personal experience of transitioning in overlapping relationships,

each with implications for what therapy would represent.

Analysis of this theme was difficult to portray in succinct excerpts. The

participants’ expression of confidence (or lack thereof) as they made sense of their

therapy was frequently understood through the nature of their animation and cadence

within recordings. My own clarifying comments were sometimes seized upon with a

sense of enthusiasm from the participants from being understood. This informed the

analysis through the difficulty that participants experienced in expressing themselves

confidently in a novel context (a research interview), perhaps as a mirror experience

of the themes content, should I be saying this.

The theme ‘is it me, therapy, or the therapy?’ could be understood from a

relational epistemology yet the analysis focus was intended to be a reflection of the

patterns of experience represented by the participants. Naming the theme from a

participant excerpt was intended to demonstrate the complex nature of the

participants’ own experiential representations: their sense of the many things at work

within their experiences of therapy. As an analysis, many aspects of their accounts

speak directly to the nature of any alliance understanding. It seems reasonable to

conclude that negotiation (in this account on-going), the choices involved in talking

and the confidence to do so would all likely be considered part of what an alliance

construct might entail. Perhaps the defining feature of these accounts is their ongoing

and intersubjective nature. Meaning and purpose are intertwined in an ongoing

process within multiple relationships. It confronts the theoretical alliance notion of

something static, agreed or definable. This theme suggests that participants’ own

alliance with their therapy is better represented by the ongoing process of defining

itself.

Connecting the dots

The analysis for this theme was understood to represent the participants’

notion of relevance as a connection between what was occurring in their therapy and

the impact it may have on their lives. Two sub-themes were understood to have

distinct representations for the participants. Firstly, the theme ‘going somewhere else’

represented therapy opportunities that weren’t previously available to the

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participants’. Secondly, the notion of what that journey might represent when it has

been explored. In effect, this theme was represented by two connected synergistic

experiences of perspective, what path was explored connected with what therapy

might yield. Another philosophical perspective may interpret such an analysis as an

outcome or a goal. From a critical perspective, it was understood to represent the

participants’ judgement of the connections in everything that occurred. However,

analysis invoked the participants’ experience of feeling on-board (or not) with the

therapist as an imagined pathway projecting forward to something personal. It’s

relevance and the judgement of its fit was frequently judged as an alliance with that

trajectory.

Going somewhere else

Yeah, what’s relevant and where are we going. But also if we move in different directions… how it ties into the overall picture… (Fiona)

The name for this sub-theme came from a coding note from this excerpt. It

was collapsed into a sub-theme which was felt to represent the participants’

experience of new perspectives. Fiona also reported that “if you only work with what’s

inside your head, you don’t need to go”, so her experience of a desire for novel

perspectives from her therapy was not unanticipated. Yet the analysis focused on her

valenced account of her search for relevance with these new perspectives. Going

somewhere else represented her judgement by its felt sense of relevance by

‘connection’ to the therapy purpose. This judgement was expressed in many differing

ways.

…how do I feel? I wasn’t sure how to answer that. Why do you need to ask that? (Alison)

…it’s like, sort of cleaning out all the little dark places, not all of them. But if you clean out a few, then you can cope with the rest is what it feels like. (Margaret)

Both Alison and Margaret gave differing accounts to their experience of

making connections as they engaged with their therapy. Alison expressed confusion

regarding her therapists request to explore her feelings and her inability to find

relevance in his invitation. My own empathic sense of her expression was that her

feelings should be obvious to him and that her expectation was to go somewhere else

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more therapeutically valued. While a therapist might understand the request as an

invitation to explore feelings at greater depth, its relevance hasn’t been experienced

here. I presented Margaret’s excerpt with Alison’s as it represented a differing

experience of valuing the invitation to go somewhere else. For Margaret, these “little

dark places” were understood as relevant to her ability to be resilient. The sub-theme

was also represented in other ways, not just as a response to interventions.

I was like, Oh yeah, it’s a bit of a circle, I’m a bit confused. And then she was like, Oh, OK, duh, duh, duh… And then she said exactly the same stuff. I think I was like, like, Well do something different then. No actually, we didn’t. (Jade)

It may not be a surprise that this was an account of Jade’s negative therapy

experience. Here, her experience was of asking to go somewhere else as her therapy

felt confusingly stuck in a cycle and its relevance was judged insufficient for her

purposes. Jades account was also a critique of modality and her experience of being

met with a consistency of stance despite her conclusion as to its relevance and the

request to do something else. This sub-theme speaks of the judgements that were

reported by the participants on the personal places that therapy ventured to.

Participants’ ability to connect with these unique therapy destinations and its

relevance to their vision of what it might ultimately represent played a key role in

their account of what they felt important.

Nobody really knows what they are trying to achieve

Nobody really knows what they are trying to achieve. Because you can’t, you know, ultimately. (Fiona)

Fiona’s succinct style of expression again served as a sub-theme title as she

expressed her sense of therapy purpose that may ultimately be unknown. What

remains is the process of finding its relevance in a personal context. As noted

previously, this sub-theme is outcome related in one sense, yet was also anti-outcome

in that participants frequently reflected on their transitioning and the relevance of their

therapy to such a change process. Connecting what they did with what that might be

for them in their lives was an ongoing process and an unfolding of differing

possibilities; judged by their perceived relevance and their response to it.

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I do remember starting the therapy and really wanting a fix, yeah, fixing this thing. I think it took a while to get over that. (Alison)

…back then I was thinking there must be a quick fix to this, you know… Looking back that is the wrong way to do things… (John)

Both Alison and John’s excerpts were understood to capture the transition

from their preconceived notion of therapy (as an ongoing overlap between themes)

and their sense of what their change might come to represent for them. Both

participants’ report the transition from an imagined concept of “fixed” to something

less defined. Also, both suggested that the process was in tandem with what they were

experiencing in therapy (‘going somewhere else’) and their judgement of whether that

would represent the help that they sought (to “get over that” and it being “the wrong

way”). Rather than a “fix”, therapy became something that was judged by them

through the relevance with the connections that they were experiencing.

But I came out with more insight into why I might do things and not that those things needed to be changed. Yes, maybe further down the line I will begin to change but it was more about, Right, can I accept that I’m doing this first. Can I accept this part of me before I make that change. (Liz)

Liz goes further with her account and highlights how she experienced her own

search for the relevance in her therapy, through her insight. A wish to change is

transformed into acceptance and she anticipates change to occur within her life

through personal acceptance. It is a complex notion and speaks of a sophistication in

the participants’ accounts of how they understand their change process through

therapy. Significantly, it also suggests that such a valenced judgement of the

relevance of the therapeutic change was transitioning, on-going and considered in

depth throughout differing stages and potentially across the whole therapy experience.

This sub-theme was understood as a tandem process with ‘going somewhere

else’ but representing two distinct experiences of perspective-taking. ‘Connecting the

dots’ reflected the participants’ ongoing quest to make sense of what they were doing

with what that might represent to them in their everyday lives. It also highlighted the

unknown quality of such an on-going experience. What that represented was also co-

constructed in the context of their preconceptions, the multiple relationships that they

experienced as well as the relevance to their lives, as analysed here. From a critical-

realist position it suggests a search for their own meaning and that was an active

68

process embedded in everything that they did. Each intervention had a meaning for

them which was considered and in turn influenced what their response to it was.

As an insight into the research aim, the participants’ accounts speak of a

consensual process: relevance as a key on-going participant consideration. As a

personal response to the process of analysing this theme, I was struck by the

complexity of the therapy experiences that the participants’ communicated. As an on-

going search for connections between what is done in therapy and what it might mean

in the participants’ lives, their accounts don’t seem to be reflected in current alliance

constructs (something I will discuss). Perhaps the participants’ desire to engage with

that complexity in their responses challenges clinicians to also consider an alliance

construct of similar complexity.

Discussion

This research project took a qualitative exploratory position within a construct

of counselling and psychotherapy: alliance. Findings from the analysis were that four

themes were understood to be shared across the data-set. Three themes were reported

which developed the concept of alliance beyond what could have been anticipated

from existing CoP literature. Each of the themes represented a shared pattern of

experience across the data-set. Yet each of the themes was also understood to have

some present organising quality that was understood as a constant interpretative and

dynamic act within the therapy. I will report each of these qualities from the themes

here as they will form the basis of the subsequent discussion.

The first theme could be understood to reflect the participants’ experiences of

what had inspired them to enter therapy as a helping enterprise. This preconception

stayed with the participants and was used in novel ways to make sense of what

therapy became or supported their journey within the therapy. Alliance here was with

therapy’s expected qualities and frequently the ongoing transition away from this

position was retained as a baseline from which the experience could be understood.

The second themes organising definition was a multiple relational experience of

something ongoing, perpetual and dynamic. Here the experience was one of

confidence to engage across those relationships. Finding something purposeful to ally

with was complex, layered and was experienced as an often implicit negotiation in the

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space in between each of the layers of relatedness that the participants’ reported.

Finally, the theme of ‘connecting’ was analysed as an experience of valenced

judgement of what was done in the therapy and its relevance to the participants’ lives.

Taken together, the themes might be interpreted using concepts such as social

discourses and repertoire, intersubjectivity and meaning. Yet, the terms are not

axiomatic and each interpretation also has an epistemological dimension which

potentially changes its meaning depending upon which perspective is taken in

assessing the research findings. In some way, it may also be critically synonymous

with the problematic definition of alliance as suggested by Norcross (2011).

There are two key potential ways to assess the findings of this report as an

exploration of an alliance construct. The first, is from within the relational

epistemology of CoP, both as a personal position and as a professional obligation

(2014a). CoP is not alone in its attempt to understand psychological distress from a

relational perspective. Douglas (2010) points out the relational dimension in many

discourses that are readily available in Twenty-First Century Britain, from religious,

medical and psychological. CoP differs, however, in its assumption of knowledges, its

focus on well-being and its ethical values that allow a professional framework in a

context of pluralism (Strawbridge, 2016). Such a relational epistemology also offers a

potential insight into the findings analysed here.

Woolfe (2016) offers an account of professional practice that touches on the

three interpretative concepts that might be understood as running through the analysis

themes. Firstly, the discourse around professional status “is based on the claim of

technical expertise” (p.7). This notion of technical expertise was evident in the first

theme and its sub-themes. Without extending this discussion beyond the

constructionist-lite (Braun & Clarke, 2013) perspective of critical-realism, social

discourses around claims of professional expertise would seem to have permeated the

therapy space. For the participants, the professional status of the therapist seemed to

be located in a similar technical space and capability, irrespective of CoP’s ethos of a

focus on the being-with rather than a technical doing-to (Strawbridge, 2016). While

CoP may be alert to these expectancy difficulties (Woolfe, 2016), its impacts on the

participants’ preconceptions were evident in the analysis. The participants’ expectant

‘fix’ construed a power imbalance irrespective of their therapist’s sensitivity to the

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paradigm. Woolfe (2016) takes this point further by also suggesting that an emphasis

on technical expertise ignores the intersubjective frame within which therapy is

epistemologically understood and is an inevitable consequence of such professional

power. The analysis also yielded insight into aspects of this intersubjectivity as the

participants’ experience of ongoing negotiation, or negotiation in the moment and the

dilemma of making sense of that experience from a technical expert assumption

(‘should I be saying this / figuring it out myself).

The final theme and its sub-themes could also be understood through a

relational epistemology. This theme represented the participants’ judgement of

aspects of the therapy and its relevance to their lives. In one sense it was imaginative,

valenced and represented personal future possibilities changed by the things that they

did in the therapy. As with the other themes, such an experience was understood as

constantly interpretative and dynamic as each aspect of the participants’ therapy

experience was considered for its importance and what it might ultimately represent.

The theme speaks of the participants’ search for meaningful change at a personal level

and could be understood as emblematic of the validity of subjective narratives, values

and beliefs (Strawbridge & Woolfe, 2010). For the CoP, ideographically valuing the

participants’ personal meaning seems elevated to a new therapeutic importance

beyond an ethical stance precisely because participants are evaluating and valuing it

too.

Taken together and as a contribution to an understanding of the alliance, this

interpretation has something to offer the CoP. Each of the themes analysed here pose

a potential barrier to a client-informed understanding of alliance. Each of the themes

also offered a distinct insight into what clients may potentially need to overcome,

irrespective of the humanistic relational qualities that the CoP may hope to embody.

Staying faithful to the ideographic nature of this research report suggests that the

alliance that clients’ experience in their therapy cannot sufficiently be defined in

technical rational terms. However, from a client derived perspective, felt confidence

in the participants’ client-role and therapy’s perceived relevance were significant

experiential factors that contributed to their sense of being aligned with something

meaningful. A key quality of these experiences was their ongoing and fluid nature.

This fluid interpretative act was further complicated by the participants’

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preconceptions of what therapy might represent and their actual therapy experience. I

felt it was significant that the participants took a contradictory position in their

preconceived expectations of themselves, the therapy and the therapist. This

expectation of something unreal or potentially unrealisable is at odds with the very

human and democratising qualities that were evident in the two later themes. Though

it may only be conjecture, perhaps such a hope serves as motivation to seek help.

Perhaps some clients need to feel that their distress can be fixed like a car or a sore

tooth by a technically skilled mental mechanic. As part of an understanding of

alliance, such a contradiction is important to acknowledge. It seems to contrast

markedly with the participants’ intersubjective accounts of constructing and

negotiating meaning and deriving confidence in their part, all within a human and

dialogical encounter. For the participants, these two perspectives were frequently

side-by-side: contradictory, often confusing, sometimes helpful and also frustrating.

The second potential way to assess the findings of this research project is to

take a broader position and look beyond CoP knowledge with its critical edge. There

are several aspects of this analysis that are important considerations when positioning

this discussion in the wider scientific field of counselling and psychotherapy research

and practice. Psychology is a very broad church and in the introduction, I posed many

perspectives that have been brought to bear on the understanding of the alliance

construct. Politics, research findings, methodologies, ethics; each has impacted on the

understanding and use of the alliance construct.

The alliance is a much-researched concept, yet most of its investigation has

been largely through the epistemological lens of positivism. The focus has also been

predominantly trying to understand alliance as a formation process, almost always in

the early stages of therapy and quantifiably achieved to a sufficient degree. The

quantitative operationalisation of the concept has developed to allow a controlled

variable within an experimental paradigm. Criticism of this approach has highlighted

the interpretation of alliance as a therapeutic agreement of tasks and goals (Norcross

& Lambert, 2011), taken as representing Bordin’s (1979) construct. This research

confronts these assumptions directly, through the complex interplay across multiple

relationships that were analysed in the data-set, not just with the therapist. This

research also explored the many ways that clients participated, negotiated and

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considered their therapy as an ongoing interpretative experience. The findings seem

some distance from a construct of agreement, or indeed its agreeableness, but rather a

process of defining in and of itself. Critically locating this research within the body of

positivist findings is as complex as the participants’ accounts of working within their

therapy. The purpose of the research wasn’t to define alliance, my intention was to be

exploratory from a specific under-researched perspective, the clients. As such, I feel

the research poses challenges to the contemporary positivist alliance construct of tasks

and goals that are utilised within RCT methodology and favoured as ‘gold-standard’

evidence (NICE, 2014).

As noted earlier, one assumption that has directed positivist alliance research

has been that of an early formation effect. The ongoing experience that participants

reported is not represented by this theoretical assumption in two themes (‘Is it me,

therapy, or the therapist?’ and ‘Connecting the dots’). Alliance here was understood

as an ongoing interpretative act almost a way of being in the therapy. Significantly,

this experience of negotiation, making sense of being in therapy and considering what

that meaningfully represented was reported throughout the participants’ therapy

experiences. This process was also considered within several relationships, including

the often difficult relationship with their own sense of self and their psychological

distress experiences. Tasks and goals, in effect, become meaningless in a complex and

fluid interplay of the act of defining and evaluating what their alliance might be.

While the therapist may have a sense of purpose and plan, the client may not share

that experience or value the premise. It also says something of the CBT notion of

collaboration. The analysis was that participants experience was frequently more

questioning than collaboration. While participants did at times express a sense of

collaborative working together it was also represented as a collaborative treasonable

co-operation of ‘should I be saying this?’ and ‘figuring it out myself’. Participants

questioned what they did in therapy and why. The notion of collaboration does not

sufficiently grasp the ongoing nature of that questioning and the meaning of what

participants would ally themselves with.

Previously, I touched on the inconsistency that was analysed in the

participants’ accounts. The theme ‘Preconceptions of what therapy might be’ offers a

potential insight into some positivist research findings. Participants reported

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expectations of a professional mechanistic mastery and that therapy would be

transcendent in some way. What was notable here was the many ways that

participants negotiated and used such a preconception. For some, the experience was

one of transitioning away from this position throughout the therapy. For others, they

experienced a frustration that it didn’t. Yet, some clung to this premise and invested in

their therapy precisely because they experienced these on-going preconceptions as

being met. Research findings which link early positive alliance psychometric scores

with positive outcomes (Horvath & Bedi, 2002; Horvath, Del Re, Fluckinger &

Symonds, 2011) may potentially be reflected in aspects of this theme. It is reasonable

to suggest that meeting these expectations may represent one less barrier to effective

therapy for some clients. From a personal perspective, as both a training psychologist

and analysand, that would also tally with experiences of my own. Other research

findings have also suggested that clients’ have exhibited alliance styles or preferences

(Batchelor, 1995). A correlate may exist between the theme analysed here and the

clients’ expectation of what their therapy might represent. Coupled with the evidence

that clients being offered a treatment choice had improved measured outcome and

subsequently reduced dropout rates (Swift & Callahan, 1995), it suggests that some

aspect of this analysis may be detected in the quantitative measures used by

researchers; but that remains tentative. Perhaps more likely is that the positivist

reduction has lost something of the concepts nuance or cannot operationalise its

intersubjective quality.

However, this analysis extends the understanding of alliance experience

beyond clients’ expectations of technical skill alone. Firstly, it suggests that such a

‘baseline’ of expectation was also used throughout the therapy to make sense of what

was happening and what that might mean (the second two themes). Positivist RCT

research makes an assumption on the clients’ behalf of an agreeableness to the

therapist and the therapy; explicitly as a treatment agreement and implicitly as an

assumption of unyielding contract. Indeed, some aspects of this unyielding

assumption were analysed in this report, as an experience of therapy which hadn’t

been reported as successful – the participants transitioned, question and demanded

flexibility. While it is difficult to draw conclusions, it might be reasonable to

subsequently question the treatment paradigm of RCT efficacy methodology. Such a

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theoretical alliance construct of agreement on tasks and goals which has been utilized

within the marketplace of product-focus and treatment legitimacy (Corrie, 2010)

differs from the alliance perspective offered here. The theoretical construct utilised in

RCT’s seems reductive in comparison and ignores the ongoing nature of the

questioning and meaning-making experience or assumes that such experiences are

homogeneous which has not been demonstrated in this analysis.

There is another issue with RCT methodology and that is the ethical

dimension of what information is included in the evidence supporting the theoretical

alliance construct. This research took as an inclusion criteria of a range of both

positive and negative therapy experiences. As a scientific method, I intended to

explore a more diverse participant pool than is frequently represented in efficacy and

alliance research. Common-place in RCT methods is the modelling of participant data

of non-completers based on completers data or washing-out non-completers from the

data-set. Yet, any comprehensive alliance construct needs to also include those that

RCT methodology doesn’t reflect upon in a nomothetic reduction. It needs to include

those that find such alliances difficult to be clinically useful. While questionable

ethically, it also impedes the CoP’s ability to practice flexibly as a response to the

very change that is expected from therapies efforts. A narrow evidence-base of a

single methodology potentially ignores the most difficult client groups to reach

clinically, those that struggle to engage with therapy or do not fit with such a

homogeneous assumption. While I cannot make comparisons between this more

inclusive data-set and others, it would seem reasonable to conclude that differences

are likely. From a CoP perspective, these findings are commensurate with the ethical

values of the profession (BPS, 2014a) and better reflect an under-represented and

significant clinical population.

It is useful to also critically reflect upon the limitations of this research (as

well as the positivist research) to represent the UK population in all of the diversity

from which it is comprised. Taking a critical position within positivist alliance

findings also highlights the limitations of what can be deduced from the findings

presented here. Indeed, TA as a methodology specifically focuses upon shared

thematic meaning across the data-set and so participant differences are also not

included in this analysis to some degree. The methodology was employed because it

75

allowed similarities of greater depth and complexity to potentially be developed. The

research had exploratory ambitions, was small in scale and didn’t fully reflect the

broad diversity of clients that seek help and potentially have difficulty engaging with

psychological services. Further research seems justified given the findings, principally

of an increased scale to build more credible evidence but also to diversify the

participant pool to fully reflect the difference and diversity in the UK population that

CoP seeks to serve. I will finally turn to the impacts on these findings from within the

epistemology of CoP.

As a trainee CoP, my curiosity regarding the alliance was piqued by the

political impacts upon the UK practice climate through NICE (2014) guidelines and

the narrow definition of the scientist/practitioner that it suggested. It was later as my

literature-searches accumulated that I became aware that my concerns were shared

(eg. Woolfe, 2016). While many CoP authors placed alliance as central to practice

(Du Plock, 2010; Hession, 2010; Jordan, 2010; Milton, 2010; Norcross, 2011; Parritt,

2016) each frequently used the term in seemingly unresolvable ways (Campiao,

2012). Perhaps this is unsurprising as many technical psychological terms are also

contested, even from within CoP’s epistemology. Two that have been used in this

report are ‘intersubjective’ and is argued as epistemologically flexible (Spinelli, 2015)

and ‘discourse’ and the differing critical-realist or social-constructionist knowledges

of power and language (Braun & Clarke, 2013). My wish is not to undermine my own

position and use of the terms but rather to highlight how a lack of agreement has

enabled the term ‘alliance’ to be shaped outside of CoP’s epistemology and influence;

theoretically as a measurable achievable state that considers tasks as protocol and

goals as symptom reduction. Is alliance a relationship equivalent or part of an aspect

of relatedness? Is it a type of relationship? Alliance must be considered from a

relational knowledge perspective, that is part of the professions ethos (BPS, 2014a). I

would suggest that alliance is best understood as a quality of the relationships that

clients experience. It must be more than a therapist stance of collaboration because

collaboration requires two people by its definition and that cannot be guaranteed from

the client’s perspective. It is also more than protocolised tasks and goals that are

agreed. The client-alliance perspective suggests that what therapy is and what it might

represent is understood as many alliances, negotiated and their relevance considered

76

as a confidence in the clients’ role in the therapy. It differs from the stance taken by

the therapist, be it collaborative, tabula rasa, even humanistic. While such a stance

would likely influence the alliance experience for the client, therapists cannot fully

ally the client no matter what their technical skill. Within the limited scope of this

research, I propose that alliance is a relational act best understood as the therapeutic

stance of the client; with the therapist, the therapy and their own sense of self and the

distress that brings them into the therapy.

As an aid to the credibility of this research report it is also important to reflect

on my own personal position within the research. The first major reflexive comment

must begin with “why this question?” and not another. I approached my own training

with a personal desire to engage with the science around psychotherapy, not just the

client work that I had enjoyed previously. Yet, my experiences within NHS

placements suggested that CoP was marginalised by its epistemological differences

with much of service provision. It asked questions of my own alliances: professional,

scientific and ethical. I asked this question to further explore my own practice

experiences of delivering protocols in an NHS setting. For me, it represented a

scientific response to a clinical dilemma surrounding the ethics of informed consent

and those clients marginalised by protocolised service assumptions of ‘resistance’ to

treatment. I felt that CoP had ignored the debate around the alliance construct,

possibly as a dismissal of it within a relational epistemology (a criticism also made by

Vermes, 2017). From a practice position, I questioned my own ability to exercise

modal flexibility as a CoP practitioner in a context of overwhelming positivist alliance

representations and pre-defined treatment protocols. It was at times overwhelming,

frustrating and ethically uncomfortable.

This research became my response to that situation. I wanted to be able to

respond to the evidence debate within the context of a NICE guidelines informed

service with something scientific, reasoned and more clinically useful. The clients that

I had the privilege of working with were frequently worn down, by their life situations

but also by a system that felt stretched and coping rather than caring. Given the

limited sessions available, most of my first-year placement seemed to be spent

addressing the clients’ pent up anger directed towards the service through me. And if

I’m honest, it felt fair enough. I was frustrated too. This isn’t a critique of services per

77

se., waiting lists were long and economic pressure limited what could reasonable be

offered and that is perhaps beyond the services control. However, within CoP, there

seemed limited scientific resources to affect any meaningfully different way of

working with any evidence that could support a Humanistically informed clinical

rationale, rather than a strict methodological rationale. I didn’t expect to change the

service, I just understood that I would need to be prepared as a scientist if I wanted to

improve what practitioner services I could provide. I did gain valuable experience

using protocols. Flexibility and RCT evidence does suggest that if that suits a client

and the therapist and it represents a clear client choice and their life context then I am

amenable. However, in the absence of research findings that supported ways of

working which were more inclusive and respected personal choice, I felt that I needed

to respond as a CoP scientist/practitioner and make a contribution to that research

myself.

The second major reflexive comment must also be my part in the analysis

findings. Checking my findings with the participants post-analysis was helpful and

insightful. While the dual-role that I had with several of the participants was an ethical

concern, I introduced the findings and made my analysis position clear; I hoped to

capture their voices and so it needed to resonate with their experiences. Feedback was

positive and several participants assumed that they had said each of the quotes used as

sub-theme titles. While that is little guarantee of credibility, the participants were as

curious about the themes drawn from the data-set and their specific alliance focus. It

forced me to question my analysis; “have I found what I sought?” It is a reasonable

question. One participant suggested that I should call it a “working relationship – you

know, the bit of being with someone at the office that is good for you even though

you don’t really know each other very well”. In truth, my analysis was more complex

and more diffuse than I had anticipated. For me, that goes some way towards

confidence in my own efforts to reach beyond what I expected to find. I learned a lot

about being reflexive in those moments. The research was conducted with a sense of

isolation: deadlines, late nights and piles of texts and literature. Speaking to the

participants again and discussing my findings felt like the social in social-psychology

research. It was an important part of my learning. It connected what I did with what it

might mean and how that knowledge can affect peoples’ lives, including my own.

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Conclusions

The aims of this research report were to explore participants’ alliance

representations and responses using an experiential TA method. This method was felt

to be more suitable to the relational epistemology of CoP and potentially counter-

reflect the positivist uses of the alliance construct in efficacy-based evidence

currently. The analysis offered an account of alliance that suggests that participants’

representations were of an ongoing nature. Their considerations included multiple

relationships within the therapy and the relevance to their therapy. This research

provides a small insight into alliance processes from a client’s perspective which

could support CoP’s and their understanding of how clients experience and

understand their therapy alliances. A hoped for impact of these findings is to better

support CoP’s pluralistic therapeutic stance, an ethical valuing of client choice and to

be alert to potential client therapy needs transitioning throughout the therapy.

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Neil, P. (2014, Unpublished). Literature Review. The epistemologies that inform the ontologies of alliance in Psychotherapy and Counselling. Unpublished manuscript, Guildford: Surrey Library.

Norcross, J. (2011). Psychotherapy Relationships That Work: Evidence-Base Responses, Second Edition. New York: Oxford University Press.

Norcross, J. C. & Lambert, M. J. (2011). Evidence-Based Therapy Relationships. In J. C. Norcross (Ed), Psychotherapy Relationships That Work: Evidence-Base Responses, Second Edition. New York: Oxford University Press.

Papayianni, F., & Cooper, M. (2017). Metatherapeutic communication: An exploratory analysis of therapist-reported moments of dialogue regarding the nature of the therapeutic work. British Journal of Guidance & Counselling, 1-12.

Parritt, S. (2016) Working with difference and diversity. In Douglas, B., Woolfe, R., Strawbridge, S., Kasket, E. & Galbraith, V. (Eds). The handbook of counselling psychology (4th ed., pp. 198-212). London: Sage.

Safran, J. & Muran, J. (2006). Has the concept of the therapeutic alliance outlived its usefulness? Psychotherapy: Theory, Research, Practice, Training, 43(3), 286-291.

Spinelli, E. (2006). The Value of Relatedness in Existential Psychotherapy and Phenomenological Enquiry. Indo-Pacific Journal of Phenomenology, 6(Sup1), 1-8.

Spinelli, E, (2015). Relatedness – Contextualising Being and Doing in Existential Therapy: Keynote talk, London 21 November, 2015. Society for Existential Analysis Annual Conference.

Strawbridge, S. & Woolfe, R. (2010). Counselling Psychology: Origins, developments and challenges. In Woolfe, R., Strawbridge, S., Douglas, B. & Dryden, W. (Eds.). Handbook of Counselling Psychology (3rd ed.). London: Sage.

Strawbridge, S. (2016) Science, craft and professional values. In Douglas, B., Woolfe, R., Strawbridge, S., Kasket, E. & Galbraith, V. (Eds). The handbook of counselling psychology (4th ed., pp. 198-212). London: Sage.

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Appendix A: Letter Granting Ethical Approval

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Appendix B: Information Sheet for Participants

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Participant Information SheetThe purpose of this sheet is to provide you with the information that you need to consider in deciding whether to participate in this research study. The study is being conducted as part of my professional doctorate (PsychD) in Counselling and Psychotherapeutic Psychology at the University of Surrey. The study has been reviewed and received a Favourable Ethical Opinion (FEO) from the University of Surrey Faculty of Arts and Human Sciences Ethics Committee.Working Research Title: The Relational Dimension of the Working Alliance.IntroductionI would like to invite you to take part in a research project. Before you decide you need to understand why the research is being done and what it will involve for you. Please take the time to read the following information carefully. I am investigating the relationship that people had with their therapist (not what was discussed during the therapy sessions). You don’t have to identify your therapist or any details about them if you wish because what will be the focus are your experiences. The background to this study is the science that tells Psychologists how well people have managed to work with their therapist is an important part of the helping process. But what makes a good relationship is less well known. I would like to understand that better but I need some help.Why have I been invited to take part in the study?Because you have that experience. The type of study that I am doing places a great importance on what people report. Importantly, there is no ‘right’ or ‘wrong’ answers. This study is about how you can help Psychologists understand what it is like talking to a therapist. As you have completed therapy and had some time to reflect on the experience you have a unique and valuable insight.Do I have to take part?You are not obliged to take part in this study and should not feel coerced. You are free to withdraw at any time. Should you choose to withdraw from the study you may do so without disadvantage to yourself and without any obligation to give a reason. Should you withdraw, you will have the option for your data to be withdrawn and deleted from the study if you so wish, otherwise your anonymised data may be used in the study write-up of the study and any further analysis that may be conducted by the researcher.What will my involvement require?As a participant you will be asked to talk about your experiences of working with your therapist, in response to broad and open interview questions, which will be used as a guide. The interview will be audio-recorded for the purposes of research transcription and analysis.

What will I have to do?Firstly, read this sheet and if you are happy to proceed and have no further questions or concerns sign a consent form. Then we will conduct the interview, of roughly one

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hour. When we have finished the interview I will ask you if you think there is anything that might help the study or that you feel needs to be added. When we are both satisfied that we have all the relevant interview material I will conclude the interview and stop recording. We will then have 30 minutes available for a debrief. This is an opportunity for you to ask questions or for us to talk about any difficult feelings that may have arisen during the interview, should you so wish. I will leave you and transcribe the interview and analyse it for the purposes of writing a report. When that analysis is complete I will call you on the telephone, at an agreed time, and discuss that analysis with you. This is an important part of reporting your experiences and I would welcome any thoughts that you may have.What are the possible disadvantages or risks of taking part?Participant safety is an important aspect of ethical scientific research. While it is not my intention to discuss the content of your therapy (and what you were attending for doesn’t need to be discussed at all) discussing aspects of therapy may be difficult and arouse unanticipated feelings. Should this occur, we can take a break, postpone the interview or abandon it completely; your participation is most appreciated but your safety is paramount.What are the possible benefits of taking part?We might make a small contribution to the science of psychotherapy. Somebody, in the future, may get better help when they need it most. Counselling Psychology is always trying to integrate science into practise and this is what that science looks like sometimes.What happens when the research study stops?The transcripts of all the interviews (between six and ten) will be anonymized and kept for ten years (one copy encrypted, password protected and the audio recordings deleted) as per university regulations on research projects. Data will be stored securely in accordance with the Data Protection Act 1998. I will make a copy of the completed project available to you if you so wish.

What if there is a problem?If you have any questions or concerns about how the study has been conducted, please contact the research supervisor, Dr Dora Brown, School of Psychology, University of Surrey, Guildford, Surrey (email: dora.brown@surrey.ac.uk).Thank you!Researcher: Peter NeilEmail: pn00053@surrey.ac.uk Mobile phone: 07767 371619Thank you for taking the time to read this Information Sheet.

Appendix C: Sample of Participant Consent Form

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Consent Form

I the undersigned voluntarily agree to take part in the study on The Relational dimension of the working alliance.

I have read and understood the Information Sheet provided. I have been given a full explanation by the investigators of the nature, purpose, location and likely duration of the study, and of what I will be expected to do. I have been advised about any discomfort and possible ill-effects on my health and well-being which may result. I have been given the opportunity to ask questions on all aspects of the study and have understood the advice and information given as a result.

I agree to comply with any instruction given to me during the study and to co-operate fully with the investigators. I shall inform them immediately if I suffer any deterioration of any kind in my health or well-being, or experience any unexpected or unusual symptoms.

I consent to my personal data, as outlined in the accompanying information sheet, being used for this study and other research. I understand that all personal data relating to volunteers is held and processed in the strictest confidence, and in accordance with the Data Protection Act (1998).

I understand that I am free to withdraw from the study at any time without needing to justify my decision and without prejudice.

I understand that in the event of my suffering a significant and enduring injury (including illness or disease) as a direct result of my participation in the study, compensation will be paid to me by the University of Surrey, subject to certain provisos and limitations. The amount of compensation will be appropriate to the nature, severity and persistence of the injury and will, in general terms, be consistent with the amount of damages commonly awarded for similar injury by an English court in cases where the liability has been admitted

I confirm that I have read and understood the above and freely consent to participating in this study. I have been given adequate time to consider my participation and agree to comply with the instructions and restrictions of the study.

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Name of volunteer (BLOCK CAPITALS) …...................................................

Signed …..............................................................

Date …..............................................................

Name of researcher/person taking consent ……………………....................

Signed …............................................................

Date…………………………………………

Appendix D: Participant Interview ScheduleProtocol 1What were your experiences of being with your therapist like for you?

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What sort of things did you decide to do while in therapy, if any?What was working towards something like with your therapist?Finally, is there anything about your experience of your therapist that we haven’t talked about or that you thought was important to you?

Protocol 2 & 3What were your experiences of being with your therapist like for you?What sort of things did you decide to do while in therapy, if any?What was working towards something like with your therapist?Other participants in this study have reported an unexpected change in some aspect of their therapy. Does this tally with your experience?

Protocol 4What were your experiences of being with your therapist like for you?What sort of things did you decide to do together in therapy, if any?What was working together with your therapist like for you?Other participants in this study have reported an unexpected change in some aspect of their therapy. Does this tally with your experience?

Protocol 5 & 6What were your experiences of being with your therapist like for you?Do you remember exploring the therapy process with your therapist, if at all?What was working together with your therapist like for you?Other participants in this study have reported differences in how they experienced their therapist? Does this tally with your experience?

Protocol 7 & 8What were your experiences of being with your therapist like for you?Do you remember exploring the therapy process with your therapist, if at all?Other participants in this study have reported experiencing change in the way they were working with your therapist? Does this tally with your experience?Other participants in this study have reported differences in how they experienced their therapist? Does this tally with your experience?

Appendix E: Analytic Procedure

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Braun and Clarke (2006, 2013) propose a six-phase process for TA analysis

which was adhered to throughout including during the writing phase. While the aims

of this study were to analyse the data inductively, some deductive concepts were used

in the analysis which had been explored in a previous literature review. These

consisted of findings from a critical review of the methodologies that had been

utilized in previous alliance research and the subsequent alliance constructs that

emerged in differing epistemological discourses (Neil, 2014, unpublished). Indeed,

the notion of alliance and relational constructs are deductive as they have a theoretical

assumption of broad applicability. The position taken within this analysis procedure

was that an experiential, data-led approach was adhered to which was anticipated to

allow a rich account of the data-set with a focus from the participants’ perspective.

Reflexively, it would seem questionable to assume that the author could ‘put aside’

such prior theoretical knowledge and allow a wholly inductive account given the

research premise of an alliance construct. Such a bottom-up and top-down analysis is

often combined in TA analysis (Braun & Clarke, 2013) and is anticipated to allow an

exploration of the theoretical research premise from a data-led perspective. In keeping

with such an approach, themes were descriptively coded for their semantic content in

analysis of patterns across the data-set. This method’s steps are outlined as follows.

The first stage of analysis required the transcription of the audio recordings of

the participants’ interviews. The process of verbatim transcription allowed the

researcher to become familiar with the data. Following each completed transcription,

each transcript was read again while listening to the audio to be certain of the

transcripts accuracy and note any significant auditory moments. The transcripts were

then read again with initial codes entered into the right-hand margin in pencil. The

second stage of analysis consisted of rereading and coding the entire data-set, again in

the right-hand margin. Braun & Clarke (2008) recommend coding for as many themes

as possible and to give equal attention to each item in the transcripts. This was

maintained by ignoring the research question (or as best as could be maintained) at

this stage of analysis. The focus was on semantic content and coding reflected the

participants’ descriptions from the perspective of their voices. An example of a coded

page from the first interview transcript appears in Appendix F.

The third analysis stage began with compiling all of the codes onto sheets of

A4 paper (see Appendix G). Interview and page number of each code was also

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recorded with the code to enable sourcing the codes occurrence in the respective

transcript (which would be required at a later stage). Copies of the completed codes

were made and these were cut into ribbons to enable the sorting of codes into potential

themes. Broad levels themes were analysed within the data and code paper ribbons

were sorted into initial groupings of theme concepts. Each potential theme and the

codes that were felt to be reflected within the theme were placed on a sheet of A4

paper where potential theme concepts and definitions were analysed and tested. Initial

themes were also explored using thematic maps to help organise the analysis process.

A full list of initial themes is presented in Appendix H. Stage four of the analysis

involved a refinement of the many potential candidate themes. This process also

required returning to the transcripts to check that themes may be misrepresented or

that some themes were not supported across the data-set. Refinement also included

collapsing some themes together as definitions of themes converged or separating

candidate themes into separate themes as their definitions were understood as distinct.

When a coherent pattern was felt to be represented in each theme the full data-set of

transcripts was reread to check that the thematic map was an “accurate representation”

(Braun & Clarke, 2008, p.91) from the analysis perspective. Braun and Clarke suggest

caution with the notion of an accurate representation. Not least due to the potential for

ad infinitum with recoding and theme analysis. Analysis of themes was revisited twice

during the final process of reading the data-set with the candidate thematic map. The

first re-analysis consideration was in relation to the level of detail that had been

recorded as initial codes on paper strips. Recoding of those transcript regions in

greater detail required several themes to be reanalysed and other potential themes

considered. The second re-analysis consideration was while reading the transcripts

with the thematic map and recording initial thoughts on candidate excerpts to support

the theme and its definition. However, ultimately the analysis was felt to be supported

and no changes to the thematic map occurred.

The fifth stage of analysis involved the selection of suitable excerpts to

support the sub-themes. This was facilitated by the transcript and page numbers

recorded with each code and also helped in the naming of themes and the definition of

each themes essence (Braun & Clarke, 2008). Sub-themes were analysed for their

distinctness within a thematic description and organised within superordinate themes

(see Appendix I for a diagrammatic overview). Data extracts that supported each sub-

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theme and definitions of each theme were finalised. Finally, the themes were named

using participant quotes wherever possible to facilitate the research aims of reflecting

the participants’ perspectives inductively. At the completion of stage five the findings

were made available to the participants by email (having sought agreement of their

desire to participate in this exercise). This was intended to improve the credibility of

the analysis as it allowed the participants to offer feedback on the analysis findings.

The final stage of analysis was the process of writing this report in consultation with

my supervisor.

Appendix F: Example page of initial codesJohn: To begin with it was pretty nerve racking actually because I'd never opened up really as much as

I thought I needed to. To a, to a therapi... well to

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anybody. Yeah, I knew it would probably be disgusting stuff that I hadn't even talked to (name of partner) about. Researcher: Uh huh.John: Uhh, not sort of serious stuff.Researcher: Private?John: Private stuff, you know like, um... stuff like about my mother who's not been well and... l… and things like that and, ah... Um, it was pretty daunting. I found it really daunting. It's not something I, I, I would have done off my own back, um. But it got to a point where, at work, where I was sort of ready... I was ready to pack it all in. And I wanted to make sure I was doing it for the right reasons. Um... and it wasn't just because I didn't enjoy the job and I wasn't sort of sticking it out. I needed to, sort of, go a bit deeper than that.Researcher: Uh huh.John: And um, but, but by the time I'd… yes… started a few sessions with her, I started opening up and I realized that it was actually quite easy to speak to someone about it and… I felt, even if she might not have got much out of it, you know, I, I'd never thought about it from her point of view, I came out and it felt like a load off my shoulders after every session. You know, one hour a week. You know, it was… it was really therapeutic.Researcher: Wow.John: This is the best way to, to describe it. Um, you know, I was a bit apprehensive about telling people about it at first. But, like a mentioned inside about (partners name) not talking to her mum or, you know, or someone a bit older, I told my dad about…a, about it and he was fine… he was fine about it, you know. As… as soon as he knew that it felt like another sort of load off my shoulders. So, you know, I was already sort of walk… going down the right path.

Initially nerve rackingOpening up as newOpening up as neededMy stuff as disgustingStuff kept deeply private

Upset as not serious stuff

Upset as privatePrivate as family fears Opening feelings as dauntingNeed assistance to open upCrisis point at workCrisis leading to job doubtsCertainty as right reasonsExploring reasons deeper than occupation satisfaction

Change in early sessionsChange in opennessRealisation of ease in talkingNot much value for therapistDidn’t consider Ther. POVUnloading of weight/burdenConsistent unburdeningUnburdening as therapeuticUnderstanding thru descriptionApprehension to share expQualities of diff age group experiencesFather as receptive

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Uncertainty in sharing Unburdening load through opennessSharing my feelings as a known / right path.

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Appendix G: Compiled list of codes

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Appendix H: Initial themes Change• Something I can’t get elsewhere• A fix• Relevance• Purpose• My decisionsDesires/Hopes• Find me/meet me• ReassuranceOpening up• ResponsivenessFeelings• Sanction• To vent• First memorable experience• Sharing• Losing control• ShameOutside• Therapy as extra to life• External pressure• External change• OthersConfusion• Roles• I can’t say everythingBelief• My abilityScope• Big picture, little detail• Amplification• Increasing the problem countAutonomy• I think I did it myself• Diffuse roles• To pleaseDemands• Happy• An outcome of my own• Understanding• Answers to my questions• OpennessNeeds• Bespoke• Clarity• Guidance• Rapport• Acknowledgement

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Interaction• Questioned• Closing down the distancePerceptions• Therapist as representative• What it isn’t• Say what you will doQualities of therapy• Fair• Not imposing values• Non-judgemental• Being open and honestHappenings• Making links• Bringing it all together• Always different, always changingRelational• The turn to relational problems• Comfort• UnequalTechniques• Universals• ToolsTheory• Boxes of problemsPast• ImmunityEffort• Pain• Figuring it outTransitioning• Expanding• Small steps• Sessions as discrete• Standard TreatmentProcess• The progression retrospectively

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Appendix I: Thematic map of themes and subthemes

Preconceptions of what therapy might be

Therapy as extra to life You’re the mechanic

Is it me, therapy, or the therapist?

Negotiating in the moment Should I be saying this? Figuring it out myself

Connecting the dots Going somewhere else Nobody knows what they are trying to achieve

Alliance representations and responsesfrom participants’ accounts

of working with their therapist

The unequal relationship

Separateness and relatedness The power in differing roles

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Appendix J: Interview transcript excerpt (interview one)

Researcher: What were your experiences of being with your therapist like for you?

John: To begin with it was pretty nerve racking actually because I'd never opened up really as much as I thought I needed to. To a, to a therapi... well to anybody. Yeah, I knew it would probably be disgusting stuff that I hadn't even talked to (name of partner) about.

Researcher: Uh huh.

John: Uhh, not sort of serious stuff.

Researcher: Private?

John: Private stuff, you know like, um... stuff like about my mother who's not been well and... l… and things like that and, ah... Um, it was pretty daunting. I found it really daunting. It's not something I, I, I would have done off my own back, um. But it got to a point where, at work, where I was sort of ready... I was ready to pack it all in. And I wanted to make sure I was doing it for the right reasons. Um... and it wasn't just because I didn't enjoy the job and I wasn't sort of sticking it out. I needed to, sort of, go a bit deeper than that.

Researcher: Uh huh.

John: And um, but, but by the time I'd… yes… started a few sessions with her, I started opening up and I realized that it was actually quite easy to speak to someone about it and… I felt, even if she might not have got much out of it, you know, I, I'd never thought about it from her point of view, I came out and it felt like a load off my shoulders after every session. You know, one hour a week. You know, it was… it was really therapeutic.

Researcher: Wow.

John: This is the best way to, to describe it. Um, you know, I was a bit apprehensive about telling people about it at first. But, like a mentioned inside about (partners name) not talking to her mum or, you know, or someone a bit older, I told my dad about…a, about it and he was fine… he was fine about it, you know. As… as soon as he knew that it felt like another sort of load off my shoulders. So, you know, I was already sort of walk… going down the right path.

Researcher: So there's kind of two things here. There, there's having to open up to your therapist and also having to confess that you been spending time with a therapist.

John: Yeah, yeah. I mean, um… I'd say actually… I'd say telling people was…was…was, um… was probably more… not worrying… um, it was that… I didn't want to openly tell, tell people about it. But the strange thing was that once I'd told my dad it felt easier, I was sort of less bothered about telling other people once my dad knew about it.

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Researcher: It feels like that was the most significant one.

John: Yeah. Yeah. And then I was talking to people about it very, very openly about it; family members. Um… because then then I started looking around at people in a different light and I saw that they were genuinely unhappy. Like my sister, for instance.

Researcher: OK.

John: And that she could have done with speaking to someone and getting a load off her chest. And, you know, it was on a… it's sort of… you take taking the first couple of steps in the right direction. You know… it, it didn't solve all, all the issues going to, to therapy but it sort of… put me on a path which I thought was the right path and still is the right path, you know. I, I, I decided that she didn't decide it for me but decided after those, you know, eight, nine meetings that I should… you know, work was making me really unhappy, like… extremely miserable…

Researcher: Yeah.

John: …ever since I think, you know, I've, I've been on an upward, upward curve ever since. Um…It was just… I guess it was the stigma attached going to, to see a therapist. It was um.. umm. It was putting me off at first. Yeah, once, once I got through the first few sessions it was, it was fine actually. But um…

Researcher: Can I ask you… It's so… For you it was… benefit was… sort of every session felt like it was a benefit.

John: Yeah, yeah. Because we wouldn't, we wouldn't really talk about the same stuff all of the time…

Researcher: OK.

John: Um, like there would be certain things that would be expanded and , and um… yeah, like, I, I might have been holding back first couple of sessions and as I got more into it, half way, you know, halfway through the sess… I wasn't, I wasn't holding back any more. I was telling her I, I, I ,I had total trust with her.

Researcher: Right.

John: Um, I don't know if that is lucky, you know, you get that trust with someone. Like even with a therapist I'm not sure if everybody gets that. That sort of rapport. I hit it off with her straight away.

Researcher: There's still an unfolding for you, to still…

John: Yeah, it…

Researcher: …improve.

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Appendix K: Formatting Information for Submission to the Counselling Psychology Review

Counselling Psychology Review: Notes for Contributors

Manuscript requirements:

The front page (which will be removed prior to anonymous review) should give the author(s)’s name, current professional/ training affiliation and contact details. One author should be identified as the author responsible for correspondence. A statement should be included to state that the paper has not been published elsewhere and is not under consideration elsewhere. Contact details will be published if the paper is accepted.

Apart from the front page, the document should be free of information identifying the author(s).

Authors should follow the Society’s guidelines for the use of non-sexist language and all references must be presented in the Society’s style, which is similar to APA style (the Style Guide, available from the Society, or downloadable from /publications/submission-guidelines/).

For articles containing original research, a structured abstract of up to 250 words should be included with the headings: Background/Aims/Objectives, Methodology/Methods, Results/Findings, Discussion/Conclusions. Review articles should use these headings: Purpose, Methods, Results/Findings, Discussion/Conclusions.

Approximately five key words should be provided for each paper. Authors are responsible for acquiring written permission to publish lengthy

quotations, illustrations, etc. for which they do not own copyright. Graphs, diagrams, etc., must have titles. Submissions should be sent as e-mail attachments. Word document

attachments should be saved under an abbreviated title of your submission. Include no author names in the title. Please add ‘CPR Submission’ in the e-mail subject bar. Please expect an e-mail acknowledgment of your submission.

Proofs of accepted papers will be sent to authors as e-mail attachments for minor corrections only. These will need to be returned promptly.

Publication ethics:

All submissions should follow the ethical submission guidelines outlined the documents below:

Ethical Publishing Principles - A Guideline for Authors

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Research report two: Holding the tensions within evidence-based practice: An IPA study of Counselling Psychologists’ experiences of making clinical choices.

Abstract

For Counselling Psychology, tensions exist within the professional status of evidence-based practitioner drawn from a narrow methodological context of efficacy evidence. Such a professional context however ignores the professions ethical practice values, its pluralist approach to practice and evidence, and the assumption of personal difference and diversity. This research study explores Counselling Psychologists experiences of making clinical choices within the current UK EBP climate?

This study used Interpretative Phenomenological Analysis methodology as the research premise was to explore experience and meaning of phenomena. The study used seven interviews from chartered Counselling Psychology participants, with more than two years post-Doctoral training.

Findings were three major themes; ‘big brother is watching’, ‘can I add a bit more’ and ‘the professional altar of necessity’. Each reflected differing aspects of experience and the participants’ perceived positioning in relation to their dialectical pluralist practice stance. Their clinical choices retained a Humanistic valuing of ‘otherness’ implied by pluralism but that perceived constraints on their dialectical engagement within EBP constrained aspects of their professional autonomy and practice choices.

The research findings reported here reflected a broad critical understanding of evidence that informed the CPs clinical choices and practice rationale. Findings were considered as supporting the professions movement towards a dialectical pluralistic stance within EBP and a broader understanding of effective practice evidence. Participants’ experiences suggest that courage and management of their broader practice context enabled many of CoPs key identity platforms to be evident in their practice choices.

Keywords

Dialectical Pluralism, Psychotherapy, Alliance, Interpretative Phenomenological Analysis

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Introduction

The current UK healthcare context that Counselling Psychology (CoP) exists

within continues to be transformed by the “contemporary emphasis on evidence-based

practice (EBP) defined by empirically supported treatment protocols” (Woolfe, 2016,

p.14). Since its inception within the US and its adoption within the UK (Blair, 2010),

EBP has become a potent narrative of the application of science-informed therapeutic

interventions in the mental-health services sector. Yet, the dilemmas for CoP within

such a paradigm are multiple and are challenged from a critical scientific philosophy

and a practice-led perspective of values and ethics (BPS, 2014a). CoP neither rejects

nor accepts the EBP model supported within the UK health-care sector by institutions

such as NICE (2014) and Cochrane (2016). Rather, it seeks to hold this tension to

dialectically engage with and transform how the model is understood and applied in

contemporary therapeutic practice (McAteer, 2010). At a broad theoretical level, such

professional tensions between service provision’s EBP assumptions and the

Counselling Psychologist’s (CP) professional practice position have been anticipated

and discussed (eg. Strawbridge, 2002). Yet little empirical investigation has explored

these tensions despite calls within CoP for a deeper understanding of the practice

pressures that they represent (Norcross, 2011; Corrie, 2010; Hardy, Cahill and

Barkham, 2009). Current CoP literature anticipates that without success in

challenging the EBP paradigm the profession is faced with a potential loss of identity

or marginalisation within the UK healthcare sector (Woolfe, 2016). With each

intervention choice, it suggests that CPs are forced to align with powerful discourses:

on what can be understood as evidence, as scientifically valid interventions and

potentially of professional survival. Such an understanding of these practice

experiences is also a corner-stone of CoPs ethical position, to be practice led and

value subjective accounts as valid in their own right (BPS, 2014a). Such an ethical

position is as equally pertinent to clients as it is to CPs as practitioners, professionals

and employees. By exploring the experience of holding such tensions, CoP can better

reflect on what dialectical engagement with EBP might mean for the practitioner and

their practice position. This study seeks to explore CPs practice experiences of

making clinical choices within the contemporary UK healthcare services EBP context.

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To understand the potential tensions that CPs hold in their professional

practice, it is useful to critically explore the current UK context of EBP. While the

model might seem uncontentious from a perspective of service provision (NICE,

2014), such a position is not necessarily shared within CoP. The nature of its

contentiousness is multiple and is central to many key aspects of the profession’s

ethos, aims and values. Strawbridge (2002) draws on the work of Weber and Schon to

argue that the technical-rational model that underpins EBP can be viewed as a move

towards the science of psychology and away from the disciplines of counselling and

psychotherapy. It is considered compatible with the scientist-practitioner identity

which had developed in the US in 1950’s and has gained acceptance within the UK

(Blair, 2010) and is distinct from the reflective-practitioner model endorsed by CoP

(Donati, 2016). The technical-rational assumption is that of the CP as technical expert

in the administering of psychological treatment protocols. While such an assumption

is problematic on many levels for the profession, its key assumption is the separation

of values and ethics from its framework (Strawbridge, 2002). The purpose of the

technical-rational model is the quantification, standardisation, predictability and

control of therapeutic practice and the choices that practitioners may make in their

clinical work. Such a model is supported by NICE (2014) through a hierarchy of

evidence with ‘gold-standard’ efficacy trials representing best and appropriate

practice within UK healthcare (Corrie, 2010; Rafalin, 2010) and increasingly private

practice (Walsh & Frankland, 2009; Fairfax, 2008). Within this context, evidence

supporting clinical choices becomes something quite specific, defined

methodologically, philosophically and, critically for the CP, is ethically mute. Yet

CoP asks it members “to always work in ways that empower rather than control”

(BPS, 2014a, p.2) which represents a conflict with the technical-rational model of

EBP, to empower versus control. Within CoP, is it reasonable or helpful to describe

the professional experience of navigating such an ethical gulf as ‘tension’?

CoPs Humanistic values

CoP has, as a guiding ethical principle, a commitment to humanistic values.

These values encompass the validity of subjective and intersubjective experience, a

belief in self-determination and personal responsibility, an understanding of human

beings as dynamic in nature and an agenda of social justice (Strawbridge, 2016). It is

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an engagement with such differences and diversities of all people that informs CoPs

epistemological pluralism (McAteer, 2010). Pluralism represents a negotiation

between perceptions and knowledge paradigms with a critical understanding of their

limitations across multiple domains of “experiencing, feeling, valuing and knowing”

(BPS, 2014a, p.2). It could be understood as a practice-led position and is

epistemologically discordant with the technical-rational assumption of superior

nomothetic validity. Rather, pluralism suggest a both/and perspective rather than an

either/or assumption (Cooper & McLeod, 2012). For the CP however, an idiographic

perspective also allows clinical choices to include the valuing of the ‘other’ as a

Humanistic respecting of “first person accounts as valid in their own terms” (BPS,

2014a, p.1). It offers a more holistic account of human distress and well-being that

values the client’s position, yet such values are not represented in the technical-

rational model of practice. Each clinical choice that CPs make is fused to this

dilemma of an evidence-base that is unreflective of the professions identity, values

and ethical humanistic stance. This tension is existential, both for the profession and

for the CP as employee within the healthcare context (Hemsley, 2013). Empirical

exploration of these key practice experiences may offer valuable insight into CoPs

dialectical engagement within EBP and a deeper understanding of how these tensions

are experienced.

Evidence and pluralism

Within contemporary CoP literature, much has been made of the need to

broaden what constitutes evidence within EBP (Blair, 2010; Rafalin, 2010; Woolfe,

2016). Such calls are a response to the reductive and excluding nature of nomothetic

‘gold standard’ evidence but also to the very nature of what constitutes evidence

within EBP. Critically, there are limits to the efficacy evidence that conforms to the

technical-rational model. Efficacy trials have largely rested upon inclusion criteria

derived from medical diagnosis which is contested as unscientific, lacking construct

validity and diagnostic reliability (Pilgrim, 2016). CoP takes a sceptical position

within positivist claims of generalisability but also to the power to dictate, define and

locate such presumed dysfunction that is embedded within medical diagnosis

assumptions. It reflects a professional valuing of personal difference and the cultural

diversity that is fully representative of the UK population (Parritt, 2016). From a

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critical perspective, evidence derived from such a construct is limited by its

unrepresentative nomothetic ambition and its relevance to ethical clinical practice is

questioned (Milton, Craven & Coyle, 2010). It reflects the tension between CoPs

practice-led (BPS, 2014a) idiographic approach and the medicalised and positivist

context of EBP in which the profession is embedded.

If practice evidence derived from efficacy trials can be critically questioned

from within positivism, it can also be question from within CoPs relational

epistemology. The professions relational focus suggests the therapeutic dyad can be

understood, as a ‘being with’ rather than a technical-rational account of ‘doing to’

(Gillies, 2010). The CPs relational stance views emotional distress as embodied and

dialogical in nature and always in relation to the social, contextual, historical and

political dimensions in living (Manafi, 2010). Devoid of any meaningful social

context, or an understanding of distress as relational and intersubjective in nature, a

disorder construct offers no insight into the meaning of distress for the individual

and/or its function in his/her life. As a result, it could be argued that protocolised

interventions can only focus on the eradication of symptoms. Such a construct

therefore ignores and obscures the impacts on the facilitation of personal

understanding and strengthening of the individual’s sense of agency, autonomy and

responsibility for his/her life and modes of being. Subsequently, the notion of ‘doing’

therapy techniques becomes meaningless in the absence of a relational frame of

reference, seeing techniques within EBP as relational acts (Safran & Muran, 2000).

By ignoring the relational aspects of therapy, possibly due to the difficulty in

operationalising such an intersubjective experience (Bennett-Levy & Thwaites, 2009),

the personal meaning of clients’ distress is assumed not relevant or homogeneous. The

tension here is within the socio-political context of structural power that dictates what

constitutes best-practice ‘evidence’ and ignores the relational aspects of the

therapeutic dyad. While much CoP literature anticipates this loss of persons-in-

relation understanding within EBP (Cooper, 2008; Gilbert & Leahy, 2009; House &

Del Loewenthal, 2013, Norcross, 2002, Norcross & Lambert, 2011; Strawbridge,

2016) little empirical evidence has explored such practice experiences.

Dialectical pluralism

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While a pluralistic view of evidence within EBP can be understood to

represent a significant tension for CPs, dialectical pluralism also represents an

engagement and valuing of the inevitable differences within the practice context. The

construct of ‘alliance’ is useful here, as it demonstrates both the contested

philosophical territory that impacts how EBP is understood and CoPs position within

that tension. Bordin’s (1979, 1994) tripartite construct has been utilised within

efficacy trials, representative of treatment protocols as therapy tasks and measured

outcome as alliance goals (Neil, 2014, unpublished). Within a technical-rational

understanding of EBP, it is synonymous with client agreement on a course of

treatment and goals of measurable symptom reduction. Yet the term is also central to

CoP practice and philosophy (Milton, 2010) and differs in its assumptions,

representing a Humanistic valuing of the human capacity for personal responsibility

and the CPs stance of empowerment (BPS, 2014a).

It was with the intention of dialectically engaging with these assumption

differences that I conducted research to explore the alliance construct from the largely

neglected perspective of the client (Neil, 2015, unpublished). The qualitative findings

were that alliance was represented by therapy clients as a complex and ongoing

interpretative act which were value-laden and personally meaningful. Conclusions

were that participants explored these ongoing experiences to make sense of their

therapy, irrespective of the therapist’s modality or its scientific validity. The impact of

such findings suggest that evidence to support clinical choices as therapeutic

interventions is an ongoing and intersubjective process allying therapy’s personal

relevance. CoP is alert to the power dynamics inherent within the technical-rational

model of alliance control and the ethical practice valuing of client empowerment.

Further empirical investigation of the experience of holding such seemingly

contradictory positions potentially offers a deeper and richer understanding of practice

contexts, the modal flexibility that CoP endorses and a reflexive opportunity for both

practice and the CoP profession (BPS, 2014a)

That CPs can and do hold this tension is self-evident. Professional numbers

have grown since inception and CPs work beside many other professions within

institutions that also assume to narrow practice choices in their client work (Woolfe,

2016). Qualitative evidence suggests that CPs do engage with NICE guidelines and

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that a pluralist framework enabled them to retain a sense of professional jurisdiction

and autonomy (Hemsley, 2013a). While this research gives an insight into how CPs

might explore their professional context within EBP, it says little of the wider

scientific understandings and the structures of meaning that ‘evidence’ potentially

represents. The profession emphasises a broader research gaze in the exploration of

the dynamics of difference and the power within systems that people, therapy and

professional life are embedded within (Rafalin, 2010). A pluralist stance asks the CP

to hold multiple tensions within the science of practice and the evidence that guides

their clinical choices. Shedding empirical light on such practice experiences may

further assist the professions dialectical engagement within its own professional body

and the contexts within the which the profession is embedded.

Research question

For CoP, tensions exist within the professional status of evidence-based

practitioner drawn from a narrow methodological context of efficacy evidence. Such a

professional context however ignores CoPs ethical practice values, its pluralist

approach to practice and evidence, and the assumption of personal difference and

diversity. This tension is potentially evident in many of the clinical decisions that CPs

make, in their clinical work and their professional context. Yet, within scientific

literature scant rigorous explorations of CoP’s experiences of making clinical choices

within the current UK context of EBP exist. Many authors also ask for such questions

to be empirically addressed (Norcross, 2011; Corrie, 2010; Hardy, Cahill and

Barkham, 2009). This research asks; what are the experiences of CoP practitioners

making clinical choices within the current UK EBP climate?

Method

This research study’s intention is an in-depth exploration of CPs engagement

with the experience of making clinical choices within a context of EBP. In accordance

with such research aims, its intention is to better understand the subjective lived

experience of engaging with choices and the meaning of such experiences. The

critical position that I have taken within the research posits that multiple influences

impact on knowledge production: history, culture and language. A critical realist

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position allies this with the post-positivist concept of a potential reality that is beyond

our comprehension, therefore incomplete and constructed (Bhaskar, 1978). As such,

an appropriate methodology would be one which did not impose the researcher’s

meaning and ask participants to fit within preconceived notions of experience (Willig,

2013). The exploration of participants’ subjective meaning-making lends itself to an

inductive and idiographic qualitative methodology.

Interpretative Phenomenological Analysis (IPA) was considered the most

appropriate method to address the research question given its epistemological

assumptions regarding experience, meaning and sense-making. The focus of IPA is

the “detailed examination of human lived experience” (Smith, Flowers & Larkin,

2009, p.32) expressed in its own terms. As a methodology it represents the

exploration of phenomena, the things that matter to us, as people, within our lived

world. As a method, it draws on Husserl’s (1970) descriptive phenomenological

approach but is grounded in Heidegger’s (1962) existential philosophy which

questions Husserl’s notion of the bracketed outsider. A hermeneutic approach

suggests that all knowledge production is inevitably interpretative and emphasises the

nature of understanding, as embedded in language, social relationships and their

historicity. IPA is therefore both descriptive and inevitably interpretative of embodied

and intersubjective lived experience (Finley, 2008). Its central concern is with

subjective meaning-making, acculturation and intersubjectivity and is therefore

broadly consistent with symbolic interactionism’s agency in cognitive and symbolic

activity (Smith, Flowers & Larkin, 2009). Therefore, IPA aims to understand

perceptions and cognitions, as a descriptive and interpretative exploration of the

phenomena relevant to the research aims.

IPA also involves a double hermeneutic of the researcher making sense of the

participant making sense of their experience (Smith, Flower & Larkin, 2009). This

double hermeneutic suggests both a co-construction of the research data (as

interviewer/researcher) and within the iterative analysis process, as a setting aside of

preconceptions and a reflective understanding of their part in interpretations. A co-

constructed understanding of the phenomena under investigation, as implied by

hermeneutics, acknowledges the part of myself, as the researcher, in the production of

the knowledge reported here. Such a reflexive position also acknowledges the power

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of the researcher to dictate and define within the research process and is compatible

with the ethical position that CoP takes within all research and practice (BPS, 2014;

BPS, 2014a).

IPA’s focus on meaning-making and lived experience is argued to be a

suitable methodology for the exploration of the research premise. It is also concordant

with the critical realist position that informs this research, acknowledging the

hermeneutics of interpretation, the co-construction of knowledge, and the inevitable

limits on what can be understood outside of an interpretative position (Smith, Flower

& Larkin, 2009). CoP is also rooted in the existential/phenomenological tradition and

IPA is congruent with the professions values and relational epistemology (BPS,

2014a). It was also from this position that I have conceptualised the phenomenon of

‘evidence’ and the technical-rational construct that informs EBP in discussion. IPA is

consistent with this framework, of ones’ relatedness to a given phenomenon as

experience (Smith, Flower & Larkin, 2009). IPA, it is argued, offers a unique insight

into the subjective and intersubjective experience of making clinical choices while

holding the tension of EBP within CoP practice.

Recruitment & participants

Ten CPs were approached to participate in this study and seven met the

inclusion criteria and agreed to participate. Inclusion criteria were: active current

professional practice to allow an exploration of contemporary working-practice

insights, full membership of the British Psychological Society (Division of

Counselling Psychology) and a minimum of two years full-time post-doctoral practice

to ensure a level of experience with the phenomenon under investigation. This sample

size was considered appropriate, in consultation with my supervisor, given the length

of time available to conduct the research, the projects word limit, and also allowing a

sufficiently rigorous depth of analysis. Participants were recruited using purposive

sampling and selection sought to ensure a broad homogenous sample that was

relevant to the research question (Langdridge, 2007). All participants identified as

‘white’ of differing regional backgrounds (including myself, as researcher). While a

broad sampling of professional workplace contexts was achieved, it is acknowledged

that the sample lacks representativeness of the differences and diversity within the UK

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CoP profession. It is likely a function of the recruitment strategy and possibly the

outer-London region from where the research was conducted. Stratification sampling

was attempted to reflect a broader ethnic and gender demographic more representative

of the diversity within CoP. Only two male CPs indicated interest in participating and

only one met the inclusion criteria.

Recruitment was through six of the University of Surrey’s active trainee

placement facilities. Email contact was made with a senior member of staff within the

facility. A study outline and participant sheet (Appendix A), a consent form

(Appendix B), and a demographics form (Appendix C) were included in the email and

the senior member of staff made the material available to potential recruits who

expressed interest in participation. Telephone contact with the potential recruit

established inclusion criteria, selection and initial consent to participate. Interview

arrangements were made at that time or during follow-up telephone or email contact.

All names and identifying information of participants has been anonymised by the use

of pseudonyms.

Table 1. Demographic information of participants

Participant AgeEthnic

Background

Defined Theoretical Orientation

Years Post-Doctoral Practice

Context of Practice

Louise 58 White British Pluralistic 12NHS funded

charity

Anne 32 White British CBT 3 Charity

Mary 57 White British Systemic 6 NHS

Jane 36 WhiteSouth African

CBT 8 NHS/Private

Liz 53 WhiteBritish/Irish

Dynamic 5 Private

Sally 32White/Greek

CypriotIntegrative 3 NHS/Private

Tom 52 White British Pluralistic 5 Private

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Data Collection

In accordance with IPA method (Smith, Flower & Larkin, 2009), seven semi-

structured interviews were conducted face-to-face at an agreed location convenient for

the participant (Interview Schedule – Appendix E). Four open-ended questions were

utilised to enable participants to explore and describe their experiences with minimal

preconceptions and to address the research question through analysis rather than by

direct question (Smith, Flowers & Larkin, 2009). Participants’ responses were

explored with follow-up questions appropriate to the methods purpose and the

research aims. Engagement with the participants’ sense-making experience utilized a

co-constructed dialogue which included clarification, exploration of emotions,

tensions and contradictions to capture as in-depth exploration as possible. This is a

facet of the phenomenological and hermeneutic IPA method and it allows for a rich,

detail and extensive exploration within the data-set (Smith, Flowers & Larkin, 2009).

Interviews lasted approximately 60 minutes and were digitally recorded using

a small stereo recorder. Following the interview, the digital file was stored on a

password locked computer, transcribed and then anonymised, in accordance with the

Data Protection Act (Great Britain, 1998).

Ethical Considerations

This research project adhered to three professional regulatory frameworks and

current UK legislation to ensure appropriate ethical research practice. Guidance on

conduct and ethics was in accordance with the Health Care Professionals Council

(2012) and the code of ethics and conduct outlined by the British Psychological

Society (BPS) (2009). Before any participant recruitment took place, ethical approval

was obtained from the University of Surrey Faculty of Health and Medical Sciences

Ethical Committee (Appendix H). In accordance with the BPS human research ethics

guidelines (2014) participants were provided documents which outlined the aims and

the research objectives (Appendix A). Such documents were reviewed and concerns

addressed before the interview procedure. Informed consent was obtained in writing

(Appendix B) prior to any data collection and following explanation of the

participants’ involvement, including: the interview procedure and anticipated

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duration, the right to withdraw consent at any time (and all relevant documents

destroyed), the confidentiality of the participant’s name or any identifying details, and

the participant’s right to stop the interview at any time.

During the interview procedure, participants were monitored for any untoward

distress or discomfort that may have been provoked during the procedure on an

ongoing basis (Guillemin & Gillam, 2004). This reflexive attitude was also

maintained during debrief following the interviews which offered the participants the

possibility of communicating any queries, consternations and concerns. While no

explicit risks for participants were identified prior to this research gaining ethical

approval, consideration of the sensitive nature of some aspects of participant

experience under investigation required on-going monitoring. Participants were

informed of this consideration of their well-being and that, in the event of distress, an

intention to explore how best to proceed or consider terminating and withdrawing

consent.

Willig (2013) suggests that a reflexive attitude throughout every stage of the

research study is paramount for two reasons; sensitivity to the power relations

inherent within the researcher/participant dyad, and the power inherent within

interpretation as an IPA method. These two aspects of reflexive research practice

speak to ethical and credibility concerns within any research approach. An

interpretative analytic position is a subjective process that acknowledges and

considers the researchers own impact on the research process. Reflexivity was an

ongoing phenomenological attitude of openness and curiosity towards the participants

and the data set that was derived from the interviews. This encouraged a full

consideration of my own fore-conceptions and judgements to allow a rich exploration

of the participants’ experience within the phenomenon that was being considered

(Finley, 2008). This reflexivity was an iterative process in itself, moving and

negotiating between identifying and bracketing my own assumptions and experiences

and using them as a source of analytic insight. This stance of both detachment and

involvement within the analytic process reflected my ambition to remain as

empathically open and a critical self-awareness of my part in the co-creation of every

aspect of this report.

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Credibility of this report must also consider its compatibility and interpretative

rigour in relation to the ontological, epistemological and methodological positioning

of the researcher aligning with the research aims (Fossey et al., 2002; Yardley, 2000).

Several key tasks were utilised to enable such a critical stance within the research.

First, an ongoing personal diary allowed a frank reflexive account to facilitate the

iterative process of awareness and consideration of my own fore-conceptions and

interpretations. Second, verbatim quotes that reflected the multiple voices within the

analysis are presented to support the analysis position. Third, the supervisory

relationship facilitated the questioning of my analysis position and the data that I

presented to support my position. Four, the drafting and redrafting process allowed an

exploration of the power within scientific discourses as a knowledge paradigm that

must also represent the participants’ voices. Finally, the exploration of my drafts and

conclusions with other doctoral students and CoP practitioners enabled a reflexive

assessment of this reports credibility.

Analytic Procedure

For a complete account of the analytic procedure I would direct the reader to

Appendix F. The analytic procedure was concordant with Smith, Flowers and

Larkins’ (2009) six stage method. The first stage required transcription of the first

interview audio recording followed by reading and re-reading of the text while

listening to the audio to explore not only the text document but to attend to the vocal

nuances such as emotional tone, hesitancy and clarity. In the right-hand margin, pencil

notes were added that expressed some aspect of the text: descriptive, metaphorical,

social comparisons and linguistic. This process was repeated several times and

enabled different coding focuses, on emerging concepts, subjective differences,

empathic derivatives and implicit communications. Emergent themes were then added

to the left-hand margin, as pencil notes, that were felt to summarise the initial codes.

Development of emergent themes were then conducted on separate sheets of paper to

test initial thematic ideas and explore coding possibilities across emergent themes.

This procedure was then conducted on the next interview transcripts recursively.

When all seven transcripts had been coded, cross case analysis began by

utilising a compilation table of all themes. A legend associated with each theme and

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code facilitated this iterative process as themes were organised and reorganised,

coding notes were re-assessed as themes were developed, conflated, reworked, recast

or rejected. The coding legend also facilitated the checking of thematic concepts and

ideas against potential transcript excerpts which aided the reflexive process by

continually grounding the thematic concepts from the participants’ perspective. The

process was lengthy, challenging and at times intimidating. The process entailed an

ethical responsibility to fully represent the participants’ voices while also

acknowledging my own interest and experience as a trainee CP in the research

premise. My own practice doubts were recorded in a reflexive journal and my

tentative thematic map was explored with two other trainee CPs, reflexive issues

discussed and concerns addressed with re-analysis. Emergent reflexive thoughts were

recorded and used in the analysis and discussion section of the research writeup. They

reflect my engagement with the analysis process and offer my best efforts at

maintaining transparency of my own position in the co-creation of transcript data, the

analysis and conclusions drawn from the research.

Analysis & Discussion

Analysis of the data reported here was represented by three major themes.

Each focused on differing aspects of experience regarding engagement with evidence-

based practice and the meaning of its impact on their clinical choices. Within major

themes were subthemes that took the major theme concept and extended the narrative

to specific qualities of experience. Each will be explored individually and in turn.

Where themes can be understood within a wider context of scientific literature and

debate a discussion follows.

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Table 2. Major themes and subthemes

Big brother is watching

One eye on a safe place

I can hear you, can you hear me?

Fear and loathing

Can I add a bit more?

Tangible evidence

Part objects

Two alliances and two goals

The professional altar of necessityFeeling short changed

All of these things

Big brother is watching

The major theme of ‘big brother is watching’ reflected the participants’ lived

experience of space as a relationship with an unseen other, frequently institutional or

societal. Often, this ‘other’ was expressed as powerful or foreboding but also

controlling. The participants wrestled with the sense that they were watched, or that

their therapy sessions might be scrutinised. Secondary to their felt sense was the

notion that they were also in relation to this ‘other’ as a spatial experience of

proximity and such an experience was as support or lack thereof. All the participants’

accounts had some quality of external presence that extended beyond the closed

therapy room environment and that this was considered in their experience of making

clinical choices.

One eye on a safe place

Participants often reported their subjective experiences in relation to a

professional evidence-based practice context as one of safety or security. The

experience of felt scrutiny was often expressed as requiring active management from

unforeseen accountability. This accountability related to the participants’ mode of

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working and the things that they actually did in therapy, relative to what the ‘other’

(‘big brother’) assumed that they were doing. However, analysis suggests that safety

as an active and organising experience of the participants’ clinical choices was also

varied. For some the experience was facilitative and others a curse.

Louise: And, ah, so it's like having that overarching thing but bringing other stuff in to perhaps reinforce it, make it richer, um. But still, you know, having if you like the so called balls, if you like, to sort of know that you are doing things correctly. Um, and that you’re giving the best you can and, um, and you know if there’s crises or complaints for anything, you can refer back to them, you know.

Louise, expressed her practice as comprising an “over-arching thing” that can

be referred back to if scrutinised. Although her practice also comprised other ‘richer’

qualities, these required fortitude and courage (“balls”) to implement as differing

activities in the therapy. My interpretation of Mary’s courage is that it is a reflection

of her own sense of artistry, not only with richer practice, but also a professional skill

honed within a context of scrutiny and fear of reprisal for her commitment to richer

practice choices. Other participants approached this safety experience differently.

Mary: …if you look in the NICE Guidelines, family interventions work is just as, you know, prioritised in the targets as CBT for psychosis […] I work predominantly with an evidence-base bolstering me up. Which doesn't mean to say that it informs my practise at all, but it allows me… to argue for it and I don't have to do it by subterfuge...

Mary describes the paradox of her practice not being informed by an evidence-

base yet her experience is of release from the requirement to deceive (“subterfuge”).

For her, the experience is of “bolstering”, or supporting, and the metaphorical weight

is of elevation above the potential of professional and institutional scrutiny. This

facilitates a strengthened professional experience of safety, not a felt sense of

appropriate clinical practice. Mary often took a very rejecting view of the perceived

institutional expectation of being able to justify her clinical choices from a narrow

technical-rational assumption. Her felt sense of opposition is named here as an

observing ‘other’ (“NICE”) from which she can hide her personal practice position in

plain sight. Sally and Liz equally allude to the notion of safety, and more specifically

as an experience of protection within the context of scrutiny.

Sally: I did everything that I needed to do, and therefore I'm, I'm, I'm safe.

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Liz: …some psychologists adhere to the NICE guidelines as if they were a life raft…

Two accounts here highlight a proximity experience of safety from

professional scrutiny, one as an experience of compliance, the other as a criticism of

others too fearful to swim in such an environment. Within this sub-theme, evidence is

understood as an experience relating to compliance and evokes an assumption of an

“overarching” nomothetic approach to practice. The experience is of fear and the

management of fearful connotations from being positioned outside an EBP model of

practice. As an experience, it is political in its purpose of maintaining a superficially

compliant position between the institutional power that they feel they must act within

and a richer practice position that they protect. In one sense, the theme evokes a

panopticon model of institutional power as all seeing and controlling through

structural discipline (Foucault & Gordon, 1980). Yet the participants awareness of

what can be achieved in such a context remains optimistic and reflects a ubiquitous

post-modern understanding of the power dynamics that they are confronted with and

must accommodate (Edwards, 2013). From an evidence perspective, it suggests that

their CoP practice position is fostered, protected and enriched by other things but it is

a fearful practice experience that is managed and monitored.

I can hear you, can you hear me?

Analysis of this sub-theme was felt to reflect experiences of anger and

frustration within an institutional relationship that was perceived as one-way, hearing

as an act of understanding that wasn’t reciprocated symbiotically. What was not felt to

be heard was interpreted as a protective stance between ‘big brother’s’ unyielding

practice assumptions and its potential negative impacts on their clients. The

participants’ experiences positioned them in between, shielding their clients and

demanding to be heard and understood. The participants’ voices were often angry and

frustrated that their ethical valuing wasn’t a ‘common sense’, agreed or shared. It

reflected a desire to dialectically engage within discourses of evidence, treatment and

psychopathology out of respect for the ‘otherness’ of their clients.

Jane: I can't say, “I'm sorry I can't treat you because the, the evidence protocol was only based on these people who fit these criteria”. So therefore -go away because I am not going to be successful with you. No, that's not,

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that's not how it works...

Jane invoked a fictitious exchange, which was animated, angry and directed

towards this disengaged dialectical ‘other’. It is exaggerated to full effect, possibly out

of frustration or to indicate the level of discomfort that she felt with such a perceived

institutional rejection of her personal practice values. The notion of success and

failure are rejected outright and ordered “away”, emphasising her protective

positioning between two poles of her practice context: “evidence protocol” and

“people”. The participants’ humanistic valuing of their clients’ uniqueness and the

context of the distress that they experienced was also universally acknowledged.

Liz: …if a person is depressed because they, they've been unemployed for six years, well, they're clearly faulty people aren't they, because it, it started in their heads […] so therefore we apply the correct evidence for that condition and then everything's all nice and certain.

Liz also took a position of exaggeration and finished with sarcasm, “all nice

and certain”. This was understood as an angry admonishment of ‘big brother’s’

simplistic assumptions and the feelings of constraint and scrutiny that such

misunderstanding evoked. The key experiential aspect of this excerpt demonstrates

the level and breadth of this felt sense of misrepresentation, with diagnosis, socio-

economic impacts on well-being and evidence. It was shared across the data-set as an

orientating experience between the perception of a controlling arbiter, all of the

participants’ practice complexity represented by their clients and their practice

position in between.

The sub-theme represents a dialectical challenge to the epistemology of

evidence that seeks to constrain participants’ practice choices to something felt as

unrepresentative and inadequately simplistic. However, the experience analysed here

is that engagement is frustrating, one-directional, and unyielding. The complexity of

the practice choices that the participants entertain retains its protective stance in

regards to assumptions of homogeneity and the certainty to that it presumes. Practice

choices seem to reflect rejection and acceptance, based on values that inform this

practice complexity. Such an interpretation suggests that CoP are not powerless

within this dynamic but what power that they do have is actively managed as a

positioning experience.

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Contextualising this sub-theme within CoPs discourse of literature and

research is unproblematic as many aspects here have been previously considered in

the discussion. However, Hemsley’s (2013a) qualitative research into CPs positioning

in relation to NICE guidelines suggested that a pluralistic identity fostered a sense of

jurisdiction and potential autonomy. This sub-theme questioned the power that

participants experienced to affect that autonomy as the experience was of frustration

that the dialectical stance was not shared. Power to make clinical choices was retained

as a dialectical valuing of the ‘other’ but that professional valuing was not felt to be

shared institutionally. While only conjecture, perhaps this is also reflected within the

professions discourse, as a pluralistic stance of both/and as a critical acceptance of

EBP but a significant limiting of what it can represent in their practice choices

(Henton, 2016).

Fear and loathing

This subtheme was analysed as an experience of relationship with a

foreboding other, both fear (in common with the main-theme) and loathing as a

disgust with that relationship and the subsequent practice context that it construes.

The experiences were often expressed as questions or statements that amplified their

dilemma to clarify their emotional response to such a context. These responses were

assumed to be a ‘common-sense’ of ethical values, or the dilemma was construed as a

loathsome demand to be less human and less involved with their clients. While such

explicit descriptions were seldom stated, the participants’ tone and difficulty

exploring their experiences suggested a loathing of the dilemma and a fear that they

would be mandated to comply.

Liz: …if there is a messiness around mental health it's not the government’s problem, it's the practitioners' problem. Actually, the problem resides in that we are not applying the evidence properly.

Liz locates the demand to comply as a superordinate big brother of

“government”. Her account is sarcastic and she feels the sting of criticism, in her tone,

for herself but also her professional cohort of CPs; “we are not applying”. Liz

separates evidence and application in this excerpt, which was interpreted as a threat to

her ability to make clinical choices by a structural denying of her professional voice.

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It suggests a loathing of her lack of professional jurisdiction that challenges previous

research by Hemsley (2013a). EBP is not contested in this sub-theme, rather it is the

experience of disgust at the loss of agency to interpret and engage dialectically. This

is expressed as a sense of being admonished for not complying with a technical-

rational orthodoxy. This disgust was also expressed in other ways.

Sally: …what happens to all of them? What happens to the people who the protocols don't necessarily work for, you know, what about all those people?

Sally also appealed to a moral common-sense as a social justice stance for all

people and the loathing that such ethics are not common to all clinical choices. It

represents a disgust that such a position is not shared, not expressed outright and not a

primary clinical concern. Sally pleads for an accountability, unable to demand that

people are protected from a mere probability of outcome. Her voice is isolated rather

than authoritative, questioning rather demanding. For Sally, an evidence-based

protocol represents the potential for harm and jars with her common-sense of a shared

moral identity that would value all people, not just those that respond to protocolised

treatment. It suggests a tension between an ethical valuing of differences between

people and their personal needs and the current EBP context that implies a nomothetic

standardisation of care. Such values were common currency for the participants’

sense-making experience and were expressed in varying ways.

Mary: …I believe passionately and fundamentally that, for instance, working with families makes sense. That actually positioning it all in one person is unethical and bad, and wrong…

Mary bristled verbally and physically as she stated her ethical concern and

interpreted as her disgust at such a context. Positioning and being positioned seems

evident in both what Mary says and what is implied, the person is not “bad”, the

positioner is. Mary juxtaposed two claims that support her distance from a loathsome

dictatorial context; for herself as passionate believer in shared social responsibility,

and her fear that locating fault will harm. Many of the participants’ accounts reflected

this tension between professional practice assumptions that were informed by a

protocolised evidence-base and their ethical concerns regarding the unintended

consequences of complying with perceived institutional demands. The experience of

such a tension was expressed as discomforting and loathsome that such a practice

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devoid of their ethical values could influence their therapeutic stance and the choices

that they made.

Together, the sub-themes contribute towards the major theme of big brother is

watching, being interpreted as a spatial relational experience of scrutiny. The

phenomenological analysis suggests experiences of positioning and being positioned

were key structures of meaning in the participants’ clinical practice choices. Sub-

themes reflected varying positions that the participants took within that spatial

experience and the perspectives that it offered. Critically, this touches on the

inevitable power imbalance that professionalisation represents as a technical-rational

expertise represented within EBP (Woolfe, 2016). Yet power here is reflected within

multiple relationships as a three-handed staging of institutional power, the clients

varying needs and themselves in between. Distance from a technical-rational

assumption was managed safely, positioning between was protective and that such a

dance was required was met with a loathing and disgust. The dance that ‘big brother is

watching’ suggests was however fuelled by courage and conviction. Valuing the

‘other’ despite risk and potential sanction only made the dance more important when

participants considered the choices that ethical practice entailed.

As a response to the research question, the analysis highlighted two key

aspects of experience. Firstly, the participants desire to engage dialectically was

explored in the analysis as disrupted by the distance from influencing EBP that

participants’ experienced, juxtaposed with a closer proximity of scrutiny. This

reflected the perceived loss of agency that characterised the participants’ experience

of making clinical choices. In effect, they experienced scrutiny yet dialectical

accountability wasn’t synergistic and was felt immune to their professional and

scientific critique. Secondly, the technical-rational model of EBP was explored as

ethically uncomfortable and inappropriate for ethical practice due to its reductive

omissions, notably the technical-rational’s muted ethical dimension (Strawbridge,

2002). The tension explored here could be understood as the maintaining of

professional humanistic values in compliance with the professions code of practice

guidelines (BPS, 2014a). However, analysis suggests that making clinical choices in a

contemporary EBP context is phenomenologically fearful, frustrating and loathsome.

CoP practice choices required courage and commitment which says something

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profound about the participants and the professional values that they fought to

maintain.

Can I add a bit more

This major theme captured a desire from participants to practice in a particular

way, from a critically informed evidence position. The major-theme explored an

experience of accumulation, of the things that participants valued and that also

informed their clinical choices. Adding more was a constant and ongoing experience

that represented complexity in practice, people and the context within which they

were embedded. Rather than interpreting such accounts as reflective evidence (as a

reflective-practitioner model) the participants elevated these experiences as more

valid than a technical-rational understanding. Practitioner took precedence over

scientist, as a relational being-with (Gillies, 2010) was equated with richness,

exploration and at odds with a presumed certainty within treatment protocols. This

was interpreted as a questioning experience, of their understanding of what evidence

is and its importance to the choices that they made in their work with clients.

Tangible evidence

This subtheme touched on the nature of evidence and its many forms. The

participant’s responses were often lengthy explanations of what they understood as

positivist evidence. This frequently punctuated (and at times terminated) with a felt

sense of something intersubjectively real and embodied that was experienced as an

equivalence for an evidence-base within their relational practice positions. Perhaps as

practitioner evidence contrasted with technical-rational scientific evidence. IPA is

limited in its requirement that language be the medium through which insight into

experience is gained. The use of the term evidence was considered from the

participants’ own perspective rather than technical psychological discourse.

Experience remained the focus, as participants arrived at this as a rejection process of

what is not tangible or real for them to demonstrate what is.

Sally: …if the client is coming in and saying that isn't working, that's an evidence base, you know…

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Louise: …you have the evidence in the room as well, don't you? And, you know, you see whether people are relating to you and whether they are improving, whether they are deteriorating, you know.

Anne: I do actually think evidence can be in the… form of anecdotal evidence as well, actually.

Each of these excerpts was understood to contain key narrative forms; “you

know”, “don’t you” and “actually”. Each was felt to ask myself, as interviewer and

disclosed Trainee CP, to collude or accept some aspect of their experience with

minimal explanation or justification. This was interpreted as their appeal to a shared

reality of knowing through ‘being with’ (Gillies, 2010). Phenomenologically, their

experiences were arrived at finally, as an appeal to a holistic sense of what can be

known within the therapeutic relationship. The excerpts are confident that such an

experience will also be shared because it is so tangible as to be scientifically

unequivocal. The analysis explored the hermeneutic circle, of myself making sense of

the participants’ appeal for a common ethical sense which was assumed shared within

the co-construction of the data. I do share such humanistic values and would also take

a position of “respecting first person accounts as valid” (BPS, 2014a, p.1), both from

a critical-realist perspective and as a practitioner. However, interpreting such a

position highlighted the participants’ accumulating experience of what was real for

them as practice-based evidence that informed their clinical choices. Tom was able to

articulate such an experience by using a scientific metaphor.

Tom: I want to see it as having a role, em, but not to put too much weight on it, not, not overly. Because there's the relationship and we're humans and it’s not like measuring a, em, I don't know, something, something in the physics environment or a chemistry environment […] I don't, people are so, they're so, they're just not, they're fluid, […] it’s a human thing.

The excerpt was interpreted as a rebalancing of Tom’s sense of scientific

validity to allow his own evidence to be his clinical guide. He evokes his own

sensitive human relational touch that quantitative measure cannot reach. While Tom

makes a key critical CoP argument, it suggests the contested notion of evidence and

the extra that cannot be accounted for in a strict natural scientific paradigm. Tom’s

comparison between chemistry/physics and a “human thing” questioned the positivist

epistemological assumption of people as reducible to static properties devoid of

context, relatedness and variation. His experience of metaphorical “weight” informed

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an interpretation of his experiences as adding something fundamentally important to

his clinical choices, his own felt, relational experiences of ‘being-with’ which would

not be available from within a technical-rational epistemology.

Critically, this sub-theme explores the nature of evidence reflected in

respective knowledge paradigms. Evidence experienced intersubjectively was

represented as a tangible, empirical clinical experience and no less credible than other

scientific evidence informing their clinical choices. A phenomenological account

explores human lived experience and the meaning which is grounded in the

intersubjectivity between people. It is therefore relational in its focus and evidence is

reflective of the dynamic processes of communication-with and sense-making of each

other (Smith, Flower & Larkin, 2009). A phenomenological/existential practice

position, as CoP (BPS, 2014a), therefore explores evidence within that framework:

dialogical, embodied, situated and relational. The profession is also pluralist in its

critical approach to knowledge but crucially rejects an assumption of superior

knowledge paradigms (BPS, 2014a). Within a UK professional practice context, a

tension therefore exists with a methodological hierarchy (NICE, 2014; Cochrane,

2016) that assumes to weight evidence away from intersubjective experience. The

positivist assumptions within an experimental EBP paradigm reifies a presumed

objectivity to the detriment of any subjective experiential evidence, viewed as

unscientific due to confounding subjective bias. Evidence, as considered within this

sub-theme, is a function of two differing epistemologies, the methodologies that

inform and shape them and the political traction that one paradigm has gained over

another (Corrie, 2010). The participants transcripts were interpreted to reflect their

appeal within this epistemological tension: for a weighting that fully represented their

clinical values, relational use of themselves and their own felt experiences as key

practice evidence. This is reflected in an accumulation of their potential practice

options.

Part-objects

The term part-objects is derived from a psychodynamic lexicon. For some

participants it was expressed directly as such. However, this subtheme explored the

participants’ experiences of working with an evidence-base characterised as partial,

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incomplete, a barrier or constraint. Their accounts were analysed as an experience of

disappointment that their practice isn’t supported by a holistic philosophy of what it

means to be human, both for their clients and possibly as an account of themselves.

Here, Liz names something as partial in this excerpt and judges its disappointment.

Liz: Don't move. Just stay there, don't move, yeah. I'm going to apply CBT to your brain and I'm only going to interact with your brain […] because then I'm only part object relating with you. That's a very unhealthy stance, isn't it?

Liz intimates her wish that she be in contact with more than a “brain” and

points to her more holistic view of human nature and experience. Experientially, it

reflects a disappointment that health could be understood so unhealthily. It is critique

and judgement of the technical-rational approach that presumes to constrain her

practice choices. Yet there is also a dichotomy here, that judgements of

appropriateness are also within her power, as a limiting of such partial accounts

within her practice choices. It suggests that her healthy holistic stance is supported by

values that assume a complexity within mental-health rather than a reduction to a

partial understanding. The notion of EBP is contested here within a key pluralistic

stance that evokes the ‘other’ as inevitably indefinable and complex (Cooper &

McLeod, 2012). That ‘doing-to’ is disappointingly insufficient precisely because a

unitary model of practice ignores the multifaceted uniqueness that characterises

human well-being and distress (Strawbridge, 2016). This holistic stance within the

participants practice choice was also informed in other ways.

Jane: …it's always something that's more than the sum of the parts. You know, the whole. It's, the technique on its own is not enough and the relationship on its own is not enough.

Jane’s expression of “not enough” captures the disappointment of

incompleteness that distinct epistemologies are felt to reflect in her practice. Both

modality and protocol techniques and the therapeutic relationship are considered as

insufficient alone as her experience transcends mere combining (“sum”) of such part

clinical approaches (“the whole”). It speaks of an integrative artistry and

accumulation that builds her therapeutic stance from experiencing, feeling, valuing

and knowing within the fluidity of her practice position (BPS, 2014a). This sense of

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partial therapeutic accounts of practice reality was also attributed to the certainty often

bestowed on diagnosis.

Mary: …it [NHS] says it prioritises psychological understandings and diagnostic uncertainty. Slight conflict with the fact that it is a psychosis services…, you know, you do have to have psychosis to be able to get our service...

Mary exaggerated the conflict as “slight” which gives us insight into her

experience of disappointment and her judgement of inadequacy. Her experience is of

a clarity that such partial accounts offer and the futility of such a limiting practice

rational that diagnosis represents to her. Yet it serves as the sole gateway to her

service, perhaps mirroring the logical tautology of diagnosis suggested by Pilgrim

(2016). Mary also used a plural form of “psychological understandings”. This was

interpreted to reflect her pluralist position within knowledge paradigms as a holistic

expression of her beliefs about people and her clients as more than a diagnosable

illness. It also reflected her belief that this isn’t also shared by her service, which

suggests that her disappointment functions to distance her from such service-provision

assumptions.

The partial nature of knowledge that participants drew upon to make sense of

their clinical experiences is reflected in CoPs pluralist assumption of knowledge as

contingent and relational, contextual and subject to subjectivity (|Henton, 2016).

Within the research aims, this contributes something important to an understanding of

the structure of understanding that the participants experienced in relation to the

technical rational model of EBP, their CoP identity and their practice values.

Pluralism was represented as a collection of partial accounts. Social context, relational

fluidity, subjectivity and technical-rational knowledge were used to explore what

guided and informed their practice choices. Medical, cognitive, doing-to and being-

with philosophical understandings were all considered partial accounts that required

adding to and synthesis as an accumulating experience to be useful clinically. The

participants’ critical understanding of knowledge limitations is experienced as

disappointment as a response to this practice context and the limitations that each has

within their practice choices. This analysis suggests that evidence to guide their

clinical choices is weighed within scientific and political structures of understanding

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reflecting an over-reach of each paradigms explanatory capacity. Their

disappointment is perhaps a reflection that such a critical stance is not shared and is

considered a marginalising of their professional practice identity.

Two Alliances as goals

For the participants, achieving something useful and helpful for the client was

felt as multiple and layered, structural and personal, yet also discrete and distinct. It

was interpreted as an experience of meaning-making between opposing therapeutic

purposes of technical-rational and personal that could not be reconciled. Rather than

holding this tension between poles of expectation, participants addressed each as

separate concepts that may synthesise but were not expected to become one therapy

purpose. If such poles of expectation could not be reconciled, valuing the ‘others’

subjective experience was prioritised and understood as adding more to the

participants’ clinical options. All participants expressed a sense of dual-role in this

sub-theme, frequently as a client alliance, but also as an alliance with their service,

their professional context and an evidence-base of protocolised practice.

Mary: …you're dabbling around in something that is really complex and murky and it’s so reductionist to say, you know, that if you do this and you aim for that and you do this intervention then this will be the outcome. It's just not how human beings work, on either side of the therapeutic alliance. It's really infantile that, isn't it?

Mary accepts such complexity as a maturity within her structure of

understanding and the uncertainty that such a position creates. She evokes the duality

of her understanding of therapy’s purpose as discrete by the two sides that alliance

represents. This doesn’t seem to preclude her relationship or contact with an ‘other’,

only the duality of such an experience. There is frustration also, that such a dual

alliance is unfair on her clients and also unfair on her. It suggests that a therapeutic

alliance is distinct from her institutional context expectations which are felt as

something that she struggles to ally with. ‘Adding more’ was reflected in the

structures of meaning that the participants explored as the “canons of technical

rationality do not apply” (Strawbridge & Woolfe, 2010, p.6) in this uncertain practice

context. How to navigate such a dual role was complicated in other ways as well.

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Louise: So that, um, it's not just about the therapeutic goals it's about their own personal, um, goals as well and how they can move towards those. So they can make changes in their lives really… For them, how they’re working towards those personal goals perhaps is evidence that they are doing OK or doing better than they were.

Duality is expressed here as the goals that represent therapy’s purpose.

Analysis is that personal client goals are added as extra in therapy, rather than shared

with an EBP purpose. This suggests that they might not be the same or that Louise

doesn’t expect them to be the same and alludes to the distinctness of what therapy is,

from what it might mean for her clients. What is shared is their “working” together

and has a relational purpose that has meaning within the therapy space. It says much

about the murkiness of the experience that is subtle and distinct from therapeutic goals

of symptom reduction and the technical-rational assumption that underpins them. This

felt duality of purpose and the participants’ position within it was further explored as

a valuing of one over the other.

Jane: It's the quantitative and the qualitative. So what would be most helpful to the client? So the, the outcome measure might say, there wasn't much reduction in, in symptoms. But if you ask the client how helpful was the therapy to them and they think it was really helpful… that's what's more important to me…

Jane explores her dual alliance experience and explicitly adds her qualification

as value-laden (“more important to me”). The dualism that is explored here is also

represented as an often-contradictory purpose of therapy outcome. It is merged using

practice-led values (BPS, 2014a) and an elevation of first-person accounts as more

evidentially credible as they better represent the uniqueness of the clients’ needs. This

weighing of a broad evidence-base from which to draw was throughout the data-set

and was represented as a more mature clinical rationale for the participants’ practice

choices. Interventions, therapy purpose, the dual alliance with professional context

and clients’ therapeutic needs suggests that EBP was experienced as requiring ‘more’

for such a construct to be clinically useful. It exemplifies the ‘both/and’ stance within

CoP but also highlights how values organise and structure the evidence that the

participants used in their clinical choices with their clients.

‘Can I add a bit more’ was felt to reflect a questioning position as a need to

add to something within each sub-theme: evidence in many epistemological forms, a

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more holistic understanding than one epistemology can offer and the values that guide

the dual role that they experienced their therapy contexts to be (as the three

subthemes). In relation to the research question, this major-theme highlights the

difficulty practitioners face while navigating the current EBP context. Making

professional, ethical and clinical decisions amidst the epistemological tensions that

were understood within their practice contexts was multi-layered and complex. The

theme represented the response from practitioners to these tensions; their strong desire

to ‘add more’ to the simplistic notion of therapy that they anticipated as a scientist-

practitioner expectation. Reconciling this complexity was not an expectation for the

participants. Their clinical focus within this mismatch was as a humanistic valuing of

‘otherness’ as a unique therapy experience and by drawing on their ‘both/and’

pluralistic attitude between science and practice. This analysis suggests that the

dialectical process within a UK healthcare context remains intransigent. Rather, it is

some way from synthesis and managed as a duality between both

service-provider/client, technical-rational/relational and reductive/expansive clinical

practice choices.

The professional altar of necessity

Participants frequently referenced the systems that they experienced as being

embedded within, as people and as professionals in a healthcare context. This major-

theme represented a limiting professional experience within these systems and their

pragmatic acceptance of what the participants can be in that context and its impacts on

their ability to make clinical and practice choices. It reflected an ambivalence with

their professional identity and their sense of contradiction that they were felt to be

embedded within. The two sub-themes also represented differing dialectical

orientations towards aspects of professionalisation that penetrated their clinical

thinking beyond and within psychological science. Their accounts were viewed as

inevitable, or as a necessity, as an experience of ‘thrown-ness’ (Heidegger, 1962) into

a social context of professionalisation and the limits that such a context implied.

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Feeling short changed

Both money and time were key antagonists of the participants’ experiences in

this subtheme. Analysis was of the participants’ experiences of being professionally

diminished, as a loss of their agency and professional artistry. ‘Feeling short changed’

reflected their professional context and the economic and political forces that

impacted on their practice choices masquerading as EBP. Their professional altar was

tainted by such experiences, yet were understood as inevitable and met with

ambivalence. ‘Feeling short changed’ was their experience of something that was

corrupted somewhat and yet they accepted the embeddedness of themselves as

practitioners within that distortion. This feeling was analysed within the participants’

representations of modality, science and the next excerpt considers protocols.

Anne: …probably not all protocols have large studies necessarily… I can’t remember an example off the top of my head, but I think, I think some people are very, well, good at selling their models and, eh, they will do so without such evidence.

Anne accepts many things in this excerpt but analysis suggests that she is not a

sales-person but a CP. Yet selling models of practice impacts upon her practice and

the modal choices that are available to her. The experience is of a diminishing of her

professional context and such a distortion is not through science but through

manipulation. Yet Anne accepts the inevitability of economic and political forces that

sell into her practice context perhaps because she too sells her professional services at

the professional altar. Anne’s clinical choices are structured within economic,

political and scientific contexts. It is no surprise to Anne that models of protocol have

been criticised as product-focused (Strawbridge, 2002) given that her experience is

that can be sold as well as researched. Below, Sally also accepts her limiting

professional context and its impacts of what she can do with her clients.

Sally: I think it's the way that the NICE guidelines are interpreted, you know. Nowhere in the NICE guidelines does it say that it's ok to deliver six to twelve sessions of CBT, but that's what's being done, and I think, you know… it's not good. It's not good, but also it's, you know, I think there's so many interpretations of different things that are kind of watered down.

What is “not good” seems to be the misinterpretation of evidence as an

exercise in institutional economic-expediency. Analysis suggested that what is

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described as a dilution, using the metaphor of “watered down”, is of Sally’s own

interpretative capacity as a CP. It is deemed to impact on expectations within the

therapeutic dyad, as a reduction in sessions that is beyond her control, short-changing

clients’ humanistic potential for something lesser. For Sally, such lessening seems all

too common and she experiences it as a professional threat to her agency as a

practitioner and what can be accomplished therapeutically. However, such constraints

within therapy were not always experienced similarly.

Louise: CBT is, takes less time, um, really. And you can do sort of six sessions, twelve sessions, fifteen sessions, whatever, um. So it’s more, sort of, conducive I suppose to the NHS, um. Whereas psychodynamic type of work, humanistic, tends to be less, um, less looked upon really in a serious way.

The interpretation of “looked on” emphasised the embeddedness of the

therapy within a professional context that was as political and economic as it was

scientific. It constructs “serious” therapy focus as limited intervention strategies,

presumably as symptom focused and behavioural change alone. Yet, Louise didn’t

agree with such a stance, citing her working practices as informed by

“psychodynamic, attachment-based, systemic”. Yet, she accepts the institutional

assumptions of NHS practice as epistemically defined as medical, symptom focused

and her contradictory stance within that. Given Mary’s extensive modal practice

experience, I had anticipated anger or resentment that such extensive professional

ability was denigrated. Mary was neither, which highlights the major-themes

emphasis on the ambivalence with which participants oriented themselves around

such pillars of professional context represented within EBP which constrained their

practice choices.

This subtheme represented a broad critical view of EBP embedded within

systems of psychology but also socio-economics and politics. Crucially, the

participants’ structured their understanding of such an embedded context as an

ambivalence to the politics and economics of their practice positions despite their

dialectical engagement with psychology. Constraints on their practice choices were

through their lack of agency within these domains as an inevitable aspect of their

professional mantle. Both practice time and funding were felt to be beyond their

control yet had significant impacts on what they could achieve therapeutically with

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their clients. Their experience was of an ambivalence to such a context and didn’t

reflect the dialectical stance analysed in other major-themes. It suggests some

acceptance within the vast terrain that they are in relation with: social, historical and

political dimensions in living (Manafi, 2010). Ambivalence through acceptance

suggests the limits of what the participants felt could be countered, engaged with and

influenced in their clinical work. While CoP has a professional division, the analysis

implies that what CPs can choose in their clinical judgement requires support at a

broad political and funding level. The participants accepted these limits and their

clinical work was felt to be constrained by forces beyond their individual control.

All of these things

This subtheme was interpreted to reflect the experience of ambivalence when

participants oriented themselves to a sense of vastness and scale. Such a vast scale and

the complexity that it implies was considered in virtually every aspect of the

participants’ practice experiences. Yet the participants’ ‘professional altar’ concealed

this complexity, as their professional institutional contexts were felt to require a

specious expression of certainty, an outward confidence and mastery. Yet rather than

daunted, the participants were comfortable with this vastness and their inability to

actually be the professional masters that their ‘altar’ elevated them to. It represented a

broad pluralistic viewpoint full of possibilities and pressures on practice choices and

the humanistic values that helped participants orient ‘all of these things’.

Sally: …there'll be an iceberg. What one therapist might be able to see who's just been trained within a protocol-base is the tip of the iceberg. I guess somebody who has the sense of understanding will have the rest of the iceberg, um, available to them.

Sally locates herself as having an “understanding” which is something distinct

from being a more effective practitioner. Sally isn’t claiming a professional mastery

of problem-solving therapeutic interventions but rather a deeper gaze into the

complexity that psychological well-being is constituent of. This complexity is

“available” although she doesn’t claim it directly but rather suggests it of “them”.

This distancing was interpreted as a tempering of any claim that Sally might be

professionally masterful or effective in a technical-rational sense. Rather, her claim is

of an artistry to see rather than do. Seeing ‘all of these things’ impacts on her clinical

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choices below the “tip” of emergent symptoms to a practice depth commensurate with

the whole of the person of her client. It is an expansive framework reflecting multiple

knowledges and practice approaches beyond a limited surface of symptomology.

Other accounts built on the participants’ sense of ‘all of these things’.

Liz: …we can't actually give a really quantifiable trajectory of your recovery because you're human, because you live in a context and that context will affect you. And that context is not only their family system, but the political system, and everything that, that, that, that forms around them. There's a massive, these massive interactions, these massive systems that lay on layer upon layer to that particular person and how they're feeling about life...

This was considered a key analysis excerpt as it explored the interpretative

framework of professionalisation by what it is not. Liz states what she cannot do as an

expression of her pluralistic understanding of mental health as contingent on many

systems beyond her control. By relinquishing that control she takes a position that

excludes technical mastery and a rational understanding of disorder (Strawbridge,

2002). At the same time, it is not a rejection of quantification outright, only that life is

never fully representable and “quantifiable”. This suggests a pluralism within the

psychology of distress and well-being and Liz holds this tension as an idiographic

understanding within ‘all of these things’. People are unique from her practice

position and her professional skill is being open to the individual terrain of those that

she seeks to help. Technical professional skill is meaningless in this context and her

clinical choices are guided by her understanding of the vastness of scale that an

‘other’s’ life represents. Jane, below, holds this tension in a different way.

Jane: I think, in, in life everything is grey and they're somehow having to make sense of something or create something that's somehow a little bit black and white, because, it, otherwise how do we, how do we manage it all?

“They” is juxtaposed with “we” in this excerpt and it positions Jane apart from

the simplistic thinking that presumes to inform her practice choices. Yet she gives it a

functional purpose, as something better managed because it might be too complex for

her as a professional necessity. It suggests that science requires simplicity rather than

clinical practice which reflects the complexity of life as shades of “grey”. It is

contradictory in the sense that professional science-based practice requires fostering

and simplifying out of a necessity to manage ‘all of these things’. It suggests that, for

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the participants’, a professional mantle of technical mastery is as specious as real

practice is complex.

Aspects of these findings are also reflected in qualitative research conducted

by Hemsley (2013a) that concluded that NICE guidelines were experienced as

containing in response to the uncertainty that pluralism was analysed to represent.

However, the later sub-theme was characterised by a dialectical engagement within

the psychological understandings of practice complexity but was absent in the former

(‘feeling short changed’) which explored political and economic practice contexts.

Similarly, the later sub-theme explored the need for a specious technical-rational

professional identity to be distanced from the reality of practice complexities which

were engaged with dialectically. For the participants, dialectical engagement was only

considered within what they experienced as meaningful enough to affect, the dyad.

Perhaps this is reflected in a pragmatic practice position, offering a dialectical valuing

of the ‘other’ because CPs accept that they have the power to offer that relationship in

the therapeutic dyad. Power here is to offer flexibility in practice and to empower the

client’s engagement amongst ‘all of these things’, possibly as an alliance experience

of investment (Neil, 2015, unpublished). Dialectical engagement with the politics and

economics of service provision may however be felt to be beyond their reach,

reflecting their ambivalence to what can be personally realisable.

Further discussion

The research premise was to explore in detail the lived experiences of CPs

making clinical choices in the context of EBP within UK healthcare. In introduction, I

presented the practice tensions anticipated within CoP literature from the developing

EBP model that has gained traction within UK healthcare (Corrie, 2010). A key

finding within this research was the dialectical pluralism (and attempts to maintain

such a stance) that permeated the participants’ sense-making experiences. Analysis of

the major-themes suggests that many of these experiences retained a relatedness to

multiple contexts and participants’ felt position within them. Their clinical arsenal of

choices was frequently shaped, constrained and managed in relation to these domains

and their Humanistic values were only realised largely within the closed therapy

room. For CoP, this gives a key insight into the sense that the participants’ made of

136

their professional identity context. It suggests that the scientist/practitioner model was

felt as largely separate, rather than as any meaningful synthesis which had been

anticipated by Strawbridge (2002). It was the limits to any felt sense of synthesis that

the participants explored, which foregrounds the complex and multiple practice

contexts that impacted on the clinical work and their practice choices.

One key practice context that the participants explored was a critical notion of

evidence, the multitude of evidence ‘types’ available to them and its impacts on their

therapy choices. Milton’s (2010) assessment of ‘alliance’ within practice as central to

CoPs project suggests that credible relational evidence (can I add a bit more) may be a

function of such an alliance concept. Qualitative research exploring a client alliance

representation (Neil, 2015, unpublished) concluded that negotiation of therapies

purpose and its relevance was an ongoing interpretative and dynamic act within

multiple alliance relationships, not just with the therapist. These findings support such

an alliance concept as participants valued and accumulated the immediate and

tangible experiences that informed their ongoing clinical choices. Clinical choices

were functionally intertwined with “evidence in the room” as an ongoing assessment

of experiential and intersubjective evidence that therapy had purpose and meaning

that was shared and explored with their clients.

It is useful to explore this concept of subjective and intersubjective evidence as

it suggests a ‘use of self’ that has penetrated the scientist/practitioner model in an

unanticipated way. By taking a strong critical position within EBP, a both/and stance

strengthened the practitioners use of self as evidential, and valid as their clients first

person accounts. Their position was strengthened by the broad context of this

evidence and was considered from within scientific epistemologies but also social and

political influences, socio-economics and institutional economies and the person

before them. The findings support a conclusion that key CoP values continue to guide

the participants’ clinical role by the foregrounding of this relational experience as the

most reliable within the multiple contexts from which evidence is construed. The

technical-rational understanding of their practice choices was viewed with suspicion

and the deficit anticipated within CoP literature (Corrie, 2010; Norcross, 2011;

Strawbridge, 2002; Woolfe, 2016) would seem to be reflected in their critical

emphasis on an accumulation of practice-led evidence, perhaps as a reflective-

137

practitioner model (Donati, 2016). Yet, the duality experience that was analysed here,

however, suggests that a dialectical synthesis within practice choices isn’t necessarily

achieved currently and that a critical assessment of evidence, rather than a reflective

stance, exists in its place. Scientist and reflective-practitioner were largely understood

as separate nomothetic/technical and idiographic/relational entities of evidence and

clinical practice required choices to be made for both. Pluralisms both/and creed is

understood here as limited to a critical assessment of evidence but they remain as

distinct and largely separate concepts. Analysis suggests that this was not ideal for the

participants and they expressed anger, resentment and frustration that such a valuing

of the ‘other’ as a dialectical stance was not evident in the technical-rational

considerations of appropriate practice. Yet this experiential analysis also suggests that

other dialectical stances were evident and that they were also not necessarily

anticipated.

Dialectical engagement was analysed as complex and differed depending on

what the participants oriented towards. A key finding here was the experience of fear

of scrutiny and protection that participants felt was required for themselves and their

clients. This research suggests that CoP retains its Humanistic values and a dialectical

valuing of the ‘other’ of the client but that such a dialectical engagement was not

always evident within other contexts. Alongside the fear of scrutiny and sanction for

not complying with technical-rational practice choices, was frustration and disgust

that an ethical valuing of difference and diversity were not evident within the EBP

model. Such practice experiences suggest courage and conviction were requisite

practice strengths to maintain a dialectical stance at all. While strong emotions were

evident towards the scientific and psychological aspects of their practice choices,

there was also ambivalence when oriented towards the wider context of political and

economic forces within their practice contexts. The participants drew on these

systems that their practice is embedded within and saw limits in their ability to

dialectically engage with the vast and ongoing context of their practice. Hemsley

(2013a) concluded that “structure implicitly offers relief from the tensions that

pluralism bestows” (p.98) and that would seem to reflect the participants experiences

but only in contexts beyond psychological practice influences. Here a distinction is

drawn between an expectation of dialectical engagement within psychology and an

138

ambivalence that the practitioner is isolated from political and economic power.

Perhaps it reflects CoPs consideration of the context and its impacts on the client’s

therapeutic experience (BPS, 201a) but also a pragmatic acceptance of what can be

realised within their practice choices.

To return to the research aim, each intervention, each clinical choice and

practice approach was explored by the participants for its meaningfulness within a

dialogical pluralistic framework with their clients. Yet the technical-rational EBP

paradigm that such practice was experienced within was considered as less dialogical

and CPs required significant practice courage to maintain a humanistic valuing in

their client work. Acknowledgement of the difficult practice experiences that

participants reported here within training and professional practice competencies

might facilitate and support a more fruitful and representative dialogical engagement

within the socio-political context of employment expectations.

Conclusions

The research findings reported here reflected a broad critical understanding of

evidence that informed the CPs clinical choices and practice rationale. Findings were

considered as supporting the professions movement towards a dialectical pluralistic

stance within EBP. Participants also experienced a fearful pressure to comply within

an institutional context that sought to predefine the participants evidence-base from

technical-rational epistemology. Participants’ experiences suggest that courage and

management of their broader practice context enabled many of CoPs key identity

platforms to be evident in their practice choices.

Impacts of this study suggest that the scientist-practitioner/reflexive-

practitioner model do not adequately account for the CoP practice experiences

reported here. However, this report supports the call within CoP literature for a

broader consideration of what constitutes best-practice evidence and may also better

support clinical judgement (NICE, 2014) within evidence paradigms. The validity of

first person accounts was also discussed as therapeutically relevant which could be

integrated within an ethically-informed EBP model of practice. This has the potential

139

to broaden practice efficacy by accommodating personal uniqueness and the ongoing

nature of practice-led evidence.

Limitations and future research implications

Several limitations of this study should be considered when assessing the

utility and credibility of the report offered here. As researcher, I sought to maintain an

explicit interpretative stance and acknowledge my influence on the co-construction of

the data-set and my subjectivity in the report. The research process, conducted by

another person, would likely produce differing results reflecting aspects of their

subjective position. Also, the participant pool was only partially reflective of the

wider UK demographic, notably ethnic and cultural differences. However, no

discernible differences were detected within the demographics that were represented

in this study. It would be anticipated that a broader representation would likely impact

on the results and a national project would strengthen the credibility of these findings.

Inclusion criteria for the study was of few limiting conditions: years of practice and

current CoP practice status. Studies that addressed differing inclusion criteria may

have explored other aspects of the experiences reported here. It would be anticipated

that years of experience, gender differences and preferred modality may offer unique

insights that are unaddressed by this report.

Further research that supports the broader evidence-base explored in this

report is vital to support practice-led positions and pluralist practice models. Research

that further explores a client-derived alliance conceptualisation could also strengthen

the practitioners ‘use of self’ as a model of client engagement and purpose as ongoing

evidence to support more flexible therapy choices. This research has highlighted the

contested nature of evidence within an EBP paradigm. Key research findings that

question the many assumptions embedded within such a paradigm might also

facilitate a dialectical engagement with service providers. Treatment of choice is one

such consideration for further research and would also support the pluralistic model of

practice to which CoP subscribes and the relational epistemology that is alert to such

fluid therapeutic clinical choices.

140

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Appendix A

Participant sheet

My name is Peter Neil and I am currently attending my third year of Doctorate

studies in Counselling Psychology at the University of Surrey. This research project is

part of my course-work and will be available to the public on completion of my

course. Any identifying information (names, identifying features, places, etc.) will be

anonymised and small verbatim selections of this interview may be reproduced in the

published report.

The project will be the third such report in my academy course-work. I began

researching the therapeutic alliance in my first-year literature review. It comprised of

reading extant literature from many sources and databases. I specifically focused on

the debate that was happening in the early 1990’s at the American Psychological

Association regarding evidence-based practice. The merits of different types of

methodology and the types of research that should underpin practice were debated

(notably between Counselling Psychology and Clinical Psychology). This has

relevance for current UK practice due to the acceptance by NICE of Cochrane review

evidence and Cochrane’s hierarchy of methodology informing perceived validity of

therapy effectiveness. I concluded that treatment protocols that emerged from

randomised controlled outcome trials had a potential therapeutic impact on the

working alliance; notably the tasks that were undertaken and the goals that were

deemed appropriate.

My second research project undertook Grounded theory methodology to

explore what client experiences were of alliance tasks and goals. My curiosity was

whether measurement tools of alliance processes were sufficiently sensitive enough or

conceptually accurate enough to capture their experience of the tasks that were

undertaken and the outcomes that may be appropriate for them. My findings were that

alliance processes, which had been conceptualised as tasks and goals, were

understood and used by clients in many unaccounted for ways. Three dimensions of

experience were analysed which overlapped, and the participant’s meaning extended

outside of the therapeutic encounter.

146

This project seeks to explore the Counselling Psychologists experiences of

working within; the wider epistemological perspectives of therapy modality, practise

within a medical framework (eg. NICE guidelines or pharmacology), outcome

research and evidence-based practise, and the professional guidelines of a humanistic

stance within Counselling Psychology. The research is informed by my prior research

as I hope to build on the theme that I was first drawn to - how do therapists choose

what to do and why that might be important for the client? Personally, I feel that this

is an important question for Counselling Psychology generally but it also has some

resonance for me as a trainee. All Counselling Psychologists do it, but what is their

experience?

This research study will be analysed and reported from a scientific perspective

of phenomenology. As such, there are no right or wrong answers. The focus of

analysis will be how participants make sense of their experience of evidence-based

practise from the epistemological position commensurate with Counselling

Psychology.

If you are prepared to participate in this study then please keep reading and I

will outline what your participation will entail. If you don’t want to participate then

please say so, that is your right and I respect that fully. If you have any questions then

you can contact me by telephone (17767 371 619) or by my university email

(pn00053@surrey.ac.uk).

147

Participant Information Sheet

Participants in this study will be interviewed for approximately one hour. The time

and location of the interview is at your discretion subject to my availability and to be agreed.

Interview questions will be minimal and ask you to reflect on your own personal experiences

of working as a Counselling Psychologist. No question relates specifically to client/patient

experiences and no such information will be sought.

You have the right to withdraw at any point in time, including during the interview.

You have the right to have any records or recording destroyed at any time. If you decide to

participate the information that I collate will be password protected, encrypted and

anonymised as soon as possible. All recordings will be destroyed when the research report has

been marked. All data will be handled in accordance with the Data Protection Act (1998).

A risk assessment has been conducted by me and my university supervisor. While we

do not anticipate any untoward or distressing content we remain sensitive to the possibility of

professional issues of a personal nature. If at any time you feel concerned then please don’t

hesitate to indicate that you would like to halt the interview and stop recording. I will do my

best to resolve any issues or discuss your involvement.

This study has ‘confirmation to proceed’ from the Faculty of Health and Medical

Sciences at the University of Surrey. My supervisors and my details are below…

Supervised by: Dr Elena Manafi, CPsychol, AFBPsS, HCPC, UKCP reg.

Counselling Psychologist and Existential Psychotherapist

Chair, Training Committee Counselling Psychology (TCCP)

DPsych in Psychotherapeutic and Counselling Psychology

Programme Director/Teaching Fellow

Email: xxxxx

Rsearcher: Peter Neil

Trainee Counselling Psychologist at The University of Surrey

Mobile Phone: xxxxx xxxxxx

Email: xxxxx

Appendix B

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Consent Form

I, the undersigned, voluntarily agree to take part in the study titled:

Working Title: An IPA study of the Counselling Psychologist’s experience of making clinical choices.

I have read and understood the Information Sheet provided. I have been given a full explanation by the investigators of the nature, purpose, location and likely duration of the study, and of what I will be expected to do. I have been advised about any discomfort and possible ill-effects on my health and well-being which may result. I have been given the opportunity to ask questions on all aspects of the study and have understood the advice and information given as a result.

I agree to comply with any instruction given to me during the study and to co-operate fully with the investigators. I shall inform them immediately if I suffer any deterioration of any kind in my health or well-being, or experience any unexpected or unusual symptoms.

I consent to my personal data, as outlined in the accompanying

information sheet, being used for this study and other research. I understand that all personal data relating to volunteers is held and processed in the strictest confidence, and in accordance with the Data Protection Act (1998).

I understand that I am free to withdraw from the study at any time without needing to justify my decision and without prejudice.

I understand that in the event of my suffering a significant and enduring injury (including illness or disease) as a direct result of my participation in the study, compensation will be paid to me by the University of Surrey, subject to certain provisos and limitations. The amount of compensation will be appropriate to the nature, severity and persistence of the injury and will, in general terms, be consistent with the amount of damages commonly awarded for similar injury by an English court in cases where the liability has been admitted

I confirm that I have read and understood the above and freely consent to participating in this study. I have been given adequate time to consider my participation and agree to comply with the instructions and restrictions of the study.

149

Name of volunteer _______________________________

Signed _______________________________

Date _______________________________

Name of researcher/person taking consent

_______________________________

Signed _______________________________

Date _______________________________

Appendix C

Demographics Questionnaire

150

Name: _______________________________

Age: _______________________________

Gender: _______________________________

Ethnic background: _______________________________

1) When did you complete your training?

___________________________________________________________________

2) What is your preferred theoretical orientation?

___________________________________________________________________

3) Please confirm that you are a chartered psychologist with full membership of the Division of Counselling Psychology

YES / NO

4) How many years have you been practicing as a chartered Counselling Psychologist?

___________________________________________________________________

5) In which context/setting are you currently working? (e.g., private practice, NHS, organisational setting, charity, etc)

___________________________________________________________________

Appendix D

Demographic information of participants

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Participant AgeEthnic

Background

Defined Theoretical Orientation

Years Post-Doctoral Practice

Context of Practice

Louise 58 White British Pluralistic 12NHS funded

charity

Anne 32 White British CBT 3 Charity

Mary 57 White British Systemic 6 NHS

Jane 36 WhiteSouth African

CBT 8 NHS/Private

Liz 53 WhiteBritish/Irish

Dynamic 5 Private

Sally 32 Greek Cypriot Integrative 3 NHS/Private

Tom 52 White British Pluralistic 5 Private

Appendix E

Interview Schedule

1. Can you tell me about a recent experience of working professionally with evidence-based practice.

2. How do you understand evidence?

3. How do you understand evidence-based protocol?

4. How do you actualise the relational qualities of the Counselling Psychologist and the standardised mode of treatment required by protocol?

Follow ups: How would you describe your way of being with your clients?

Is there anything else that you could add that we haven’t covered today?

How do you experience an alliance with your client’s?

Appendix F

Analytic Procedure

152

The analytic procedure was in line with Smith, Flowers and Larkin’s (2009)

six stage analysis procedure. There were variations within this procedure and I will

explore them here in detail. The first stage of the procedure was the transcription of

the first interview which was conducted after all seven interviews had been

completed. Following transcription, reading of the transcripts while also listening to

the audio allowed me to focus on one transcript alone and separate out my experience

of having conducted other interviews. During passages that were felt to be more

difficult to explore and subsequently code, returning to the audio allowed me to

immerse myself within the interview context. This was as an effort to better

understand the participant’s sense-making experience rather than my own, coupled

with the nuance, intonation and pauses that were key aspects of the interview. This

was challenging initially as my own reflexive sense of fore-conceptions was

developing and many journal entries were recorded in this phase of analysis. Codes

reflected four emphases that were derived from the lines of transcript. Descriptive

information focused on summary of the sense-making or experiential aspect of the

transcript line, sometimes as only a single word. Linguistic information reflected the

language that was used by the participant, often as metaphor or prosodic elements.

Social comparison allowed the codes to reflect how participants reflected on their

social sphere and their part within it. Conceptual information reflected the early

exploration of links between the text and participant’s meaning (examples of

transcript coding appears in Appendix G).

When this process was felt to be satisfied, I moved to an analysis of these

codes. These were entered in the left-hand margins initially, but moved to separate

sheets of paper as the analysis was worked and reworked, ideas and themes tested and

reflexive fore-conceptions understood and explored. Many possibilities existed for

how these codes could be understood as themes and my own fore-conceptions in the

analysis became evident through the reading and exploring of my reflexive journal.

As an example, my deductive understanding of the ‘alliance’ had been previously

explored through extensive reading of journals, essays and scientific research papers.

It was a difficult process of separating this understanding from the research aims and

at times I returned to the initial coding stage to emphasise the inductive exploration of

the participants voices. While I accept that the research piece is ultimately through my

153

interpretative framework, such a lengthy and difficult process sought to retain as

much of the participants’ part in the co-construction. This process also highlighted my

own fear of misrepresenting the participants and remaining as true as possible to their

accounts, as difficult as that was to maintain. My own personal discomfort with being

positioned (reflexively, within a masculine heteronormative assumption) made me

sensitive to the possibility of myself making assumptions on behalf of an ‘other’. By

returning to the coding stage and occasionally the listening stage allowed an analysis

that was as reflexive and honest as I could have hoped to be achieved but I also

acknowledge my part within the analysis.

Themes were guided by Smith, Flowers and Larkin’s assessment of this

stage’s process: “usually expressed as phrases which speak to the psychological

essence of the piece and contain enough particularity to be grounded and enough

abstraction to be conceptual” (2009, p.92). As the analysis progressed, themes were

recorded away from the transcript documents to allow changes and different

understandings to develop and be worked with. A numbering code system allowed

more space on the transcripts to prevent the documents from being congested with my

theme notes and thoughts. This process reduced the volume of the data-set to a list of

themes and retained a method of tracking the developing analysis but also allowing

the themes to be related back to transcripts and excerpts for later stages of the analysis

process. When I felt that my themes analysis wasn’t offering any further development

I progress onto interview two and the process was conducted again, recursively. When

all the interviews had been analysed using this method I had a complete set of themes

derived from codes. While analysing themes I was able to allow some themes to

group, merge and at times separate, guided by the themes ability to reflect some

aspect of the participants meaning-making experience. As the process is one of

reduction it required returning to original transcripts to test interpretations as coding

emphasis shifted. This allowed the themes to reflect idiosyncrasies while also sharing

higher order concepts. This was an extensive and engaging process that was at times

overwhelming but I also felt my responsibility to remain grounded in the data.

Checking back with transcript excerpts and codes allowed my confidence in this

process of developing an analysis position within the data-set.

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As a list of master themes and sub-themes was developed, I reflected my

findings with my Supervisor. Her thoughts suggested that the analysis was descriptive

but that I may have missed key aspects of the essence of the data-set. Further reading

on hermeneutics and other methodologies that also take an interpretative stance within

the data were revisited and explored for a deeper understanding of the analysis

process and my position within it. On revisiting my analysis, I read and re-read my

transcripts and entered summary notes in my reflexive journal of what I thought was

the essence of each interview and how each narrative had been co-constructed. This

highlighted the difficulty that I was experiencing with my own ability to communicate

my analysis as prose of sufficient complexity, yet also clearly and consicely

communicating my analysis position. In some respects, the hermeneutics were

recursive in multiple ways, the participant, my analysis and the analysis read by an

‘other’. This stage of the analysis was cyclical and involved returning to the

transcripts and reconsidering each theme and I entered additional notes which were

intended to further develop the essence of the data-set. With a revised set of themes, I

was able to revisit my cross-case analysis and develop a final list of major-themes and

sub-themes and also consider appropriate excerpts to support each (which appear in

the Analysis section of this report). This table of themes and sub-themes was felt to

reflect a broad consensus of similarity across the participants. Some themes were

dropped as they were specific to a single participant or the experience that they

analysed was not considered to address the research aims (Smith, Flowers & Larkin,

2009).

This did not conclude the analysis procedure. A key aspect of analysis is the

write-up process which contains a power to represent the participants in a particular

way. I was aware that a difficulty that I was experiencing at that stage of my training

within the academic environment was my difficulty communicating my ideas as prose

in the format style that doctoral studies demanded. This had been an issue that I had

addressed with my early analysis within supervision and the report writing retains an

importance within the analysis process as it represents the participants’, the analysis

and myself as writer. I was also aware of the complexity of my own feelings

regarding power within representation and the write-up process has been helped by

supervision, checking and discussing my findings and supporting excerpts with other

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cohort members, defence of my report within the viva process and subsequent

rewrites. These aspects of the research are key as they reflect what is presented and

how the research aims can be understood from the report presented here.

Appendix G: Example pages of coding process (Louise & Anne)

Louise: Interview excerpt one

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TRANSCRIPT

Int: Um, How do you understand evidence?

Louise: I suppose, ah... With evidence I understand it, um, as being part of, um, th..., sorry, that there's research behind it really, research studies. Which, ah, you know, um, depending how scientifically they are thought through. But at least it's research. Um, randomised controlled studies are supposedly the, thought to be the gold standard, really, of evidence. Um, because the more people, presumably, who improve with a certain treatment, you know, the sort of more valid and more reliable and that, you know, research is supposed to be. But then I do recognise that, ah, there are some methods of treatment which don't have so much evidence behind them. You know, not what, for instance, one looks perhaps... hasn't, um, hasn't got so much research, um, as how, how useful it is.Particularly with certain client groups, um. But doesn't mean to say it doesn't work. But it's just, you know, that sort of evidence hasn't built up, um. So perhaps rigidly, and ah, yeah.And I do think there are lots of debate about what, what evidence is.

Yeah, because you have the evidence in the room as well, don't you. And, you know, you see whether people are relating to you and whether they are improving, whether they are deteriorating, you know. Um, so there’s, there’s evidence of the session, um. We give psychomet's out and things like that. But sometimes the psychomet's don't measure everything.So there is a difference sort of evidence.Um, there is the self-belief and belief

INITIAL CODING

Evidence as research part.Evidence has research behind it.Evidence as scientific, thought through.Research retains an importance.RCT superiority suspicion.Assumptions - linking people improving with research evidence.Suspicion - supposed validity & reliability-suspicion.Inequity in representation of treatment possibilities.Evidence does not equate to usefulness or efficacy of therapy.Samples unrepresentative.Evidence as contested. Suspicion through rigid/absolute assumptions.Dialogues on evidence – contentious.

Evidence in the room/relational equally important.Improvement/deterioration as dynamic ongoing client evidence.Retrospective session evi.Interpersonal not measurable, client evidence real.Evidence sorts: intimate/contact vs theoretical.Clients beliefs as

THEMES

Part not holistic.

Research as part support of evidence.Critical position of practitioner.Scientist identity.

Suspicion of unaccountable over-arching evidence assumption.

Augmenting partial evidence.Practitioner need to interpret evidence.

People as different from person.My dialectical engagement.Their dialectical rigidity.Listening to debates about evidence.

Felt evidence additional and real.

Progress and process as real/tangible.

Interpersonal experience as sensitive and real.Tangible evidence & theoretical scientific.Client belief in

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in the therapist. Things like that are so important as well.

Int: Hmm. I'm curious about what that experience is like for you. To reconcile the debate, reconcile your experience, reconcile your facility. All of which seem to be drawing on a broad therapeutic...

Louise: Yeah.

Int: ...skill-set.

Louise: Yes, I think that, you know, I like, I like working that way.And, I think, at the end (coughs) it's client-centred as well. You know, so, um... And of course, nurses are involved so it's not just myself. But, you know, they have, you know, a treatment plan.But within that they can actually think about their own goals, ah, and they can revisit that throughout the programme.

And so it’s about having goals that a person, personally, meaningful for them really. So that, um, it's not just about the therapeutic goals, it's about their own personal, um, goals as well and how they can move towards those. So they can make changes in their lives really. And that’s, you know, depending on... For them how their working towards those personal goals perhaps is evidence that they are doingOK or doing better than they were. Um, and making those goals realistic and not raising their expectations too much and that they are not going perhaps to be cured, well they won't be cured when they leave but hopefully they will have moved a little bit further on and they can continue doing that.

important form of evidence.

Practitioner’s unique way of working.Relational as additional.

Helping is not just my decision.System has a plan: MD approach.System ‘plan’ and focus on subjective experience: unique & meaningful goals.Flexibility not rigidity - ‘how’ is diff. for each person.Phenomenological focus of personalised goals.Therapeutic goals &personal goals.Goals as a movement & fluidity in therapeutic encounter.Purpose allows change.‘How’ they work as therapy evidence.

Limiting goals to realistic.Managing expectation away from medical assumption.Medical ‘cure’ as misunderstanding.Therapy purpose as social.

therapy/therapist as additional to scientific research.

Practitioner choices are key part of whole.Accumulating therapy parts.Therapy as within systems of influence.

Plan (treatment) goals and personal goals.

Strict assumptions and flexible difference.Therapy must be personally meaningful.Two goals, each with implications.Fluid accumulation of guidance.Meaning guides therapy choices.

Realistic limitations versus expectation.Inevitable professional expectation.Inevitable implications of medicalised context.

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Anne: Interview two excerpt

TRANSCRIPT

Anne: Um, so I guess if I feel like, um, someone is avoiding for example, em, I might... I might ask them for feedback if they, if they are finding it difficult. I might be quite up front about it. I might, um, might try a different intervention, although sometimes I might be wary of that because it might be colluding with their avoidance.

Um, so, I guess, it, it changes what I do, in terms of I probably stop what I do about it and explore that with them. So, then you, then that's where a flexibility might be needed, for it. Yeah.

Int: So if I understand that it feels like it is extra information...

Anne: Mm.

Int: For you it feels like extra information?

Anne: Yeah, I think it probably is extra information. Probably in a box that doesn't exist on a CBT model somewhere. So yeah I probably agree it is extra information because it is that sense that they can't put into words, that they can't describe, so when you're asking about thoughts and feelings you're limited by however much they can, they can tell you.So then you've got the additional... because sometimes people aren't very good at acknowledging what their thoughts are, what their feelings are, they're not very good at labelling them.They might say I'm feeling anxious,

INITIAL CODING

My feel as therapy information.Interventions as clarifying feel..

‘Self’ as choosing & reacting.

Choices as responsive.I include my ‘self’ in my choices.Flexibility and rigidity as modes of choices.

Information as extra evi.Relational experience outside of modality.

Sense beyond words, description.

Limits to the explicit communication.Implicit additional evidence.

Language as limited, augmented by feel.

Developing a consensus

THEMES

Choices as guided by embodied feel/tangible.

Multiple role parts.

Personal/relational responsiveness.

Two therapeutic modes – personal & planned.

Accumulating evidence.Personal as variation/difference: outside of theory.Felt sense of person beyond (scientific) explanation.

Additional as accumulation of felt sense.

Implicit feel.

Building consensus

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anxiety, because that's what they are familiar with, but actually it might be something else.

Int: If I just pull on that a little bit...does that mean the only things that you can do within the way you work now is things that are explicit?

Anne: No. no I can go, certainly go away and have my own hypotheses about it, and I do. So I think, say, say, take that example about someone says that they are anxious and I think they are actually a little bit more embarrassed or ashamed. They're just not naming it. I would, probably, go away and hypothesise, think about it, see, probably see if I can make sense of that. And then I may, um, depending on what it is, I may then bring it back actually and say “I wonder if there's a sense of this going on”. I might...

Int: Mm.

Anne: …I might bring that in. That really depends on, on, what I think is going on though, to be perfectly honest. I wouldn't do that with everybody...

Int: So you would, in the right circumstances, you'd potentially bring that into the room.

Anne: Yeah, yeah, in the right circumstances and with enough of a relationship actually. I think you've got to build that, build that relationship...

of persons distress.

Retaining a theoretical stance.

Sense-making as hypothesis and personal.

Sharing and questioning personal and theoretical.

Choices guided by personal over theoretical.

Choices guided by relationship strength.

Relationship as built as an addition.

and purpose(s).

Two modes: theoretical/personal.

Two modes:Scientist/practice

Values as reconciling modes.

Values reconciling practice modes.

Relational as person mode (not scientific).Relational as constructed (ideo).

Appendix H

Ethical Approval

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Appendix I

BPS Publication Submission Guidelines

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162

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Appendix J: Interview transcript excerpt (interview one)

Interview One with Louise.

Int: It's the (explicit date). Um, Interview at um, one forty. First question. Can you tell me about a recent experience of working professionally with evidence based practice?

Louise: Alright. Um...Yes, I mean... I think that I'm working according to evidence based practice quite a lot with, with clients, um, because we work within a framework, a CBT framework, so, um, a lot of the work in the one to one's, um, is based on that. And then we also we run groups here as well, CBT, and I am involved in facilitating those groups which is part of the treatment. Um, and then we also do things like mindfulness, which is, um, evidence based, according to NICE guidelines and research. So, um, yeah, it's all the time really.

Int: So If I understand that, for you, the… Seems like the thing you have mentioned clearest is the NICE guidelines.

Louise: Yes.

Int: They for you represent an evidence base.

Louise: Well, I know it's debateable because, um you know, um, there's lots of other reasons for NICE guidelines as well. You know, the way that research is, ah, decided upon and selected, um. For quite practical reasons as well, you know. CBT is, takes less time, um, really. And you do can sort of six session, twelve sessions, fifteen sessions, whatever, um. So it’s more, sort of, conducive I suppose to the NHS, um. Whereas psychodynamic type of work, humanistic, tends to be less, um, less looked upon really in a serious way. Because of, you know, the research is perhaps more variable and it also takes, takes longer to do the therapy.

Int: Uh huh. There's two things there. There’s, um, you mentioned serious.

Louise: Aha.

Int: For you it seems like evidence is linked to seriousness.

Louise: Yes. Yes, I think that, um, again, it depends on the research methods. But the research methods that tend to be used is, are, quite sort of medical, scientific, um, data rather then, you know, qualitative data. And I suppose that, again that that tends to be the sort of research that is valued higher, more highly, in the medical and psychological fields, if you like. So, seriousness I suppose, um. I suppose I mean by that it tends to be more, sort of, data orientated; figures, numbers of cases, um. Things like that.

Int: That for you is important because it informs your practise?

Louise: It's not important for me, because I have come through different groups, and in my training I did different models, um. And I mean I've also done an existentialist, um, diploma. So, um, but I think I have come to realise that, that we have to work within this framework as well. Because that's, you know, the funding problems and, and so on. And I know, and I have worked in previous services that were very good, um, where clients got a lot of sessions. Which was more sort of psychodynamic,

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attachment based, systemic, which have actually, the service has actually, sort of, closed down, you know. So I think realistically, um, that's the way things are. And I think there is, there is benefits to it. But because, um, you know CBT has got the pluses for it. But it’s the way now, as well, you do CBT. So I think you can bring in other things, um, you know. You can still, I think anyway, you can still work a bit existentially, psychodynamically, even when you've got some of the CBT stuff. Because it's still about the therapeutic relationship for instance.

Int: Ah huh.

Louise: Um, You know, I mean, here for instance endings is kind of, just had groups of people leaving, endings is a big thing, you know. And lots of the men here have had attachment problems. It's very attached to the military. So you know, you have to work in a psychodynamic way. Some of them have had childhood issues, um, which is the reason why they went into the military. So you can't just work in CBT in a hard sort of way. But I still think you can use some of the techniques, um, and that can be quite helpful as well.

Int: So, if I understand what you are saying, you, you feel like there is an umbrella of evidence efficacy for the way you are working.

Louise: Yes

Int: But for you, as a person, as a counselling psychologist, there are other things that you try to include.

Louise: Yes. Yes, and I think we do here. Because I think, I mean, it's quite an advantage really that I am not just doing one to one work. I'm doing group work. Because there are lots of psychodynamic issues with groups, isn't there. Um, and we also, here, we may do art work for instance. They do art therapy and they sometimes, like, bring that to the session. Because they've done a particular piece of painting or something. Or written a poem and they want to bring that in. So, in a way, even though you know we do do the CBT groups and we do the hot cross bun and what have you, and so they do get a grasp of that within that framework, we also do bring in other things as well.

Int: Uh huh, I get a sense that, for you, there is a benefit in looking for other ways of understanding the way you are working. You mentioned pictures.

Louise: Yes, yes, and um, sometimes our clients find it very, very difficult to communicate, um, you know, the traumas. So therefore, paintings, um, can help with that, the communication side of that, yeah.

Int: And I guess I… The question was about evidence based practise and protocol and I'm wondering how you understand an experience working with somebody and you are asking them to, perhaps, do things that might be outside of that protocol. You talk about pictures.

Louise: Yes.

Int: And I get a sense for you that there obviously is a benefit.

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