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Editorial: What we write about when we write about psychotherapy and counselling

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Rhys Price-Robertson, PhD, PACJA Editor

 

This journal is a forum for people to share their writing on psychotherapy and counselling. To enter this forum, writing must meet certain criteria. There are the explicit criteria of academic style and prose (e.g., word count, referencing style, line spacing). And then there are the largely implicit criteria; the assumptions we share, as a community of practitioners, about the topics that are pertinent for us explore, the questions that are meaningful for us to ask, and the forms of knowledge that best guide our work. While the explicit criteria are provided on this journal’s website, it tends to be shared assumptions that most powerfully shape the contributions that appear in this journal, and, more generally, the written voices we assume as professionals.

One widely held assumption is that psychotherapy and counselling should be informed by evidence of some sort. Few call for a return to the days when the “literal Babble in the field of psychotherapy” meant there was “little way of distinguishing (or helping the public distinguish) useful therapeutic interventions from useless or destructive ones” (Westen, Novotny, & Thompson-Brenner, 2004, p. 632). The past two decades have witnessed the rapid spread of the notion of “evidence-based practice” (and related ideas, such as “empirically supported therapies”) from medicine to our field. This notion was originally intended to provide a new paradigm, one where psychotherapy and counselling were underpinned not by received opinion or the pronouncements of charismatic founders, but on the three foundations of empirical evidence, clinical expertise, and consideration of clients’ culture, values, and preferences (Kazdin, 2008). 

Yet what once seemed progressive now often appears reductionistic and retrogressive. In some quarters, the term “evidence-based practice” has taken on a narrower meaning than was originally intended. Indeed, a defining feature of many current conceptualisations of evidence-based practice is the promotion of the randomised controlled trial (RCT) as the “gold standard”; the method of knowledge production that trumps all others. While the RCT methodology certainly has a place in a healthy economy of knowledge—perhaps even a prominent place—its widespread promotion as the sole gold standard in almost every circumstance has contorted the field of psychotherapy and counselling.

This contortion manifests most obviously in a kind of unofficial hierarchy of therapeutic approaches, with “empirically supported therapies” at the top, and everything else staggered somewhere below. The obvious problem with this hierarchy is that it bears little resemblance to the reality of the effectiveness of the different approaches. Decades of “common factors” research has demonstrated that specific psychotherapies generally do not differ significantly in their effectiveness (Wampold & Imel, 2015). An important question, then, is this: if the hierarchy of approaches does not reflect actual effectiveness, what then does it reflect? Short answer: it reflects the logic of RCTs. The only approaches that stand much chance of being labelled “empirically supported” are those whose techniques and procedures align with the practical requirements of the RCT methodology. In other words, those that are: (1) focused on discrete and easily measurable problems (often a disorder in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders [DSM]); (2) short-term (because long-term interventions pose threats to the internal validity of RCT studies); and, (3) manualised (because the RCT methodology depends on treatment fidelity) (Westen, et al., 2004).

This contortion also manifests in the ways we write about our work. We are pressured to write about the discrete, the easily measurable, the short-term, and the manualised. Many students are predominantly taught “empirically supported therapies,” and so the words that populate their assignments and exams trace the topographies delimited by these approaches. Many practitioners can only provide their clients with government subsidies if they demonstrate that they provide “focused psychological strategies,” and so regardless of what their actual practice involves, their writing about their work (e.g., in case notes and correspondence with other professionals) is drawn towards the dialects of standardised measures, diagnostic frameworks, and practice manuals (Bueskens, 2014). Those who share their words in academic forums feel the pressure, too; the narrowing in breadth of what it feels possible to write about, the thinning of narratives, the risk in asking questions that resist articulation. None of this is said to disparage short-term and manualised approaches, nor the words that are written about them. Such approaches do and should occupy an important space in our field. Yet when they are elevated so far above other approaches, we run the risk of losing some of the great richness and diversity that exists in our field.      

As the incoming editor of this journal—this forum for people to share their writing—I hold the assumption that psychotherapy and counselling should be informed by evidence of some sort. Yet I also see it as my obligation to ensure that reductionistic understandings of evidence play no role in determining the voices that seek expression herein. I feel supported in this conviction by the recent release of the Psychotherapy and Counselling Federation of Australia’s (PACFA; 2019) Evidence-Informed Practice Statement, which encourages, “an approach to practising psychotherapy and counselling that is informed by current theory, empirical research evidence and expertise from clinical practice, which reflects the impact of client characteristics, including culture, life experience and preferences, on treatment outcomes” (p. 1). I see the prominent inclusion of theory in this definition as particularly important, because a significant weakness of many systems of evidence-based practice is that they ignore theory (e.g., on mechanisms of change) and the evidence that exists to support it (David & Montgomery, 2011). And I enthusiastically endorse PACFA’s choice to speak of practice that is evidence-informed rather than evidence-based, because, as their statement indicates, this terminology, “is considered to be more compatible with the full breadth of research approaches that are valued in our field, including Indigenous methodologies, inclusive research approaches and case study research” (p. 1).

My hope is that promoting a broad and inclusive understanding of evidence-informed practice will see contributors to this journal feel less constrained by the forces that seek to circumscribe and standardise their writing. I hope it will lead to good writing—writing that is pertinent, innovative, and engaging. It is my responsibility to uphold, and steadily strengthen, the methodological and intellectual rigour of the writing that appears in this forum. Yet I will not allow this journal’s measure of rigour to be determined by assumptions that have been uncritically imported from the medical sciences, or by hierarchies of knowledge that do not map on to reality. This forum remains very welcoming of contributions based on RCT or meta-analytic methodologies, but such contributions will sit alongside those grounded in other methodologies (e.g., clinical observation, effectiveness studies, ethnographic and auto-ethnographic research, process studies, case studies, qualitative research), as well as those that explore the philosophical, sociological, political, and historical dimensions of psychotherapy and counselling. As both a writer and an editor, I find inspiration in the words of my teacher, gestalt therapist Leanne O’Shea (2018), who suggests that,

writing, and writing with a kind of undefended, courageous honesty, opens the door and fosters the spirit of inquiry that stands at the heart of the best kind of research… description of what it means to be a therapist, of what it means to be human, and all the glory, shame, despair, love and hope that this entails. (p. 87)

Her words remind me that methodological and intellectual rigour does not depend on the exclusion of honesty, courage, and a willingness to explore the richness and depth of this important work that we do.

There are articles in this issue that demonstrate something of the spirit of enquiry to which O’Shea (2018) refers. Schirmer’s (2019) contribution stands out to me as an innovative example. In it, he provides an interpretation of PACFA’s Code of Ethics (2017) grounded in the philosophy of virtue ethics, a tradition that can be traced to Aristotle. He argues that an essential function of professional training and development is to immerse the trainee in the ethos of the profession, to encourage the integration a kind of moral vision “constituted by the underlying and often unarticulated values about what a human being is and what a human being should be and become”. As I argued above, such unarticulated values or assumptions can most powerfully shape our professional lives, so I applaud Schirmer’s efforts at using ancient philosophy to attempt to articulate an expanded agenda for training and development in contemporary psychotherapy and counselling. I also applaud Ryan’s (2019) creative and densely theoretical interrogation of postmodern identity, which he explores through the metaphor of “threads and patchworks that are relational and contextually dependent”. I especially appreciate how his voice is at once intellectually rigorous and playful (e.g., he bookends his article with reference to a conversation between Alice and the caterpillar in Lewis Carroll’s Alice’s Adventures in Wonderland).

Other articles provide examples of the innovative application of particular research methodologies and theories. The contribution of Barna and O’Hara (2019) stands out to me in this regard, as it combines a single case study design with interpretive phenomenological analysis to better understand the effects of the Radical Exposure Tapping (RET) protocol, a seldom-studied clinical intervention that aims to address some of the limitations of eye movement desensitisation and reprocessing (EMDR) and the emotional freedom technique (EFT). As the authors note, “it has been found that clinicians are more likely to alter their clinical practice on the basis of particularly rigorous case studies and examples rather than large-scale randomised controlled trials and meta-analytical studies, which are often devoid of detail on the clinical process”. I imagine this article will expose a larger audience of clinicians to the theory and actual practice of RET, and perhaps influence the ways in which they treat clients with trauma-related symptoms.   

I hope that those who spend time in this forum will be rewarded with writing that inspires, nourishes, affirms, challenges, provokes, and delights. I am grateful to have been given the opportunity to play a role in bringing such writing into the world. I give thanks to my immediate predecessor, Dr James Vicars, who began the preparation for the current issue. And, as always, I warmly welcome the feedback, questions, and submissions of those who would take the risk of sharing their own writing (editor@pacja.org.au).

References

Barna, E., & O’Hara, D. (2019) Applying the Radical Exposure Tapping protocol in the treatment of trauma-related emotional reactivity: A phenomenological case study. Psychotherapy and Counselling Journal of Australia, 7.

Bueskens, P. (2014). Is therapy a form of paid mothering? In P. Bueskens (ed.), Mothering and psychoanalysis: Clinical, sociological and feminist perspectives (pp. 85-112). Bradford, ON: Demeter Press.

David, D., & Montgomery, G. H. (2011). The scientific status of psychotherapies: A new evaluative framework for evidence‐based psychosocial interventions. Clinical Psychology: Science and Practice, 18(2), 89-99. http://dx.doi.org/10.1111/j.1468-2850.2011.01239.x

Kazdin, A. E. (2008). Evidence-based treatment and practice: New opportunities to bridge clinical research and practice, enhance the knowledge base, and improve patient care. American Psychologist, 63(3), 146-159. http://dx.doi.org/10.1037/0003-066X.63.3.146

O,Shea, L. (2018). On writing and the art of reflective practice. Gestalt Journal of Australia and New Zealand, 14(2), 83-88.  

Psychotherapy and Counselling Federation of Australia (2017). Code of ethics. Melbourne, Australia: Author. Retrieved from https://www.pacfa.org.au/wp-content/uploads/2017/11/PACFA-Code-of-Ethics-2017.pdf

Psychotherapy and Counselling Federation of Australia (2019). Evidence-informed practice statement. Melbourne, Australia: Author. Retrieved from https://www.pacfa.org.au/research/evidence-based-practice-statement/   

Ryan, G. T. (2019). The threads of a narrative: An exploration of identity. Psychotherapy and Counselling Journal of Australia, 7.

Schirmer, J. (2019). From ethics to ethos: An expanded agenda for counsellor training and development. Psychotherapy and Counselling Journal of Australia, 7.

Wampold, B., & Imel, Z. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work. New York: Routledge.

Westen, D., Novotny, C. M., & Thompson-Brenner, H. (2004). The empirical status of empirically support psychotherapies: Assumptions, findings, and reporting in controlled clinical trials. Psychological Bulletin, 130(4), 631-663. doi:10.1037/0033-2909.130.4.631

 


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