Brief Person-Centred Therapies

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Edited by: Keith Tudor

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  • Brief Therapies Series

    Series Editor: Stephen Palmer

    Associate Editor: Gladeana McMahon

    Focusing on brief and time-limited therapies, this series of books is aimed at students, beginning and experienced counsellors, therapists and other members of the helping professions who need to know more about working with the specific skills, theories and practices involved in this demanding but vital area of their work.

    Books in the series:

    Solution-Focused Therapy

    Bill O'Connell

    A Psychodynamic Approach to Brief Counselling and Psychotherapy

    Gertrud Mander

    Brief Cognitive Behaviour Therapy

    Berni Curwen, Stephen Palmer and Peter Ruddell

    Brief NLP Therapy

    Ian McDermott and Wendy Jago

    Transactional Analysis Approaches to Brief Therapy

    edited by Keith Tudor

    Handbook of Solution-Focused Therapy

    edited by Bill O'Connell and Stephen Palmer

    Brief Gestalt Therapy

    Gaie Houston

    Solution-Focused Groupwork, second edition

    John Sharry

    Copyright

    View Copyright Page

    Praise for the Book

    ‘This is a book that the person-centered psychotherapy community has been waiting for. An accomplished and wide-ranging group of theoreticians, practitioners and researchers convincingly demonstrates how an approach that puts the client's process at its center may be enriched by techniques from many more instrumental orientations without losing its integrity. Resembling nothing so much as a therapeutic Goldberg Variations on a basic Rogerian theme, the authors included in this volume reveal the enduring power of Rogers’ original emancipatory theory even in a time-strapped world that demands swift results.

    ‘The inclusion of case material – including a historical case of Lewis, Rogers and Shlien, enlivens the book and provides a glimpse of a variety of brief person-centered therapies in action. Particularly useful are chapters that operationalize person-centered practices within settings such as trauma centers, prisons and in the workplace where access to therapeutic contact is severely limited. By sharing their own challenges and solutions to dilemmas such as instrumentalism vs. emergent humanism, or reliance on expert systems vs. trust in the self-healing capacities of the client, this book opens a creative space in which the ongoing conversation about therapeutic efficacy in times of shrinking resources can be successfully engaged’.

    Professor MaureenO'Hara, PhD, Chair, Department of Psychology, National University, La Jolla, California

    ‘Critics of person-centred therapy have at various times accused the approach of being ill-equipped to engage in brief therapy, inadequate to respond to the seriously disturbed and the marginalised, or trapped in a fossilised theoretical framework. This wide-ranging and scholarly book convincingly refutes all such accusations. It demonstrates the theoretical and clinical vibrancy of an approach which is fully alive to the challenges of the twenty-first century and whose practitioners demonstrate a creativeness which, while drawing on the rich inheritance of the past, breaks new ground and offers fresh hope to a wide range of clientele.

    ‘A wide-ranging and scholarly book which shows that person-centred therapy is fully alive to the challenges of the 21st century and is breaking new ground both clinically and theoretically. It demolishes convincingly and authoritatively the common criticisms that the approach can only serve an articulate middle-class and is ill-suited to brief and focused work’.

    Professor BrianThorne, Emeritus Professor of Counselling, University of East Anglia, and Co-founder, The Norwich Centre.
  • Epilogue

    KeithTudor

    I hope that by now, the reader who reads in a linear fashion will have enjoyed this book. If, by chance, you've skipped pages or are reading this first, I hope you go on to enjoy it!

    My aim in editing and structuring the book in the way I have has been to provide a good account of the field of brief person-centred therapies and, as the plural indicates, of a number of tribes or approaches within the person-centred and experiential ‘nation’. Now, having completed my task and having re-read the book, a number of things strike me, which form these closing reflections.

    The first is on the range of applications of person-centred and experiential therapy. Although the contributors espouse a range of theories and demonstrate clearly diverse practice, each draws on the fundamental principles of the person-centred approach: the client's tendency to actualise, the therapist's non-directive attitude, and the framing of the therapeutic relationship in terms of certain conditions. Just how much the therapists trust in the client's tendency to actualise, how non-directive the therapist is, and whether the therapist regards Rogers' therapeutic conditions as necessary and sufficient varies. For some readers the variation represented may be too great, and put some contributors outside the person-centred nation; for others there may not be enough diversity of theory or practice.

    This leads me to a second reflection on the richness of the dialogue between person-centred and experiential therapies, represented here in the three chapters in Part I. Those familiar with the different traditions encompassed by the person-centred approach will not be surprised by the strong presence of theorists and practitioners who draw on the experiential tradition. Its origins in focusing (Gendlin, 1981) and its emphasis on experiential work arguably lends itself to time-limited, brief work; and it is interesting that none of these authors have the same qualms about time-limited work as others represented in the discussion in Chapters 1 and 6. For those interested in reading more about this tradition, I recommend Rennie's (1998) book on an experiential approach to person-centred counselling, and Levin's (1997) excellent volume of reflections on Gendlin's philosophy.

    My third reflection is about research. I am pleased to have been able to include in this volume an original paper (Chapter 5) which was part of a research project on time-limited work. I am also interested to note the number of references in other chapters to research and that practitioners such as Gibbard (Chapter 7) are conducting their own research and service audits. It is deeply ironic that, despite the fact that Rogers himself was a pioneer in psychotherapy research, and the fact that the person-centred approach has, over 65 years, been well researched and has, in turn, generated a lot of research, notably about the therapeutic relationship and its conditions, the person-centred approach still has a reputation of being not proven. This continues despite recent studies which demonstrate therapeutic equivalence (Friedli et al., 1997; Stiles et al., 2006; Stiles et al., in press, 2008). For those interested, there are a number of papers on research in Cain's (2000) collection of articles from the now defunt Person-Centered Review; the international journal Person-Centered & Experiential Psychotherapies (http://www.pce-world/pcep.htm) also carries articles on research; there is at least one book on person-centred research currently being written; and more person-centred practitioners are having their work published in the generic psychotherapeutic press.

    Obviously there are gaps in any book, of some of which I am aware; there are others, no doubt, of which I am unaware. Two that I know of are concern training and supervision – and they are deliberate. If one takes the view that short-term or brief therapy is a form of therapy in its own right, then, logically, it makes sense to argue that practitioners should undergo specialist training. If, on the other hand, one takes the view as I do (see Chapter 1) that, as practitioners, we need to be conscious of time, limits and limitations, then, it follows that we need to pay attention to these issues in our training, and continuing professional development, whether through further training, study, supervision and/or personal therapy. This represents an ongoing commitment to self-reflection, as distinct from a one-off training course. So, it is with supervision. Some, such as Feltham (1997), complain that there is a lack of experience amongst supervisors of short-term work. I have responded to this argument elsewhere (Tudor, 2007, p. 201), commenting that:

    Ultimately, this is a hierarchical model of supervision, based on the view that the supervisor has to have more and relevant experience of what the supervisee/therapist is working with than the supervisee him or herself does. This approach to supervision both mistrusts the therapist and misunderstands the facilitative, reflective and meta-role of the supervisor.

    The chapter from which this is taken appears in the second of two books on person-centred approaches to supervision titled Freedom to Practise (Tudor and Worrall, 2004, 2007). It seems to me that, whatever differences there are between people who associate themselves with person-centred and experiential approaches, such freedom underpins or should underpin our common understanding, values, attitudes and practice.

    References
    Cain, D. (ed.) (2000) Classics in the Person-Centered Approach. Ross-on-Wye: PCCS Books.
    Feltham, C. (1997) Time-Limited Counselling. London: Sage. http://dx.doi.org/10.4135/9781446222034
    Friedli, K., King, M., Lloyd, M. and Horder, J. (1997) ‘Randomised controlled assessment of non-directive psychotherapy versus routine general practitioner care’, Lancet, 350: 1662–5. http://dx.doi.org/10.1016/S0140-6736%2897%2905298-7
    Gendlin, E.T. (1981) Focusing (
    rev. edn
    ). New York: Bantam.
    Levin, D.M. (ed.) (1997) Lanaguage Beyond Postmodernism: Saying and Thinking in Gendlin's Philosophy. Evanston, IL: Northwestern University Press.
    Rennie, D.L. (1998) Person-Centred Counselling: An Experiential Approach. London: Sage.
    Stiles, W.B., Barkham, M., Twigg, E., Mellor-Clark, J. and Cooper, M. (2006) ‘Effectiveness of cognitive-behavioural, person-centred, and psychodynamic therapies as practised in UK National Health Service settings’, Psychological Medicine, 36: 555–66. http://dx.doi.org/10.1017/S0033291706007136
    Stiles, W.B., Barkham, M., Mellor-Clark, J. and Connell, J. (in press, 2008). ‘Effectiveness of cognitive-behavioural, person-centred, and psychodynamic therapies in UK primary care routine practice: Replication in a larger sample’, Psychological Medicine.
    Tudor, K. and Worrall, M. (eds) (2004) Freedom to Practise: Person-Centred Approaches to Supervision. Llangarron: PCCS Books.
    Tudor, K. and Worrall, M. (eds) (2007) Freedom to Practise II: Developing Person-Centred Approaches to Supervision. Ross-on-Wye: PCCS Books.
    Tudor, K. (2007) ‘Supervision of short-term therapy’, in K.Tudor and M.Worrall (eds), Freedom to Practise II: Developing Person-Centred Approaches to Supervision (pp. 195–204). Ross-on-Wye: PCCS Books.

    Appendix 1 An Illustration of the Eight Communication Exercises in TIR Training in terms of Rogers' Six Conditions

    Henry J.Whitfield

    While Rogers is hailed for his groundbreaking and highly influential work on the qualities required for effective therapy, one might still ask how these qualities might be successfully acquired. Below is a description of how these qualities may be acquired and/or operationalised in current TIR training.

    Presence – A Foundation for Communication

    Rogers (1986/1990), particularly later on in life, put emphasis on his ‘presence’:

    When perhaps I am in a slightly altered state of consciousness in the relationship, then whatever I seem to do seems full of healing. Then simply my presence is releasing and helpful. There is nothing I can do to force this experience. (p. 199)

    Like Rogers, TIR training puts a great deal of emphasis on presence. It employs three structured exercises for strengthening this ability. Meditational practices for practising the ability to be present have existed for millennia. Mindfulness meditation in particular, which has recently gained significant empirical validation as a therapeutic intervention, (Baer, 2003) focuses particularly on practising the ability to be present to both inner and external phenomena. TIR practitioner training makes extensive use of such meditational exercises. Out of the eight ‘communication exercises’ (CEs) in TIR training, the first three are applications of mindfulness meditation for developing one's presence:

    • CE1 – Being present (without a particular focus)
    • CE2 – Confronting (remaining comfortably present to a human being)
    • CE3 – Maintaining confront (or the ability to remain present during more challenging circumstances)

    The remaining five communication exercises are:

    • CE4 – Delivery (of communication)
    • CE5 – Full acknowledgements (Receiving communication)
    • CE6 – Encouraging communication
    • CE7 – Getting questions answered
    • CE8 – Handling concerns (of the client)

    The first two of these exercises (CE1 and CE2) are forms of mindfulness meditation. Dimidjian and Linehan (2003) describe mindfulness as:

    awareness of what is, at the level of direct and immediate experience … the act of repetitively directing your attention to only one thing … [and] the practice of willingness to be alive to the moment and radical acceptance of the entirety of the moment.

    CE1 – Being Present

    In CE1 counselling, trainees are asked to sit comfortably on a chair with a hand on each knee, their feet flat on the floor, with their eyes closed. In yoga, this is known as the Egyptian position. The TIR training manual states:

    you should be comfortable just being present and being purely receptive, purely aware. Do not try to resist thoughts or feelings but rather simply remain aware of them without trying to change or affect them in any way. The point is for you to remain present and not to get lost in thought or preoccupied. Avoid using any system of being present [i.e. avoid doing anything]. Just remain aware of present time and location. (Gerbode and French, 1992/2007, p. 41)

    Here the use of a system is advised against whilst practising the ability to be present. This appears to be a harmony of the preference for not using systems or techniques in person-centred therapy (PCT). In this exercise, trainee therapists are practising the ability to stop doing and just be.

    Simply being aware or ‘observing’ is arguably the action that contains the least action. It still contains some active intention or doing, the fulfilling of the intention to be present. This ‘minimal doing’ of presence can still be perceived in the bodily and facial language of the person who is actively being present. Perhaps the only way to truly cease all doing is to be brain-dead. This form of meditation, done with eyes closed, is very similar to a form of mindfulness meditation known as ‘choiceless awareness’. Choiceless awareness meditation is taught to clients in Kabat-Zinn's Mindfulness-based Stress Reduction, which has gained empirical validation in recent years (for more on which see Kabat-Zinn, 1990). Trainees are encouraged to do this exercise for extensive periods of time, although the time restraints of modern life and work can make this difficult in practice. This ability or quality of genuine presence is seen as the most fundamental element of TIR counselling training. This is because one's ability to remain present affects everything. Every quality that the therapist either exhibits or manifests in an action, touches the counselling relationship. This ability to be present can be significantly developed over time. It has a lot to do with being able to remain non-judgemental or the ability to stop doing the many automatic things that people tend to do (whether thoughts or involuntary physical movements). The non-judgemental present quality of this exercise aligns very well with Rogers' fourth condition that the therapist experiences ‘unconditional positive regard’.

    The remaining seven communication exercises consist of a gradient of abilities, each of which is added to the previous. Each subsequent exercise or ability is directly enhanced by the previous ones. Hence they are practised in sequence from CE1 to CE8.

    CE2 – Confronting

    CE2 is the second form of mindfulness meditation in TIR training. It is much the same as CE1 but with the added layer of eye contact. Trainees sit opposite each other and practise the ability to remain present for extended periods of time, whilst maintaining eye contact with a partner. This brings about a feeling of empathic attunement between the two engaged in the activity, once the two minds have quietened and come to meet in the present moment through visual contact alone. The time it takes to reach such an attunement decreases with practice. It is not uncommon for a new trainee to feel uncomfortable at first and to manifest such reactions as excessive blinking or fidgiting. Continuing CE2 provides the opportunity for trainees to (1) experience their own inner ‘organismic’ reactions as they wax, wane, and change in quality, just as the inner experience of emotions shifts when a client examines them in detail; (2) increase their ability to maintain empathic attunement; (3) resolve any inner reactions and judgements of their own that may surface during the exercise; and (4) to increase their ability to genuinely accept their own reactions as they arise moment to moment. The practice of these exercises helps foster at least three of Rogers' conditions. These are (1) that the therapist experiences unconditional positive regard towards the client (condition four); (2) that the therapist is experiencing an empathic understanding of the client's internal frame reference (condition five); and (3) that client perceives, at least to a minimal degree, the unconditional positive regard and the empathic understanding of the therapist (condition six; Rogers (1957)).

    CE3 – Maintaining Confront

    CE3 adds the layer of facing a client who exhibits challenging behaviour or communication. It is harder to be unconditionally acceptant and empathic when a client projects his anger on to you or tells you they have done something you consider morally wrong. Whilst Rogers' six conditions may exist with some clients some of the time, how might this be increased to most clients most of the time? One approach is that of structured practice. PCT therapists are taught not to moralise to their clients. However, clients can easily perceive automatic, inner moralising in a therapist's face or physical attitude. These inner, automatic reactions can be overcome with systematic practice. Such practice (in CE3) is achieved through the searching and finding of such reactive ‘buttons’ followed by repeated exposure to each ‘button’ until it no longer produces a reaction. In TIR terminology this is referred to as ‘flattening a button’. CE3 therefore provides practice in holding conditions 4–6 under more challenging circumstances.

    The removal of all unnecessary actions in a session and the focused application of only what is necessary make TIR and related techniques highly efficient. The TIR style of working has a certain ‘shortest distance between two points’ philosophy to it. TIR's tenth rule of facilitation states ‘Do not do anything in a session that is not directly conducive to the counselling process’ (Bisbey and Bisbey, 1998, p. 15). This principle harmonises with Rogers' preference of ‘being’ over ‘doing’, if one argues that the less one is engaged in doing, the more one is able to simply be.

    CE4 – Delivery

    CE4 addresses the delivery of communication from the therapist to the client. In this exercise, trainees practise the ability to remain present, empathic, and in control of their non-verbal communications while speaking to the client. It is surprisingly easy to find oneself unconsciously adding to one's various utterances on a non-verbal level. As with the earlier communication exercises, CE4 trains therapists to do less than they would otherwise be doing. According to Applied Metapsychology theory, the presence of unnecessary actions (e.g. involuntary bodily movements) may interrupt the client's therapeutic process.

    CE5 and CE6 – Acknowledgements

    CE5 and CE6 (Acknowledgements) comprise structured exercises for making your client feel heard. As with all TIR-related methods, they are, again, done in a minimalist way. Great emphasis is placed on communicating that you are congruently with the client, and on doing nothing else. This is typically done with one or two words such as ‘okay’ or ‘thank you’. In acknowledging well, you are neither verbally nor non-verbally evaluating, or assuming you have similar experience, or making comments or interpretations. You are simply communicating that you are humanly and congruently ‘getting’ the clients internal frame of reference, nothing more. CE5 provides practice in the ‘full acknowledgment’ or acknowledgments that have an air of finality about them. The therapist uses these when it is clear a client has completed describing a particular thing, or fulfilled a particular intention. CE6, encouraging communication, may also be achieved with a single word. This difference is in the tone of voice which communicates ‘I'm with you and am interested to hear more about that’. This type of acknowledgment is largely used in situations where the client has stopped speaking, but clearly has more to say.

    CEs 5–6 most closely align with Rogers' third and sixth conditions. These are respectively, the therapist's ability to maintain congruence and integration in the relationship, and for the client to perceive the therapist's unconditional positive regard for him and the therapist's empathic understanding (communicated to the client with congruent acknowledgements). CEs 1–3 (for strengthening presence and empathic attunement) enable therapists to experience psychological contact, unconditional positive regard and empathy to ever higher levels, and thus align most closely with conditions one, four and five (see Table 1 below). The degree to which a trainee therapist can be congruent is dependent on how present the therapist is. Hence CEs 1–3 are practised before CEs 4–6.

    Table A1 A summary of the presence of Rogers' conditions in TIR practice.
    Roger's therapeutic conditions (1957/1990)How they are operationalised in applied metapsychology/TIR practice
    • That two persons are in psychological contact
    Eight ‘communication exercises’ or ‘CEs’ are used to train a therapist to maintain such contact consistently, moment to moment. Particularly CEs 1–3 develop the ability to make and maintain empathic attunement with a client, and therefore be in psychological contact.
    • That the client is in a state of incongruence, being vulnerable or anxious
    • CEs 1–8 + 13 rules of facilitation teach the therapist how to maintain an environment from the beginning to the end of a therapeutic relationship, that is safe enough for negative affect to surface.
    • Assessments are used to identify areas of incongruence, vulnerability, and negative problematic affect.
    • Structured exercises provide the opportunity for clients to hold their awareness in such assessed areas.
    • That the therapist is congruent in the relationship
    CEs 1–3, enhance the therapist's ability to be present to the client. An enhanced reception of a client's communication, in turn, enhances the ability of the therapist to remain congruent. More attunement is more opportunity for congruence. The CEs 5–6 actively practise communicating where the therapist is in relation to the client (acknowledgements of client's responses).
    • That the therapist is experiencing unconditional positive regard towards the client
    TIR therapists tell their clients that there is nothing they can do wrong. Great care is taken to ensure that nothing the therapist does could be perceived as an evaluation or even an interpretation (rules 1–2 of the 13 rules of facilitation). The trainee therapist is taught to accept unconditionally anything the client says. This is actively practice and tested in CEs 1–3, though all eight CEs contain this element.
    • That the therapist is experiencing an empathic understanding of the client's internal frame of reference
    CEs 1–3 also provide active practice at maintaining empathy in order to be aware of how the client is doing.
    • That the client perceives at least to a minimal degree the unconditional positive regard for him and the empathic understanding of the therapist.
    5th rule of facilitation: ‘The counsellor makes sure he comprehends what the client is saying … A client knows right away when she is not being comprehended. When this happens she feels alone and unsupported … [the counsellor] must seek clarification by admitting her lack of comprehension’. Gerbode and French (1992/2007, p. 26) CEs 4–6 bring about a clear experience of unconditional positive regard and empathic understanding for the client. CE 8 focuses on maintaining this condition when it is more tricky to do so, e.g. when something is going on that the client is not telling the therapist, or the client has a concern that is interrupting the therapeutic process.
    CE7 – Getting Questions Answered

    CE7 and CE8, known respectively as ‘Getting questions answered’ and ‘Handling concerns’, both take the form of mock therapy sessions. During CE7, trainees experience and practise applying CE1–6 whilst asking repetitive questions. CE7 is called ‘Getting questions answered’ because trainees are tested in their ability to spot when a client (acted by a peer trainee) does not answer a question. This is test of the trainee's ability to be on the ball whilst continuing to apply CEs 1–6.

    CE8 – Handling Concerns

    The final exercise focuses on responding to client concerns and momentary needs. This is structured practice in the ability to depart from a structure in order to go with the client's unique process, and then to return to the structure, if appropriate. Common examples of such a concern are: the client has questions he or she wants to ask, the client has distracting physical sensations or pains that arise during the session, or a client becomes aware of another issue during the session and seems more interested in that issue.

    In the description of CEs 1–8 above, we saw how conditions 1, 3–6 are operationalised in TIR training. Rogers' second condition – ‘That the first person, whom we shall term the client, is in a state of incongruence, being vulnerable or anxious’ (Rogers, 1957/1990, p. 221) – is brought about by three principle factors:

    • The safety of the space held by the therapist and of the application of the 13 Rules of Facilitation (Bisbey and Bisbey, 1998). These rules may be summarised as a description of how to create an environment that is safe, distraction-free, and conducive to maximising the client's inner focus of awareness, without fear of consequence.
    • Extensive assessments are used to identify specific areas of emotional charge that the client is interested in addressing and that provoke anxiety other unwanted emotional reactions.
    • The use of structured repetitive exercises that systematically invite (if the client is willing and interested) the client to hold her awareness in an area he or she wishes to address. Such areas often contain incongruent material and negative affect.

    The eight communication exercises and the 13 Rules of Facilitation all largely align with the principle that the client's degree of inward focus, or awareness of unprocessed material, is proportional to the degree of therapeutic process. Therefore, anything else that occupies the client's mind while he focuses may slow down that process. TIR and metapsychology techniques owe much of their briefness to the application of this minimalist principle.

    Summary

    I have illustrated how TIR training employs structured methodologies, not necessarily to contain the client, but to teach, develop, and operationalise in therapists, the six conditions advocated by Rogers. In line with Rogers' preference for principles or qualities over techniques or instruments, CEs actually enable therapists to do less of what is unnecessary to the therapeutic process, and to exhibit more the qualities that are necessary, according to Rogers, for therapeutic process or change.

    References
    Baer, R.A. (2003) ‘Mindfulness training as a clinical intervention: A conceptual and empirical review’, Clinical Psychology: Science and Practice, 10: 125–43. http://dx.doi.org/10.1093/clipsy.bpg015
    Bisbey, S. and Bisbey, L.B. (1998) Brief Therapy for PTSD: Traumatic Incident Reduction and Related Techniques. Chichester: John Wiley & Sons.
    Dimidjian, S. and Linehan, M.M. (2003) ‘Defining an agenda for future research on the clinical application of mindfulness practice’, Clinical Psychology: Science and Practice, 10: 166–71. http://dx.doi.org/10.1093/clipsy.bpg019
    Gerbode, F.A. and French, G.D. (1992) Traumatic Incident Reduction Workshop Manual. Menlo Park, CA: IRM Press.
    Kabat-Zinn, J. (1990) Full Catastrophe Living: The Program of the Stress Reduction Clinic at the University of Massachusetts Medical Center. New York: Delta.
    Rogers, C.R. (1990) ‘The necessary and sufficient conditions for therapeutic personality change’, in H.Kirschenbaum and V.L.Henderson (eds), The Carl Rogers Reader (pp. 219–235). London: Constable. (Original work published 1957).
    Rogers. C.R. (1986) ‘A client-centered/person-centred approach to therapy’, in H.Kirschenbaum and V.L.Henderson (eds), The Carl Rogers Reader (pp. 135–52). London: Constable.

    Appendix 2 Time-Limited Group Counselling with Women Survivors of Childhood Sexual Abuse: Weekly Log of Themes

    TrèsRoche
    Week 1
    • Safety: Relief in joining the group, and in the similarities of group members. Relief at meeting other survivors. Need for the group to be ‘good’. How feeling understood creates connection with others. Difference between group environment and ‘real life’.
    • Naming the impact of childhood sexual abuse.
    • Trust: Difficulties in trusting others, yet an immediate sense of trusting the group – exploring connection between the dynamics of abuse and the development of trust.
    • Issues of control and choice and consent.
    • Survival strategies: Naming and understanding self-harming behaviours.
    Week 2
    • Fear of engaging with the enormity of the impact of the abuse. Fear of connecting with histories of abuse and fear of overwhelm: Can feelings be contained and survived?
    • Fear of the judgement of others: ‘If people really knew what happened to me they would despise me’.
    • The need to be understood, yet the utter terror of risking connecting to others.
    • Self-harm as a coping strategy.
    • Protection of others: Protecting family members as children and how that continues in ongoing family relationships.
    • Guilt/shame about the sexual abuse suffered.
    • Responsibility – exploring ways in which the context surrounding the abuse conspires to engender responsibility in the survivor.
    Week 3
    • Some disclosure of abuse histories.
    • The huge complexity of feelings about the abuse. Naming the complexity of feelings towards the perpetrators of the abuse.
    • Terror of connecting with the feelings about the abuse, recognising that previous coping strategies have been about blocking the experience through fear of overwhelm. How can feelings be named, contained and survived?
    • Guilt and responsibility linked to feelings of self-blame and self-hatred.
    • Coping strategies as children and as adults: What is/was necessary to survive?
    • The difficulty in prioritising own needs above the needs of others.
    • Hope: The desire for aspects of life to be different alongside the fear that hope risks disappointment – how this connects to childhood experiences.
    • Trust and discernment.
    Week 4
    • Some disclosure.
    • Languaging memories, flashbacks and nightmares.
    • Disappointment: A desire for a ‘cure’, and the acknowledgement that the pain isn't disappearing.
    • The absolute grief for the loss of childhood.
    • Powerlessness: Linking childhood experiences of power with assumptions about power as an adult.
    • The need for understanding and to make sense of the past.
    • What can and can't be spoken about. Speaking the unspeakable.
    • Naming of personal goals.
    • Sharing resources for surviving.
    Week 5
    • Some disclosure.
    • Emerging anger towards mothers (or the non-protective parent).
    • Revenge fantasies.
    • Fear of madness.
    • Flashbacks: Understanding the need for memories and feelings to receive attention.
    • Distress triggers: Exploring and understanding what triggers distress and why.
    • Self-sabotaging survival strategies – other options?
    • Desire for and fear of change.
    • Belonging: Need to belong, fear of rejection.
    • Sense of self as contaminating and destructive.
    Week 6
    • Some disclosure.
    • Rage: Acknowledgment and fear of rage.
    • Memories of childhood before the abuse.
    • Terror of connecting to and integrating abuse histories.
    • The effects of change perceived through the group process on partners and families.
    • A desire for a cure.
    • Power: Powerlessness being the familiar position.
    • Lack of self-esteem.
    Week 7
    • Some disclosure.
    • The need for resolution – the anxiety of the unresolved.
    • Staying silent or speaking out as an adult. How this links with distorted thinking around protection of others – fear of rejection.
    • The personal cost of adaption.
    • Similarities and differences between the powerlessness of a child and the choices available to an adult.
    • Compassion for other group members, compassion for self.
    • Questioning impulsive behaviours – what is the underlying need?
    • Awareness of own vulnerability and vulnerability of others.
    • Responsibility, exploring more accurate descriptions of responsibility in childhood.
    • Endings.
    Week 8
    • Hope for the future: Choice, power and autonomy.
    • Fear of ending linking to abandonment.
    • Some disclosure.
    • Choice and taking power.
    • Responsibility and self blame.
    • Fear of own needs.
    • Desire for and fear of more intimate relating with others.
    • Importance of self-expression and being heard as a basis for connecting with others.
    Week 9
    • Endings linking to abandonment and betrayal.
    • Fear of causing damage to others: If members allow more intimate relating with others, others will be damaged by them.
    • Endings: Grief and loss.
    • Hope – imagining the future.
    • Recognising the difference between past and present.
    • Support needs for after the group.
    • The familiarity of rigid expectations for self, other, the environment.
    Week 10
    • Achievements and disappointments within the group.
    • Next steps.
    • Realistic expectations of self and others.

    Notes on Editor and Contributors

    Keith Tudor has worked for 30 years in the helping professions in a number of settings. He is a qualified and registered psychotherapist, and has a private/independent practice in Sheffield offering therapy, supervision and consultancy. He is a Director of Temenos and its course in Person-Centred Psychotherapy and Counselling, the first of its kind in the UK, and is an Honorary Fellow in the School of Health, Liverpool John Moores University. He is a widely published author in the field of psychotherapy and counselling, and mental health with over 50 professional papers and 10 books to his name, of which five define, develop and advance the person-centred approach, its psychology, therapy and supervision. He is the series editor of ‘Advancing Theory in Therapy’ (published by Routledge), and is on the editorial advisory board of three international journals.

    Robert Elliott, Ph.D., is Professor of Counselling in the Counselling Unit at the University of Strathclyde, and Professor Emeritus of Psychology at the University of Toledo, Ohio. He is co-author of Facilitating Emotional Change (Guilford, 1993), Research Methods in Clinical Psychology (Wiley, 2002), and Learning Process-Experiential Psychotherapy (APA, 2004), as well as more than 90 journal articles or book chapters. He is a Fellow of the APA in both Divisions of Psychotherapy and of Humanistic Psychology, and is the 2008 recipient of the Carl Rogers' Award from the APA's Division of Humanistic Psychology. He is Editor Emeritus of Person-Centered Counseling and Psychotherapies.

    Isabel Gibbard originally completed a degree in Biology at London University in the early 1970s, but decided that she was not an academic and didn't want to spend the rest of her life in a lab. She then spent several years as a full-time mother bringing up children. She went into counselling through working as a volunteer in a prison, and qualified in 1995. She began work in the NHS in 1998, first as a staff counsellor for a hospital trust, and then as a primary care counsellor. She now manages the primary care service which operates in the community and in two prisons.

    Barrie Hopwood is a counsellor, supervisor and trainer in private practice in Middlesex. He is also Project Manager for Hounslow Youth Counselling Service at Feltham Young Offender Institution and Student Counsellor at Cranfield University. Before training as a counsellor Barrie studied Law and Criminology, and taught in Further Education in Harrow. Barrie's particular areas of interest are exploring the potential of the spiritual dimension in the counselling relationship, developing ways of working with the ‘Inner Child’ in supervision, and raising awareness around the theme of men and masculinity in the world of counselling.

    Bala Jaison, Ph.D., the author of Integrating Experiential and Brief Therapy: How to do Deep Therapy – Briefly and How to do Brief Therapy – Deeply (Focusing for Creative Living, 2003), is an internationally recognized lecturer, trainer and workshop leader. She is a psychotherapist in private practice for individuals, couples and families; Director of Focusing for Creative Living in Toronto, a government recognized training institution for mental health professionals; and a Certifying Coordinator for the International Focusing Institute, offering a focusing-oriented certification programme for therapists. Dr Jaison is also the co-editor of the Folio, the academic journal for the International Focusing Institute, and has written extensively on how to integrate focusing and brief therapy. She can be reached at balaj@sympatico.ca.

    Mia Leijssen is Professor at the University of Leuven, Belgium. She teaches client-centred psychotherapy, counselling skills and professional ethics in the Psychology Department. She has been practising client-centred/experiential/existential psychotherapy since 1973.

    Madge Lewis1 was an instructor and then a counsellor in public schools in California in the 1940s. At the time of writing her contribution to the original chapter, she was a staff research counsellor at the University of Chicago, where she obtained her doctorate in 1959.

    Paul McGahey has been a practising person-centred counsellor since 1993. He is a senior accredited counsellor with the BACP. Since 2003 he has worked as a full-time student and staff counsellor, supervisor and trainer at Loughborough University in the East Midlands. In 2002 he helped to establish a person-centred group in Brighton, a group which has been a continuing source of support and professional development for counsellors and therapists in the East Sussex area, and which is affiliated to BAPCA. Paul has been actively and passionately involved in promoting the person-centred approach through the group's activities, to which his main contribution continues to be organising the successful programme of workshops with nationally and internationally recognised person-centred facilitators/speakers. His current interests include the politics of therapy, and the imminent statutory regulation of counsellors and psychotherapists in the United Kingdom.

    1 Although Madge Lewis's work does not appear in Chapter 5, I include her biographical details here as she contributed her work and reflections to the original chapter with Carl Rogers and John Shlien.

    Carl Rogers was, at the time of writing his contribution to the original chapter, the Director of the Counseling Center at the University of Chicago.

    John Shlien was, at the time of writing his contribution to the original chapter, the Service co-ordinator and a counsellor at the Counselling Center at the Institute for Communication on Human Development, and Research Associate and Assistant Professor at the University of Chicago.

    Très Roche is a BACP accredited counsellor who has been practising for 15 years. Since 1997 she has been the co-ordinator and group therapist at the Sexual Abuse Project, a specialist group therapy service for adult women survivors of childhood sexual abuse. She is co-author, with Annabell Bell-Boulé of a chapter on ‘Legal issues in therapeutic work with adult survivors of sexual abuse’, published in a book on Legal Issues in Counselling and Psychotherapy (Sage, 2002). Très is also founder and principal consultant of Psych solutions, a training and organisational development consultancy, based in the East Midlands in the UK, which works with organisations to develop solution-focused strategies to help navigate through complexity.

    Henry J. Whitfield, has run and supervised a Brief therapy for Post Traumatic Stress Disorder project for Victim Support Lambeth since 2005, and has regularly worked as a trauma counsellor for victims of crime since 2003. Henry regularly teaches and lectures at conferences and for training organisations, including the British Association of Anger Management (BAAM), and in doing so has trained the majority of the TIR practitioners in the UK. Being a qualified cognitive behavioural therapist, has contributed to his research interests in the theoretical and practical integration of mindfulness with cognitive behavioural theory, and in case-formulated applications of mindfulness, (the first field in which he published). Henry is also director of Mindfulness Training Ltd, based in Covent Garden, London, an organisation training practitioners in Traumatic Incident Reduction (TIR) and related techniques, Mindfulness-based Cognitive Therapy (MBCT), and Acceptance and Commitment Therapy (ACT) (see http://www.presentmind.org for more).

    Pam Winter has an independent practice as a counsellor, supervisor and trainer based in Greater Manchester, at the Relationship Centre (http://www.therelationshipcentre.co.uk), and is a Senior Registered Practitioner with the BACP. She has 20 years experience in working with people individually and with couples, groups, teams, and organisations. She founded the Relationship Centre with her husband in 2005, with the aim of developing person-centred work in both domestic and working relationships. She has a long-standing commitment to the person-centred approach and has also trained in body psychotherapy. She has had two previous articles published one on supervision (in the British Journal of Guidance & Counselling, 1994) and one on person-centred therapy and the bodymind connection (Person-Centred Practice, 2002).

    Abbreviations
    • APA – American Psychological Association
    • BACP – British Association for Counselling & Psychotherapy
    • BAPCA – British Association for the Person-Centred Approach
    • MBACP – Member of the British Association for Counselling & Psychotherapy
    • NHS – The National Health Service
    • REBT – Rational Emotive Behavior Therapy
    • TIR – Traumatic Incident Reduction
    • TIRA – Traumatic Incident Reduction Association (accrediting body for TIR practitioners)

    Author Index


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