Person-Centred Experiential Counselling for Depression

A manual for training and practice

David Murphy

• Publisher: SAGE Publications Ltd
• Year: 2019
• ISBN:
  9781526454607
• Edition: 2
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

This practical book focuses on humanistic counselling as an evidence-based psychological intervention and it is an essential read for trainees wishing to work in public health settings. Coverage includes: evidence-based practice and person-centered and experiential therapiesthe counselling for depression competence frameworkin-depth case studies illustrating Counselling for Depression in practicetraining, supervision and researchThe book also includes research data supporting the approach, and sources used in developing the humanistic competence framework. Vital reading for those taking counselling for depression training or a humanistic counselling and psychotherapy course, as well as for those already working within the NHS and wish to enhance their practice.

1 Introduction

Chapter overview

• Positioning PCE-CfD
• Background and development of PCE-CfD
• A positive psychology for working with depression
• A PCE basis to a positive psychology of depression
• Evidence and treatment guidelines
• About this book

The problem of psychological distress and human suffering is a significant one. Many people are struggling with the demands of a modern society and the fast evolving culture. As society becomes more unequal between rich and poor, as homelessness continues to rise in all parts of the developed world, and as education systems place increasingly unrealistic expectations on children and young people, it is hardly surprising that more and more people report feeling depressed. This book is about person-centred experiential (PCE) counselling and can be used as a guidebook for helping you to understand your work with clients who are depressed. It is not intended or advised to be used as a manual or instruction book. PCE therapy is a creative and emergent process and the intention of this book is to offer a description of this process using theory to understand working with clients who present as depressed. It is hoped that for many experienced therapists the contents of this description will be familiar and, for others, something they might at least recognise.

In the sections below the PCE approach will be set in context. This includes outlining the development of the PCE-Counselling for Depression (PCE-CfD) approach. As many readers will know, humanistic psychology, on which the person-centred approach was founded, grew out of a field of psychological enquiry based on psychologists’ interests in the positive aspects of human functioning just as much as the pathological. In this sense, humanistic psychology is located within a growth paradigm and was particularly interested in the heights of human potentiality. This approach offered an alternative to the deficit-based medical model paradigm that was and remains dominant in modern society. PCE-CfD offers a way of challenging the current dominant medical model that provides the prevailing backdrop to mental health care systems. This chapter will introduce some of the key ideas and thinking that will help to begin the task of presenting the alternative to a medical model approach to working with depression. To do this, we need to understand depression from within the growth paradigm, set out the theory of this therapy and demonstrate how it is different from other approaches. To do this, the sections that follow will begin to articulate another way of thinking about depression to the deficit model, and each subsequent chapter in the book will further elucidate a way of working with clients in a way that does not pathologise their experiences. Whether you are a trainee on a PCE-CfD course, any other kind of counsellor looking for a way out of medical model thinking, or someone feeling depressed who wants to understand a different way of getting out of the distress you experience, then I hope that you will find something in this book that will support you.

Positioning PCE-CfD

The development of PCE-CfD marks a significant step in the PCE approach being recognised by the National Health Service (NHS) and the initiative used to roll out the large-scale provision of talking therapy at the primary care level known as Improving Access to Psychological Therapies (IAPT). This book, and more broadly the approach, owe credit to the many years of work by the founders, scholars, practitioners and clients who have all contributed to what Sanders (2011) has referred to as the ‘tribes’ of person-centred and experiential counselling. Some readers will have already noticed that the approach being referred to here, ‘PCE’, is presented as a unified term and approach to therapy¹. Since the first edition of this book the context has changed and using this new term enables PCE to be acknowledged as a distinct therapy that is not integrative, but a unique and emerging expression of the PCE paradigm. Baker (2012) has suggested that PCE as a therapy evolved from Carl Rogers’ work in the late 1950s as his theories became enhanced by Gendlin’s (1962) interests in the importance of ‘experiencing’. Baker (2012) used the term ‘experiential person-centred’ to describe a specific tribe within the person-centred approach, and prior to this Lietaer (1984) was writing about the experiential nature of person-centred therapy (PCT). Indeed, Lietaer has stated that it came as an almost seismic shock to him when he learned that the classical school were not conceptualising client-centred as an experiential therapy.

In this book, whilst recognising and drawing on debates and discussion in the past (Bozarth, 1998; Kirschenbaum, 2012), the term PCE (Murphy, 2017) is used as the most contemporaneous way to define the approach. The addition of the term CfD can then simply be recognised as an indication that our focus here is on the context of working with clients who are experiencing depression. This will typically, but not exclusively, be relevant when discussing therapeutic work undertaken with clients in a healthcare setting. PCE-CfD is not therefore an integration of disparate approaches (such as the integration of person-centred therapy and emotion-focused therapy competences put forward in the CfD manual). PCE therapy can be defined as a contemporary evolution of a radical paradigm for therapy. It is a bold step to take, but the task of this book is to present PCE therapy as it applies to a specific phenomenon: depression.

Background to PCE-CfD

Given that PCE therapy is part of a long-established and evolving paradigm of therapeutic practice, how did the need for adding a specific focus of depression arise? Could we not simply refer to the approach as ‘PCE therapy’? Let’s take each of these issues in turn. PCE-CfD, as outlined in this book, is an approach to therapy that is by and large available and practised in NHS psychological therapies services. In recent years this has been provided under the IAPT programme. IAPT was rolled out after successful lobbying in the period following publication of The Depression Report (CEPMHPG, 2006) that saw the implementation of National Institute for Health and Care Excellence (NICE) guidelines for common mental health problems such as anxiety and depression. Whilst the implementation of IAPT has put psychological therapies in the NHS ‘on the map’, as Sanders and Hill (2014) noted, this has been delivered through a top-down, centralised agenda that caused significant harm to the grassroots development of a pluralistic array of psychological therapies in primary care general practitioner (GP) surgeries. A major consequence of this was that cognitive-behavioural therapy, with its vast quantity of randomised control trial (RCT) evidence supporting its effectiveness, became the frontline therapy and most other approaches were swiftly relegated to the margins.

Sanders and Hill (2014) have suggested that part of the fall-out following the introduction of IAPT was the spread of the therapeutic competences agenda. The process of developing therapist competences for humanistic therapies was led by Professor Tony Roth in conjunction with academics including Professors Mick Cooper, Robert Elliott and Germain Lietaer. They were accompanied by Janet Tolan from the British Association for the Person-Centred Approach (BAPCA) and other staff from the British Association for Counselling and Psychotherapy (BACP). As Sanders and Hill (2014) noted, this was the genesis of the development of therapeutic competences specifically for working with depression. The challenge for those involved in bringing a more specific description of a person-centred counselling approach to depression which drew from the wide range of humanistic competences was significant. Their task was to bring to bear a description of PCE therapy that could be deemed effective for depression and linked to RCTs. This was a challenging task as PCE therapy had never used diagnostic criteria as a basis for describing its practice. The humanistic competences per se were considered too broad to serve as a description for practice for individual therapists that would also be acceptable to NICE requirements for evidenced-based practice. Hence, a selection of published RCT studies was identified that included person-centred and emotion-focused therapy (EFT) to provide sufficient evidence for a specification of the wider humanistic competences to focus on the application to depression. These trials are reviewed later in Chapter 8 but, importantly, what emerged from this process was the identification of a competency framework that formed the basis for PCE therapy when working with depression. A trainers’ and practitioners’ manual was produced that provided a detailed description of the approach, highlighting how it might be practised in the NHS and IAPT setting. This had to be presented as a manual which identified key skills and competences. The framework was accepted by NICE and described within the IAPT programme as follows:

Counselling for depression is a manualised form of psychological therapy as recommended by NICE (NICE, 2009) for the treatment of depression. It is based on a person-centred, experiential model and is particularly appropriate for people with persistent sub-threshold depressive symptoms or mild to moderate depression. Clinical trials have shown this type of counselling to be effective when 6–10 sessions are offered. However, it is recognised that in more complex cases which show benefit in the initial sessions, further improvement may be observed with additional sessions up to the maximum number suggested for other NICE recommended therapies such as CBT: that is, 20 sessions. (BACP, 2010)

This statement marked a major step for PCE therapy as it was formally recognised by NICE, implemented as part of IAPT, and positioned as a legitimate alternative to cognitive behavioural therapy (CBT) for the range of severity of distress in primary care services.

The position then was this: the therapy is identified and recognised as suitable for working with clients who present with depression. However, the PCE approach, at least in the UK, had a strong investment in being an alternative to a medical model approach. How can these differences be reconciled?

Reading the above is likely to stir a mixture of feelings. It certainly does when writing. For those of us rooted in the PCE therapy approach for many years it is difficult to reconcile the tension between the radical theoretical position of the person-centred approach and its newly developed link with the IAPT project, the latter of course denoting an association with the medical model. An immediate cost of the link with IAPT is the identification of PCE therapy for a specific diagnostic category. Why not simply call it PCE ‘counselling’ and drop the ‘for depression’? In the ideal situation this would indeed be preferable. However, in the current situation there is still the legacy of the development of IAPT and its links to NICE. These agendas demand that any therapy that is offered must be evidenced as effective. If therapists want to work in these settings, then it seems these are the rules that currently govern the field. This is not to say that these authorities and the rules shouldn’t be questioned and challenged, they should and must. However, for PCE-CfD to be available to the public in a national model of health provision, there is undeniably a compromise. But are there also opportunities, and can PCE-CfD use this position as an opportunity to work on the system and bring changes to it?

Setting out a positive psychology for depression

In this book it is intended to show how the PCE-CfD approach presents a positive psychology and growth model for working with clients who experience depression. For some practitioners within the PCE approach, the very idea of developing a descriptive account of PCE therapy for a specific diagnostic category is something of an anathema. Indeed, there’s no doubt that the PCE approach has little in common with the medical model dominating current mental health systems. Developing PCE-CfD that focuses only on those symptoms associated with depression would be an act of collusion with the medical model paradigm. Not only this, but to do so would be to over-simplify a complex dimension of human function. It would be to reduce the person as a whole to a set of symptoms and deficiencies and neglect a wide range of human capabilities. In contrast to other approaches recommended by NICE, the PCE approach is unique in the growth metaphor of human development.

As a growth paradigm approach, it is rooted in a positive psychology that was originally proposed by the humanistic psychologists interested in not only the alleviation of distress but also the heights of human potential (Joseph, 2015). The term ‘positive psychology’ has become known as an unhelpful concept but humanistic therapies cannot alter the fact that they were developed from positive psychology. Instead, we should reclaim this term and demonstrate the true meaning of the growth paradigm. This is a unique feature of the PCE approach to therapy and one that must not be lost or appropriated by the medical model. The growth paradigm and the PCE approach brings with it radical consequences for individuals who participate in the therapy. Clients receiving PCE-CfD are met by a therapist who does not reduce them to a set of symptoms but considers their experiencing as part of an integrated whole. The person is understood in their social context and is thought to be striving for growth. Depression, in this sense, is an expression of thwarted actualisation processes. The person is considered not as deficient but to be making the best of what resources are currently available.

Throughout, this book will show how it is possible to present a set of descriptive competences for working with clients within PCE-CfD, whilst retaining the connection to the growth paradigm from which the approach originates. To do this, it is necessary to examine the concept of depression. The stance taken is to conceptualise the phenomenology of depression as a set of experiences that exist at one end of a bi-polar construct. Doing this turns the phenomena of depression into a continuous variable, with another set of experiences (best associated with being fully functioning) positioned at the opposite end on the continuum. Researchers who have already proposed that depression is a continuous variable include Joseph (2007) and Joseph and Wood (2010).

In recent years, there has been a shift within the literature surrounding the construct of depression. Interestingly, this shift has been driven by those with strong allegiances with the underlying philosophy of PCE therapy and the growth paradigm but operating within the counselling and clinical psychology fields. This recent shift has meant the focus within psychology (and psychiatry to some extent) moved towards a rejection of the use of diagnosis and disorder (Johnstone et al., 2018). Instead, mental health professionals are searching for alternative approaches to conceptualising and understanding psychological distress. ‘Wellbeing’ has become an important feature in shaping mental health services (Department of Health, 2009), although the use of this term has become associated with the deconstruction of long-term and deep therapy provided within the public sector and replaced with ‘light touch’ approaches that fail to appreciate the significance of people’s distress. This is unfortunate, as the word ‘wellbeing’ and the concept of psychological wellbeing are grounded in the philosophical approach termed ‘eudaimonia’; this refers to the tradition of becoming deeply engaged with the difficulties of life and of personal growth. Additionally, the concept is part and parcel of the PCE approach and since inception PCE therapists have claimed this concept and understood its true meaning. The use of the term ‘wellbeing’ as a corporate tool, pacifying and subjugating workers, is indeed pernicious and detracts from the ideas that underpin the growth model of psychological functioning. PCE therapists have a model of wellbeing that is defined in the terms of a fully functioning person and this notion needs to be maintained and remain a central feature of the approach.

For PCE therapy, the idea of full functioning logically, positions depression at one end of a continuum and is not a new way of understanding psychological distress. Nevertheless, there is a danger that in recent years some PCE therapists might have lost sight of the fact that they, and the approach, are situated within a growth model (Joseph, 2007). This inevitably requires a broader vision that can accommodate a more complex and sophisticated understanding of human functioning. Positioning depression at one end of a bi-polar continuum was recently empirically supported (Wood, Taylor, & Joseph, 2010; Siddaway, Wood & Taylor, 2017). Joseph (2007) suggested that the Centre for Epidemiologic Studies - Depression (CES-D) scale, a well-known and widely used measure of depression in research and policy studies, measures both symptoms of depression and phenomena associated with wellbeing. For example, the scale contains items such as ‘I felt sad’ and ‘I felt happy’ with the aim to measure depression. However, as Joseph (2007) argues, if a respondent scores zero overall on the test, they must have given the lowest score possible (‘rarely or none of the time’) when endorsing all negatively worded items (e.g. ‘I feel sad’), and the highest score possible (‘most or all of the time’) when endorsing all positively worded items (e.g. ‘I felt happy’). What this example shows is that a score of zero overall on the scale means that the respondent must have indicated far more than an absence of depression. They have instead also indicated positive wellbeing by affirming all the positively valenced items such as ‘I felt happy’.

A study by Siddaway, Wood and Taylor (2017) confirmed that the CES-D scale does indeed measure a depression/wellbeing continuum. Moreover, using a large sample of adolescents they also showed that as wellbeing increases depression decreases and, importantly, so do levels of a range of distressing symptoms that are associated with other problems (such as anxiety, aggression and substance misuse). What this study shows is how important it is within mental health practice to focus on all aspects of the client’s functioning and to not get hooked on the idea that eliminating symptoms is the only indicator of psychological growth. That is, we will be able to help clients more when we do not focus exclusively on what might be considered as the symptoms of depression. We should be, based on this research, tuned in and aware of other aspects of our client’s functioning that might also be indicative of personal growth, even when the client’s experiential processing is indicative of distress. Working with all these aspects of the client can be fruitful and meaningful in the client’s life.

PCE-CfD and the medical model

In some ways the original CfD project and development of the competences that resulted in having the approach recognised by IAPT was something of a Trojan horse. The approach was metaphorically ‘wheeled in’ as if it were just another specialised treatment for a medicalised form of psychological distress. There’s no doubt that we are now in a position where PCE-CfD, whilst grounded in idiographic rather than nomothetic practices, is seeking to articulate itself with the nomothetic stance of IAPT. What can be done to resolve this conundrum of PCE-CfD existing within an overly prescriptive, diagnostically fo...