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Volume 18 Number 3 August 2003

The Journal of The British Psychological SocietyDivision of Counselling Psychology

CounsellingPsychology

Review

Special IssueEvidence-Based Practice

Counselling Psychology ReviewEditor: Alan Bellamy Pembrokeshire and Derwent NHS Trust

Reference Library Editor Waseem Alladin Hull University, Centre for Couple, Marital & Sex Therapy andand Consulting Editor: Hull & East Riding Health NHS Trust

Book Reviews Editor: Kasia Szymanska Centre for Stress Management

Consulting Editors: Malcolm C. Cross City UniversityRuth Jordan Surrey UniversityMartin Milton Surrey UniversityStephen Palmer Centre for Stress Management and City UniversityLinda Papadopoulos London Guildhall UniversityJohn Rowan The Minster CentreMary Watts City University

Editorial Advisory Board: Alan Frankland APSI NottinghamHeather Sequeira St. George’s Medical SchoolSheelagh Strawbridge Independent Practitioner and Kairos Counselling and

Training Services, Hessle, East Yorkshire

SubscriptionsCounselling Psychology Review is published quarterly by the Division of Counselling Psychology, and is distributed free of chargeto members. It is available to non–members (Individuals £12 per volume; Institutions £20 per volume) from:Division of Counselling PsychologyThe British Psychological SocietySt Andrews House48 Princess Road EastLeicester LE1 7DR.Tel: 0116 254 9568

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DisclaimerViews expressed in Counselling Psychology Review are those of individual contributors and not necessarily of the Division of Counselling Psychology or The British Psychological Society. Publication of conferences, events, courses, organisations and advertisements does not necessarily imply approval or endorsement by the Division of Counselling Psychology. Any subsequent promotional piece or advertisement must not indicate that an advertisement has previously appeared inCounselling Psychology Review.Situations vacant cannot be accepted. It is the Society’s policy that job vacancies are published in the AppointmentsMemorandum. For details, contact the Society’s office.

CopyrightCopyright for published material rests with the Division of Counselling Psychology and The British Psychological Societyunless otherwise stated. With agreement, an author will be allowed to republish an article elsewhere as long as a note isincluded stating: first published in Counselling Psychology Review, vol no. and date. Counselling psychologists and teachers ofpsychology may use material contained in this publication in any way that may help their teaching of counselling psychology.Permission should be obtained from the Society for any other use.

Counselling Psychology Review, Vol. 18, No. 3, August 2003

The British Psychological Society

Counselling Psychology ReviewVolume 18 ! Number 3 ! August 2003

Editorial 2Alan Bellamy

Guest Editorial: An Introduction to the Special Issue on 3Evidence-Based PracticeMartin Milton

Keynote Paper – Information, innovation and the quest for 5legitimate knowledgeSarah Corrie

First Response – ‘Storm and Stress’: 14The experience of learning evidence-based practicePatricia Monk

Second Response – Training Counselling Psychologists: 21What role for evidence-based practice?Nicky Hart & Kevin Hogan

Third Response – Testing the way the wind blows: 29Innovations and a sound theoretical basisYvonne Walsh

Book Reviews 35

Newsletter SectionLetter from the Chair 40Trainee Column 41Correspondence 43Conference Diary 44Talking Point: A question of identity 45Sheelagh Strawbridge

ONE OF THE difficulties in writing theseeditorials is the long lead-in timenecessary for a journal such as this.

Although you are reading this in August I wrotethis editorial back in May, shortly after theDivision’s Annual Conference in Stratford-on-Avon. We have a new Chair, Stephen Munt, anda new Divisional Committee, and we areentering a new year in the life of the Division ofCounselling Psychology. There are new issues tobe considered and existing ones still to beresolved. As always an enormous amount ofwork is being done behind the scenes by themembers of the committees and workinggroups of the Division, keeping things afloatand moving things on. We will try to keep youinformed of all this through these pages.

This is a Special Issue of CounsellingPsychology Review. The main section is focussedon a single topic, that of Evidence-BasedPractice. I expect all of us will have heard of thisconcept. It raises many fundamental questions

for Counselling Psychology practitioners,trainers, students and service managers, and wewelcome Martin Milton who has guest editedthis section in which many of those questionsare debated. This Special Issue is introduced byMartin, and takes the form of a Keynote Paperfollowed by three papers in response. If you likethis format let us know; there are other topicsthat we might treat in a similar way.

In the Newsletter Section we have the firstcontribution to a Trainee Column that I hopewill become a regular feature in future, and weend as always with Talking Point, which thismonth is written by Sheelagh Strawbridge.

We hope in coming issues to simplify thesubmission requirements for contributions toCounselling Psychology Review, and to encouragemore case studies and discussions; but more onthat next time. For the present, I hope you findthe following papers stimulating and enjoyable.

2 Counselling Psychology Review, Vol. 18, No. 3, August 2003

EditorialAlan Bellamy

COUNSELLING PSYCHOLOGIST SUPPORT NETWORKFor ALL Counselling Psychologists – Chartered, Trainee, Interested in Training.

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Meetings every two months – 10.00 am to 12.00 noon.Friars House, 6 Parkway, Chelmsford, Essex.

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Possible areas of discussion: Training, Placements, Employment, News, Research Issues, Specialist Interests,

Mutual Support, Networking.

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Organiser: Susan Van Scoyoc, Chartered Counselling Psychologist.

Please e-mail [email protected] for further information.

Counselling Psychology Review, Vol. 18, No. 3, August 2003 3

IT HAS BEEN a privilege to work with theauthors who have contributed to bring youthis Special Issue of Counselling Psychology

Review. I hope that we have succeeded inproviding the membership of the Division withsome thought provoking insights into thephenomenon that is Evidence-based practiceand the meanings and implications for ourwork as counselling psychologists.

When I first approached Sarah Corrie witha request (you might also read challenge/offerof a life time/poison chalice) to write a neatsynopsis of evidence-based practice for othersto respond to, I thought that she would laughat me or tell me that she did not want to evenconsider this. I thought that she might eitherwant to avoid what can sometimes feel like themost boring debate imaginable or equally wantto avoid being the recipient of the anxiety andhostility (Milton, 2002) that is often experi-enced in relation to the discourse ofevidence-based practice. That turned out to beextremely silly of me and I am immenselypleased that not only was she very keen to rise tothe challenge, but also that she did so in sucha prompt and clear manner. Seldom have Iseen the concept of evidence-based practiceoutlined so clearly and so relevantly. I am surethat you will agree that Sarah provides the restof this issue with a wonderful foundation.

When trying to initiate a debate in thepages of a journal you cannot of course relaxwhen you have found your intrepid first author– the task of finding respondents awaits. I haveto thank Patricia Monk, Nicky Hart and KevinHogan and Yvonne Walsh for surprising me

with their openness to the idea and their keen-ness to participate. All the strong-arm tacticsthat I imagined having to use never had to seethe light of day. More importantly of course, Ihave to thank them all for their willingness tospeak both professionally and from the heart.So seldom do we see the personal struggle ofengaging with evidence-based practice repre-sented in the literature and to their credit, allof these authors speak eloquently from theheart.

I am immensely pleased that the work ofthese authors attests to the diversity that makesup the profession of counselling psychology inthis country. While the participants all note, inone way or another, that disagreeing with thenotion of basing ones practice on goodevidence is almost absurd, the four contribu-tions here manage to alert us to differentimplications of this debate and help usconsider the epistemological positions andimplications for our work. The contributorsmanage to address the manner in which theseissues are a part of so many different aspects ofour profession – training, teaching, practiceand of course research.

I have noted the brief that Sarah Corrie wasgiven and how admirably she achieved this. Ishould also inform the readers of the brief thateach of the respondents was given. All therespondents were asked to do two things.Firstly, they were all asked to respond as theysaw fit to the issues raised in the main paper. Inaddition to that, they were each asked toaddress evidence-based practice from theirparticular experience. Therefore, Patricia

Guest Editorial: An Introduction to theSpecial Issue onEvidence-Based PracticeMartin MiltonSurrey University.

Monk, a recent graduate of the Surrey course,was asked to give voice to the experience oflearning about, and how to ‘do’ evidence-basedpractice. Nicky Hart, the course director of theWolverhampton course and her colleague KevinHogan rose to the challenge of giving voice tothe issues involved in teaching evidence-basedpractice. And Yvonne Walsh, Head of SubstanceMisuse and Dual; Diagnosis for North EastLondon Mental Health Trust, was asked toreflect on working within the discourse ofevidence-based practice – or of being evidence-based in her practice. I am sure that you willfind these contributions as fascinating as I did.

The Editorial Board of CPR has long wantedthe pages of the Divisional mouthpiece todebate the main issues of the day and under theexcellent editorship of Alan Bellamy and hispredecessors, we are, of course, familiar withthis. It is in this same spirit of debate that we arehoping these articles will be engaged with andwe hope that now Corrie, Monk, Hart, Hoganand Walsh have had their say, that the member-ship will want to join us in this debate. In

particular we look forward to your responses –whether it be on the letters pages or requests tothe editor to submit an article for the newlyestablished ‘Talking Point’ or of course thesubmission of academic articles for CPR. This ishugely important as there are so many perspec-tives that we could not cover in this one issue.Representatives of particular models have notyet been able to represent their views here, norhave the recipients of evidence-based practice.The readership will know of many otherconstituencies whose voices can only enrich thedebate, our learning and of course the quality ofour work. We look forward to hearing from you.But before then, we hope that you will settledown and enjoy the next few articles.

ReferencesMilton, M. (2002). Evidence-based practice:

Issues for psychotherapy. PsychoanalyticPsychotherapy, 16(2), 160–172.


5Counselling Psychology Review, Vol. 18, No. 3, August 2003

Keynote Paper –Information, innovationand the quest forlegitimate knowledgeSarah CorrieUniversity of London.

The ever-pressing need to advance the practice ofpsychological therapy has, in recent years, led to thedevelopment of evidence-based practice: a frameworkwhich elevates research findings to the heart of the ther-apeutic endeavour. Proposed as a means of developingthe professional practice of individuals, as well asinforming service planning more broadly, the intro-duction of evidence-based practice raises critical issuesof a methodological, epistemological and professionalnature that are yet to be adequately addressed. As theseissues have a potentially profound impact on the devel-opment of the profession, they require on-goingdiscussion and review. By considering some of thepotential benefits and costs of this approach to healthcare, the aim of this paper is to create a forum fordebate and in doing so, raise questions that requireour individual and collective attention as we take theprofession forward into the 21st century.

The introduction of evidence-based practiceinto mental health care generally and thepsychological professions specifically has beenhailed as a significant advance (Chambless &Ollendick, 2001; Sacket, Rosenberg, Gray et al.,1996, as cited in Salkovskis, 2002). Based on thephilosophy that the delivery of therapeuticinterventions should be informed by evidenceof effectiveness, evidence-based practice aims to‘ground’ therapeutic practice firmly within thelatest research findings and by doing so,improve the quality of health care offered toclients in a rigorous and systematic way.

Evidence-based practice has critical implica-tions for the development of counsellingpsychology and raises certain key questions. Forexample, to what extent is its philosophy consis-tent with the underlying value system ofcounselling psychology, which at its core privilegesrespect for the personal, subjective experience ofthe client over and above notions of diagnosis andtreatment (Division of Counselling Psychology,2001)? To what extent should counselling psychol-ogists embrace or reject evidence-based practice asa means of enhancing professional effectiveness,given the profession’s explicit endorsement of thescientist-practitioner model (Woolfe, 1996)? Howare the prevalent discourses about evidence influ-encing commissioners’, clients’ and even our ownexpectations of what therapy can achieve? Giventhat both health care delivery and the policiesdevised to support it are continually evolving,these questions require on-going reflection anddebate.

The aim of this paper is to consider theimpact of evidence-based practice1 on theservices we provide and how we provide them.In particular, through revisiting some of theways in which evidence-based practice canenhance and hinder our practice, it is hopedthat this paper will create a forum for discussionabout how counselling psychologists might wishto position themselves within a professionalclimate that seems increasingly preoccupiedwith evaluation and justification.

1 As the aim here is to consider the broad implications of evidence-based practice for counselling psychology practice,individual policies will not be reviewed in depth. The interested reader will be referred to the relevant sources for furtherinformation.

The relationship betweenresearch and practice revisited: A thoroughly modernpartnership

IN RECENT YEARS, professional practice hascome under increased scrutiny. Concernsabout variability in standards of health care

delivery coupled with the need to improveconsistency of clinical decision-making havecontributed to a government driven commit-ment to quality assurance initiatives focusing onestablishing clear national standards for prac-tice (Scally & Donaldson, 1998). Inconsequence, it is now the responsibility of allNHS Trusts to incorporate systems of moni-toring clinical care which in turn can bothshape and be shaped by clinical governanceframeworks.

The over-arching aim of clinical governanceis to ensure a high quality of health care in theNHS (Department of Health, 1999). Through acommitment to audit, lifelong learning and theuse of research findings to inform therapeuticplanning, the intention is to address the devel-opmental needs of both the organisation andthe practitioners within it, thus creating facilita-tive work environments that can promoteeffective outcomes and minimise poor practice.

A central component of clinical governanceis evidence-based practice. As a framework forguiding the provision of services, evidence-based practice reflects the principle that thedelivery of therapeutic interventions should beinformed by evidence of effectiveness(Department of Health, 1996, 1997; Evidence-Based Medicine Working Group, 1992). Thus,in its simplest form, if there is evidence tosuggest that ‘Therapy A’ is effective in treating agiven disorder, then ‘Therapy A’ should be theinitial treatment of choice (Department ofHealth, 2001). In this way, research has becomeidentified as a primary means of determiningchoice of therapeutic method.

There are a number of ways in whichevidence-based practice may advance the prac-tice of psychological therapy. These includeimproving the consistency of therapeutic deci-sion-making, promoting equality of access toeffective interventions across services andenhancing the development of a systematicknowledge base about what works best for which

type of presenting problem (Shapiro, Lasker,Bindman & Lee, 1993).

Moreover, evidence-based practice has thepotential to create a closer working partnershipbetween research and practice. As McLaren andRoss (2000) observe, it has long been recognisedthat the NHS has failed to benefit from its invest-ment in research, as the world of practice hasconsistently failed to incorporate empirical find-ings into its clinical decision-making and serviceplanning. In failing to do so it could be arguedthat professional practice has fallen short of itsobligation to the public. Evidence-based practicethen, is the means of rectifying this divide bycreating closer links between what is knownempirically and what we do professionally.

Underscoring the arguments in favour ofevidence-based practice is a certain moralimperative. Within the broader framework ofclinical governance, evidence-based practicechallenges us to reflect on what we offer ourclients in a systematised way. By basing our treat-ment choices on the latest developments inunderstanding human behaviour, we can besure that we are relying on something moresystematic and robust than clinical judgement.We will also be better equipped to protect ourclients against poor practice. (‘Poor’ here, canbe understood as the uncritical application oftheory or technique that is based exclusively onpersonal preference, therapeutic tradition orpractices that are simply out of date.)

To the extent that evidence-based practice isgenuinely concerned with improving theservices we offer our clients the philosophy is,arguably, a laudable one. Who would disagreewith the need to ensure that our clients areoffered only effective interventions or theimportance of protecting them from harmfulpractices? Similarly, it is difficult to challengethe principle of using research to inform ourpractice-related endeavours, given the profes-sion’s official endorsement of and allegiance tothe scientist-practitioner model (Woolfe, 1996).Arguably, evidence is vital for counsellingpsychologists because, as Owen (1996) pointsout, if there is no reliable knowledge, how canwe progress in our understanding of humandistress in any systematic way? Evidence andknowledge are not necessarily the same thing,however, which raises questions such as:


! What sources of knowledge represent‘legitimate’ evidence?

! How much evidence is needed beforepractitioners should be expected to altertheir practice in light of it?

! How should practitioners go about applyingthe existing evidence in their work withindividual clients?

! How should we respond when faced with apresenting problem (or problems) forwhich no evidence-base exists?These questions arise, in part, from the fact

that evidence is expected to perform multiplefunctions. Even a cursory glance at the litera-ture illustrates that evidence-based practice isnot concerned solely with individual clinicians,but also with those responsible for managingand commissioning psychological services.Indeed, as Bellamy and Adams (2000) observe,discussions about the quality and quantity ofevidence are now permeating every aspect ofservice provision, including decisions aboutwhich therapies to commission and how tojustify service rationing.

It is not difficult to appreciate the appeal ofevidence-based practice to those who carry theresponsibility of deciding how to spend limitedfunds on their local populations. Basing serviceplanning on good solid evidence lends an air ofcredibility to the decision-making process,promising a means of simplifying a complexarray of factors into something more tangibleand prescriptive. After all, research evidence issomething in which we can place our faith. Byvirtue of its objectivity, it removes precedent andprejudice from the equation enabling servicemanagers to grasp ‘the facts’ about what reallyworks and thus to have greater confidence inwhich kinds of service to prioritise. However,this kind of task is fundamentally different fromimproving the practice of individual cliniciansand may require a different approach to itsinvestigation. Thus when thinking about thenature of evidence – what is meant by the term,for what purpose it is being gathered and howto translate it into a workable reality for thera-peutic practice – a more complex picture beginsto emerge.

Whose evidence is it anyway? It is important to note that the concept of‘evidence’ has not been defined in terms of anyone type of data. As Owen (2001) notes, there isroom for both qualitative and quantitativeapproaches to data collection suggesting that, atleast in principle, evidence can be gatheredfrom a rich and diverse range of sources.However, some types of research are deemed tobe more worthy of our attention than others.Specifically, in the quest for scientificrespectability, the philosophy of evidence-basedpractice privileges the rigorously objective overthe relative and subjective, identifying therandomised controlled trial as its ‘gold stan-dard’ (Department of Health, 1996; 2001; Roth& Fonagy, 1996).

This type of hierarchy is not new. Forexample, drawing on the earlier work ofKaminski (1970; cited in Kanfer & Nay, 1982),James (1994) acknowledges that whilst know-ledge of empirically derived relationships maybe the ideal, this type of information is typicallylacking when trying to understand the complexand multifaceted nature of human experience.When such information is unavailable, Jamesasserts that it becomes imperative to seek outalternative (if less rigorous) sources of knowl-edge such as theory, which enables therapists tomake informed decisions despite an absence ofempirical data. Similarly, when theoreticalknowledge is lacking, James proposes that it isentirely appropriate to base decisions solelyupon procedures established through sharedprofessional beliefs and the common practice ofpeers. In this way, the notion of evidence can besaid to include therapists’ individual, social andcultural experiences – in some circumstances, atleast.

We see this type of hierarchy played out inthe framework of evidence-based practice.Thus, the Department of Health (1999)identifies five types of evidence ranging fromType I (at least one good systematic review studyand at least one randomised controlled trial) toType V (the opinion of experts, users andcarers). The hierarchy of different types ofknowledge can be used to justify how, when andwhy certain decisions are made, but the prefer-ence is clear. Whilst there is anacknow-ledgement of non-empirical forms of


evidence, these are not given the same credenceas the aggregate studies that accumulate resultsover time and across populations. It is outcomedata, with their promise of prescriptive recom-mendations, that are considered the idealsource of information upon which to baseservice provision (Owen, 1999). However,equating optimum evidence with this type ofdata is not without its problems.

The quest for evidence andthe desire for certainty: Theimpact of prevailingdiscoursesThe difficulties in translating the findings fromrandomised controlled trials into routineclinical practice are legion and have beendiscussed extensively elsewhere (see forexample, Bower & King, 2000; Bruch, 1998;Richardson, Baker, Burns et al., 2000). Perhaps,however, the major drawback is that large-scalestatistical studies simply cannot provide infor-mation on the kinds of therapeutic innovationthat are required in routine therapeutic prac-tice (Roth, 1999).

In order to respond to people’s needs, ther-apists will always be in a position where theyhave to devise spontaneous and innovativeinterventions (Long & Hollin, 1980). Moreover,it has been shown that many therapists innovatevery successfully (Barlow, 1981). There is littlethat the research trials can tell us about theskills needed to achieve this, however, and so wefind ourselves confronting once again the voidthat exists between the carefully controlled envi-ronment of the research setting and thespontaneous, creative and more ‘fluid’ encoun-ters of the clinical domain.

Whilst outcome data produced byrandomised controlled trials are of considerableimportance in terms of producing informationabout populations, there is a problem withdefining outcome as the optimum source ofevidence. Most notably, a preoccupation withthe ‘product’ of therapy in isolation (forexample, an exclusive focus on symptom reduc-tion or behaviour change) can lead to a beliefthat therapeutic outcome can be predicted withgreater certainty than may in fact be the case.

It is not difficult to see how such thinkingmay have developed. Although never statedabsolutely, the idea of certainty is undoubtedlyimplied, as evident from the pronouncementsthat certain ‘treatments’ are best for certaintypes of ‘psychopathology’ and the movetowards creating lists of empirically supportedtreatments (Department of Health, 1996). Thisimplies that there is (or that with sufficientresearch there could be) a correct solution toevery clinical problem: an outlook more consis-tent with the medical model, than the rationaleunderlying psychological therapy.

Moreover, the desire for prescriptive solu-tions raises very real concerns both for ourselvesand our clients. Not least of these is an ethicalissue concerning how we manage clients’ expec-tations about what therapy can and cannotprovide. Could it be that the current emphasison evidence as outcome may, in some cases, bemisleading the public about what to expectfrom psychological therapy? Or that the preva-lent discourses about evidence and efficacy areframing clients’ expectations in ways that aredetrimental to the therapeutic process? Anexample from my own practice suggests that thismay indeed be the case.

During my initial consultation with a clientwhom I shall call David2 I explained the purposeof our meeting was to explore the nature of hisdifficulties with a view to establishing whetherpsychological therapy might be of benefit tohim. However, David quickly interrupted mestating that he already knew what he needed.Given the nature of his difficulties, he told me,he required ‘either IPT or CBT’.

Whilst open to exploring these possibilitieswith him within the broader assessment process,I was struck by the certainty with which heexpressed his preference for the type of ‘treat-ment’ he felt he needed. When encouraged toshare how he had arrived at his decision, Davidtold me that he had accessed the outcome liter-ature which demonstrated the superiority ofIPT and CBT over other approaches. As a result,in his eyes, any other approach would inevitablybe inferior.

Interestingly, David was unable to articulatehis understanding of what these approaches


2 In order to protect confidentiality, the name of the client has been changed.

entailed and had a number of misconceptionsabout psychological therapy itself (for example,believing that symptoms were treated withformulaic responses from the therapist, admin-istered in the form of specific instructions andadvice). Not surprisingly, perhaps, when he wasoffered therapy, he disengaged very quickly; hisexperience of therapy was not what he hadexpected.

The question here is not the supremacy ofone approach over another but rather the needto be aware of how the current focus onevidence as outcome may be framing ourclients’ expectations in ways that are detri-mental to a reflective and collaborativeexploration of their idiosyncratic needs. WhilstDavid’s expectations of therapy perhapsreflected something about his own psycholog-ical processes, I could not help wonderingwhether he would have found therapy morehelpful if his thinking had been less organisedaround the outcome literature. To himevidence-based practice meant having aprescriptive solution to a clear-cut problem, butit was a certainty that ultimately provedbeguiling.

David’s example is not an isolated one. Ihave worked with numerous clients who initiallyrequested a certain type of ‘treatment’ on thebasis of their (mis-) understanding of what theterm ‘empirically supported therapy’ actuallymeans. Of further concern, however, is thatreferrers may be following a similar trend. Thus,increasingly, I am being asked to provide aparticular type of ‘treatment’ rather than apsychological service. It is as though accessinginformation on outcomes has led some refer-rers to lose sight of the need for a thoroughassessment and clear formulation. A particularlystriking example of this comes from Dawes who,in advising general practitioners on the properuse of evidence, exalts the benefits of electroni-cally available outcome data on the groundsthat they have: ‘the additional bonus of avoiding theneed to carry out the tasks of critical appraisal’ (1996,p.68). The assumption seems to be that withenough evidence, clinical judgement can beshort-circuited, or even bypassed altogether.

Of course, it is not just our clients or refer-rers who are likely to be influenced by theprevailing discourses around evidence and

effectiveness. In research I conducted lookingat practitioners’ perceptions of the role ofresearch and evidence in practice (Corrie &Callanan, 2001), all the participants definedresearch in terms of large-scale statisticalstudies. What was striking in the context of theenquiry, however, was that they were partici-pating in a study that was qualitative. Althoughthere may be several ways of interpreting thisfinding, one possibility is that the mentality ofevidence-based practice is framing our under-standing of research in ways we are not fullyconsciously aware of. As Farhy and Milton(1998) remind us, we need to think carefullyabout how the contexts in which we work areshaping our practice. Perhaps the same couldbe said of our relationship to research.

Searching for an alternativeframework: Moving beyondevidence as outcome The problems of identifying randomisedcontrolled trials as the ideal way of evidencegathering does not undermine the value ofquantitative research methods per se. I am alwayssaddened when I hear dismissive commentsabout the contribution that quantitativeresearch methods can make to furthering ourunderstanding of human experience anddoubtless, there are many excellent examples ofquantitative research being produced and usedin the name of evidence.

Moreover, as advocates of evidence-basedpractice will be quick to point out, contempo-rary thinking has moved beyond the relativelysimplistic conceptualisations of evidence asoutcome. Ideas about evidence are being re-evaluated and expanded. Consequently, we seemore of a focus on achieving an evidence-basethat encompasses questions around process andcontext (McLaren & Ross, 2000). There is also,as Tarrier and Calam (2002) observe, a newoutlook on the research protocol which arguesfor the importance of including idiographicassessment and treatment within a case formu-lation approach (Persons, 1991). However,there may still be a need for caution. Whilstideas about ‘legitimate’ evidence may beexpanding, the emphasis on accumulatingevidence in the form of outcomes is still,arguably, alluring for those who have to make


concrete decisions about how to spend theirlimited funds. Certainly, in my own experience,conversations about evidence as it relates tolocal service planning rarely tend to go beyonda knowledge of the outcome literature.

The problem is, arguably, less to do withmethod and more about different stakeholders’expectations of method. Each type of method-ology is only equipped to answer a limited rangeof questions. Thus it cannot be assumed that themethods needed to further psychological prac-tice will be the same as the methods needed todecide how to control service delivery andjustify service rationing. If we fail to recognisethis (and help others recognise it) then we runthe risk of accumulating an evidence base thatdoes not really tell us anything of value.

A related point is made by Salkovskis, whoargues that one of the problems of equatingevidence first and foremost with outcome data isthat it confuses the reflective use of the scien-tific method with what he terms the ‘unthinkingapplication of scientism’ (2002, p.4). ForSalkovskis, current definitions of evidencelargely fail to consider the optimal relationshipbetween research and reflective clinicalthinking. It is almost as though, in the searchfor effective outcomes, evidence-based practicehas lost sight of the need to further our under-standing of the skills required for reflectivepractice. Instead, he advocates the need for‘empirically grounded interventions’ – anapproach to research in which clinical practiceis held paramount at all times because itreflects: ‘...Both the target of our work and a sourceof information and inspiration that drives otheraspects of the process of empirically grounded clinicalpractice.’ (2002, p.4)

Seen in this light, the search for evidencemust always begin with a desire to understandour clients’ stories: it is the phenomenology ofour clients’ difficulties that enables us to iden-tify meaningful hypotheses about specificpsychological problems and to use the results ofour investigations to inform subsequent theo-retical and practice-based innovations.

This sentiment is echoed by Moran whowarns against perceiving research as following aseries of set procedures and always yieldinguseful answers. He argues that we must develop(and encourage others to develop) a more

sophisticated outlook on research whichembraces a reflective and reflexive approach towhat is essentially a ‘profound engagement with aquandary’ (1999, p.45).

Although both authors come from verydifferent epistemological positions, withSalkovskis embracing the quantitative paradigmand Moran arguing from a more qualitativestance, the concerns are strikingly similar. LikeSalkovskis, Moran emphasises the importanceof being phenomenon-driven rather thanmethod-driven. This is perhaps where thecurrent conceptualisations of evidence are stilltending to come unstuck – particularly when itcomes to informing the development of profes-sional practice in a more robust and useful way.

If we regard evidence as driven primarily bya search for phenomenological understanding,then it becomes imperative to embrace a verywide range of methodologies and epistemolo-gies. This would encompass both idiographicand nomothetic approaches to informationgathering and combinations of both, asdescribed by Salkovskis (2002) and Tarrier andCalam (2002) in relation to case formulationapproaches. It might also, as Newnes (2001)suggests, take us beyond the realms of the scien-tific into the world of literature, biography andpersonal experience: not as diluted versions ofsome objective ideal, but as sources of knowl-edge that have the potential to shape how wework in profound ways. Embracing such anoutlook would require a willingness to relin-quish some of the comforting respectability thata scientific model seems to offer. However, itmight also generate a rich and diverse range ofinformation that is more congruent with theneeds of individual practitioners attempting tomeet the needs of their individual clients.

The challenge of knowledgegathering: Some conclusionsand further questionsAs Newnes (2001) observes, the concept ofevidence is neither straightforward norsimplistic. Evidence does not present itself innice neat packages with clear instructions onhow to apply it. Instead, it has to be crafted outof a multiplicity of findings which in turnrequires considerable skill in uniting enquiry,


methodology and interpretation within specificprofessional and organisational contexts.

Consequently, it would seem that there is anart to searching for and accumulating evidenceas well as a scientific basis. The relationshipbetween art and science is a topic of debate inits own right and well beyond the scope of thispaper. However, we would do well to rememberthat professional practice cannot fit neatly intoeither camp, because as Phillips (1999) remindsus, therapy is a difficult activity to place. We canexplore ways of refining skill and developempirically-grounded interventions but therewill always be elements of the therapeuticprocess that remain intangible, mysterious andeven magical (Milton & Corrie, 2002).

Ultimately, the extent to which we defineourselves as artists or scientists may reflect howwe wish to position ourselves within theevidence-based practice debate. As Strawbridge(1997) suggests, we need to be clear aboutwhether we see ourselves primarily as producersof knowledge or consumers of it. It is, of course,possible to be both. However, if we are toproduce and consume knowledge ‘effectively’then we need to be clear about the activities andresponsibilities that each position entails. Forexample, when we are operating as producers ofknowledge we must consider carefully the kindsof knowledge we are creating. Similarly, if we areactively contributing to a developing body ofevidence, it could be argued that we have aresponsibility to ‘police’ how our research find-ings are used. In this way, counsellingpsychologists may have a key role to play in chal-lenging contemporary definitions of evidence,or commenting publicly if they believe thatmethodologies are being misused or misapplied.

In our role as consumers of research ouractivities and responsibilities may look verydifferent. We need to consider how we wish toposition ourselves in relation to other people’sevidence and to what extent – and when - weshould adjust our working practices in light ofit. We also need to reflect on the kinds ofdialogue we should be having with otherconsumers – particularly commissioners andclients – about the nature of research and itsrole in shaping service delivery.

Being consumers of knowledge may alsohave implications for our identities as scientist-

practitioners. Is it still appropriate for coun-selling psychologists to identify themselves withthe scientist-practitioner model on those occa-sions when they are not actively producingevidence? Or is the scientist-practitioner model aphilosophy of practice that has outlived itsusefulness and which needs updating in the lightof contemporary health care developments?Moreover, if we are to be both producers andconsumers of research, what kind of professionalidentity would reflect the scope and diversitythat these different roles entail? These issuesraise political as well as professional questionsthat have fundamental implications for the posi-tioning of the profession in the 21st century.

Whilst these issues require our urgentcollective attention, I must confess that many ofthe concerns occupying my thinking on a day-to-day basis are of a qualitatively different kind.Typically, when I am reflecting on my own needsas a reflective practitioner, and upon thera-peutic practice more generally, the questions Ireally want answers to include: ! What are the personal qualities, skills and

types of knowledge we need to achieveoptimum practice?

! What skills do we need to innovatesuccessfully?

! What skills do we need to be effectiveknowledge- (evidence-) gatherers in ourinteractions with clients?

! What is the art/science of asking goodquestions?

! What are the skills needed to decide whichmethodology is most helpful forinvestigating a particular kind of question?

! What skills are needed for effective andethical therapeutic decision-making?

! What are the reflective abilities we need toachieve an informed use of researchfindings?Although these questions may seem less

‘dazzling’ than the promise of definitiveanswers for specific disorders, they may just bethe kinds of questions that others involved inplanning, delivering and receiving psycholog-ical therapy are interested in, too. So I presentthem as possibilities for engaging in the moreprofound type of enquiry which Moran (1997)favours. An in-depth knowledge of these areasreally would be an evidence-base worth having.


ReferencesBarlow, D.H. (1981). On the relation of clinical

research to clinical practice: current issues,new directions. Journal of Consulting andClinical Psychology, 49(2), 147–155.

Bellamy, A. & Adams, B. (2000). An evaluationof the clinical effectiveness of a counsellingpsychology service in primary care.Counselling Psychology Review, 15(2), 4–12.

Bower, P. & King, M. (2000). Randomisedcontrolled trials and the evaluation ofpsychological therapy. In N. Rowland & S. Goss (Eds.), Evidence-based counselling andpsychological therapies (pp.79–110). London:Routledge.

Bruch, M. (1998). The development of caseformulation approaches. In M. Bruch &F.W. Bond (Eds.), Beyond diagnosis. Caseformulation approaches in CBT (pp.1–17).Chichester: Wiley.

Chambless, D.L. & Ollendick, T.H. (2001).Empirically supported psychologicalinterventions: Controversies and evidence.Annual Review of Psychology, 52, 685–716.

Corrie, S. & Callanan, M.M. (2001).Therapists’ beliefs about research and thescientist-practitioner model in an evidence-based health care climate. British Journal ofMedical Psychology, 74, 135–149.

Dawes, M.G. (1996). On the need for evidence-based general and family practice.Evidence-Based Medicine, 1(3), 68–69.

Department of Health (1996). NHSPsychotherapy Services in England Review ofStrategic Policy. London: Department ofHealth.

Department of Health (1997). The New NHS:Modern, Dependable. London: Department ofHealth.

Department of Health (1999). National ServiceFrameworks for Mental Health: ModernStandards and Service Models. London:Department of Health.

Department of Health (2001). Treatment Choicein Psychological Therapies and Counselling:Evidence-Based Clinical Practice Guidelines.London: Department of Health.

Division of Counselling Psychology (2001).Professional Practice Guidelines. Leicester: The British Psychological Society.

Evidence-Based Medicine Working Group(1992). Evidence-based medicine: A newapproach to teaching the practice ofmedicine. Journal of the American MedicalAssociation, 268(17), 2420–2425.

Farhy, E. & Milton, M. (1998). Psychology,psychotherapy and paymasters: A cautionary tale. Counselling PsychologyReview, 13(1), 35–38.

James, J.E. (1994). Health care, psychology andthe scientist-practitioner model. Australian Psychologist, 29(1), 5–11.

Kaminski, G. (1970). Verhaltenstheorie undVerhaltensmodifikation. Stuttgart: Ernst KlettVerlag.

Kanfer, F.H. & Nay, W.R. (1982). Behaviouralassessment. In G.T. Wilson & C.M. Franks(Eds.), Contemporary behaviour therapy(pp.367–402). New York: Guilford.

Long, C.G. & Hollin, C.R. (1997). Thescientist-practitioner model in clinicalpsychology: a critique. Clinical Psychologyand Psychotherapy, 4(2), 75–83.

McLaren, S.M.G. & Ross, F. (2000).Implementation of evidence in practicesettings: some methodological issues arisingfrom the South Thames Evidence BasedPractice Project. Clinical Effectiveness inNursing, 4, 99–108.

Milton, M. & Corrie, S. (2002). Exploring theplace of technical and implicit knowledgein therapy. The Journal of Critical Psychology,Counselling and Psychotherapy, 2(3), 188–195.

Moran, J. (1999). Response to John Rowan’sarticle: ‘A personal view: Concerns aboutresearch’. Counselling Psychology Review,14(3), 45–46.

Newnes, C. (2001). On evidence. ClinicalPsychology, 1(1), 6–12.

Owen, I. (1996). Are we before or afterintegration? Counselling Psychology Review,11(3), 12–18.

Owen, I. (1999). The future of psychotherapyin the UK: Discussing clinical governance.British Journal of Psychotherapy, 16(2),197–207.

Owen, I. (2001). Treatments of choice, qualityand integration. Counselling PsychologyReview, 16(4), 16–22.


Persons, J.B. (1991). Psychotherapy outcomestudies do not accurately represent currentmodels of psychotherapy. AmericanPsychologist, 46, 99-106.

Phillips, A. (1999). Poetry and Psychoanalysis(in conversation). Inaugural Annual Inter-Disciplinary Lecture for The Guild ofPsychotherapists.

Richardson, A., Baker, M., Burns, T., Lilford,R.J. & Muijen, M. (2000). Reflections onmethodological issues in mental healthresearch. Journal of Mental Health, 9(5),463–470.

Roth, A. (1999). Evidence-based practice: Is there a link between research and practice?Clinical Psychology Forum, 133, 37–40.

Roth, A. & Fonagy, P. (1996). What works forwhom. A critical review of the psychotherapyoutcome literature. London: Guilford Press.

Sacket, D.L., Rosenberg, W.M., Gray, J.L. et al.(1996). Evidence-based medicine: What it isand what it isn’t. British Medical Journal, 312,559–574.

Salkovskis (2002). Empirically groundedclinical interventions: Cognitive-behavioural therapy progresses through amulti-dimensional approach to clinicalscience. Behavioural and CognitivePsychotherapy, 30, 3–9.

Scally, G. & Donaldson, L. (1998). Clinicalgovernance and the drive for qualityimprovement in the NHS in England.British Medical Journal, 317, 61–65.

Shapiro, D.W., Lasker, R.D., Bindman, A.B. &Lee, P.R. (1993). Containing costs whilstimproving quality of care: The role ofprofiling and practice guidelines. AnnualReviews of Public Health, 14, 219–241.

Strawbridge, S. (1997). Reflective practice andthe Diploma. Counselling Psychology Review,12(2), 74–78.

Tarrier, N. & Calam, R. (2002). Newdevelopments in cognitive-behavioural caseformulation. Epidemiological, systemic andsocial context: An integrative approach.Behavioural and Cognitive Psychotherapy, 30,311-328.

Woolfe, R. (1996). Counselling psychology inBritain: Past, present and future. CounsellingPsychology Review, 11(4), 7–15.

CorrespondenceSarah CorrieDepartment of PsychologyRoyal HollowayUniversity of LondonEghamSurrey TW20 0EX.



EVIDENCE-BASED PRACTICE was never farfrom our thoughts and discussions astrainees on the PsychD course in

therapeutic and Counselling Psychology at theUniversity of Surrey. The course is committed tointegration at various levels, with particularemphasis given to the integration of psycholog-ical knowledge and research evidence intotherapeutic practice. Accordingly, the demandsplaced on our ability and capacity to draw fromthe different domains of theoretical psychology,research psychology and applied psychology inorder to make sense of and account for ourwork were great. As simultaneous consumers ofknowledge, small scale producers of knowledgeand developing practitioners within specificplacement settings, the sorts of issues and ques-tions raised by Corrie resonated strongly withthose we struggled with as trainees (and those Istill struggle with). Issues related to theprocesses of identifying, using and generating‘legitimate’ know-ledge/evidence; issuesaround the dominance of particular researchparadigms in relation to evidence generally andthe stance counselling psychology as a profes-sion takes towards this situation; and issuesthrown up by the particular interpretations ofevidence-based practice within our placementcontexts. Questions we asked included: Howcan we be most effective as consumers andproducers of psychological knowledge/evidence within our developing approach toevidence-based practice? What kind of scientist-practitioner model is most appropriate for thework we do and the way we do it? How far is itpossible to hold on (at least publicly) to these

positions in placement contexts which adoptdifferent (perhaps inappropriate) interpreta-tions of evidence-based practice? It seems thatwhen these placement contexts are also domi-nant institutions in society like the NationalHealth Service (NHS), holding on to positionsdeveloped within our own house can be verychallenging indeed.

Our own house – a university departmentdedicated to the training of counselling psychol-ogists and to the advancement of the professiongenerally – emphasised the critical evaluation ofmany coexisting theories and models of thera-peutic practice. This reflected a desire to keepdifferent possibilities open to us rather thanprivileging any one stance over others. Withsuch vast knowledge bases to draw from though,the task of learning a manageable approach toevidence-based practice at times felt over-whelming. From all that is available, how do wego about searching out and selecting thepsychological knowledge and research evidencethat best informs our therapeutic work andenables us to account publicly for it? Personalpreference for particular philosophies and ther-apeutic approaches played an important part inthis process for me, along with simple exposure(via course teaching, hand-outs and recom-mended reading lists), and the preferences ofkey individuals like supervisors. Something thatproved particularly useful in helping me toassess the appropriateness of the many sourcesof knowledge was what Aveline called the funda-mental practical question. ‘What are theimplications of this theory or portrayal of life for mypractice in my working environment with the [clients]

EVIDENCE-BASED PRACTICE was never far fromour thoughts and discussions as traineeson the PsychD course in Psycho-

First Response –Information, innovationand the quest forlegitimate knowledgePatricia MonkSurrey.

that I [meet with]?’ (1990, p.329, originalemphasis). Thus as consumers of knowledge wewere encouraged to take a reflective, evaluativeapproach to areas relevant to our own practice(including areas selected through personalpreference) and to appreciate contributionsfrom other disciplines.

The group supervision sessions on thecourse provided an opportunity to give voice toour developing approaches to evidence-basedpractice. We spoke about our client work usinglanguage which reflected the defining featuresof counselling psychology as a profession – ahumanistic value base, a reaction against themedical model, a focus on understandingsubjective personal worlds and an acknowledge-ment of the importance of the therapeuticrelationship (Woolfe, 1996) – and input fromgroup members reinforced these concerns.That is not to say that we did not also considerthe merit of input stemming from other stances.For example, thinking about particular changesin clients’ behaviour with reference to changesin their medication. However, whilst we mightmake reference to different stances, writingsand research findings, the phenomena of ourwork with clients comprised not only unique lifehistories and situations, but also ‘the significantpeculiarity of the subject matter [of the human world]:People talk’ (Rickman, 1990, p.295). Specificallythe talking and the negotiation (of meaning)taking place between two individuals within atherapeutic encounter – phenomena that arenotoriously difficult to study psychologically interms of generating a body of researchevidence. Social psychology has long discussedthe problems associated with any approachwhich regards meaning as its central subjectmatter. Indeed, there are formidable method-ological problems. ‘[People], the subject ofpsycho-social science, will not hold still enough to bedivided into categories both measurable and relevant’(Erikson, 1968, p.43).

As producers of knowledge we were encour-aged to engage directly with thesemethodological problems. I recall our researchtutor, saying ‘we should not be afraid of diffi-culty’ when it comes to doing work on real-lifeissues and his ‘constant mantra [that], if youdon’t want to change the world with yourresearch, then, frankly, don’t bother’ (Coyle,

quoted in McCourt, 2002). Thus in our researchmethods courses we had the opportunity toexplore different routes to ‘legitimate’ knowl-edge/evidence and to undertake research wefelt committed to and passionate about.

Whilst accepting the need for a ‘scientific’basis to counselling psychology, we also consid-ered the usefulness and appropriateness ofdifferent interpretations of the term scientificand associated research paradigms. The quanti-tative vs. qualitative research debate serves as auseful illustration here. We could even acceptthat, as a profession, we are perhaps well placedto occupy a pivotal position between positivismand phenomenology (Woolfe, 1996), howeverwobbly this position might be. Thus in a climateof tolerance and feeling like we might have achance to change the world, it made sense toconclude that counselling psychologists shouldembrace a wide range of possible identities,modes of practice, methodologies and episte-mologies – depending on their own style oftherapeutic practice, the clients they work withand the working environments they find them-selves in. The kind of inclusive stancerecommended by Corrie.

Leaving home: Welcome tothe real world However, changing the world is very difficultand I was quite unprepared for the intolerantclimates of some placement contexts. As Corrienotes, the climate within the NHS seemsincreasingly to reflect a preoccupation with eval-uation and justification. The co-ordinatingprinciple of clinical governance and its centralcomponent of evidence-based practice areclearly informed by particular dominantdiscourses – the medical model of disease, thesupremacy of positivist routes to ‘truth’, arelated evidence hierarchy - with a focus firmlyon outcomes. Indeed, it has been argued that inorder to promote and maintain quality in theNHS, strategies should continually bedeveloped ‘to ensure decision making about clinicalservices at all levels is driven by evidence of effective-ness coupled with systematic assessment of healthoutcomes’ (Winyard, 1995, p.1).

In our placement contexts we came face toface with the embodiments of these dominantdiscourses. A senior NHS manager responsible


for service planning was visiting the CommunityMental Health Team I was working in. Hestopped to ask me ‘what exactly is the differencebetween counselling psychologists and otherpsychologists or counsellors?’ I have been askedthis question many times and it seems that ouridentity does remain unclear within the NHS.Although this is a topic that has received a lot ofattention on its own, I will briefly outline its rele-vance for me in the evidence-based practicedebate. Insofar as founding traditions are char-acterised by basic assumptions which in turndistinguish particular methods and epistemolo-gies (Glassman, 1995), if counselling psychologydefines itself at least in part by reference to itsfounding tradition (Woolfe, 1996, 2002), then itcould be argued that our approach to evidence-based practice (or certainly our interpretationof science) should be congruent with ourfounding tradition. In answer to the manager’squestion, I acknowledged the difficulty withtrying to differentiate counselling psychologyfrom other professions on the grounds of thework we do and instead described our under-lying value system rooted in humanism and ourfocus on the therapeutic relationship as avehicle for change.

In the discussion that followed I emphasisedthat counselling psychologists acknowledge theneed to use robust evidence to inform theirtherapeutic practice, but added that theyperhaps accepted a broader definition ofevidence and valued qualitative methods morethan other psychologists. To illustrate this, Idrew on my own research into the outcomes ofpsychological therapy within a specific primarycare setting (Monk, 2001). He listened withinterest as I described my use of narrativeanalysis to characterise outcomes in the post-therapy accounts of clients I had interviewed. Ithought I had made a fairly strong case for theuse of qualitative approaches to evaluateoutcomes at a local level. However, his partingcomments firmly reinstated two dominantrepresentations within the NHS – the evidencehierarchy and the hierarchy of professions.‘Qualitative research can yield some interestinginformation about outcomes, but in my job Ineed numbers and the back-up of the really bigquantitative studies. Have you accessed theCochrane data base? That’s very good for

outcome data. But do you know who really bene-fits most from counselling in Primary Care?’ Iremained positive and optimistic and replied ‘Ithink largely it’s those clients who take up theoffer of therapy and engage well with the thera-pist and the process’. ‘No, no’, he said. ‘It’s GPs,they’re the ones who really benefit from coun-selling in Primary Care’.

I remember feeling disappointed, slightlypatronised and more than a little angry. Of mostconcern to me though was the realisation that,at least for this manager, counselling psychologyand its (qualitative) methods of research wereregarded as having little value in the NHS. Littlevalue to clients in primary care and little valueto managers responsible for planning clientservices (we were only redeemed by our value toGPs). I also felt resentment towards the exclu-sive nature of ‘evidence’ as it had beenrepresented by this manager, when in our ownhouse we had been at pains to be so inclusive inour consideration of what constitutes legitimateevidence. Of course we can understand thisexperience with reference to the kind of (neces-sary) compartmentalisation process that Corrieoutlines when she notes ‘it cannot be assumedthat the methods needed to further psycholog-ical practice will be the same as the methodsneeded to decide how to control service deliveryand justify service rationing’. This process ofcompartmentalisation can, I believe, extend tothe developing professional identity of thetrainee. We simultaneously hold the identitiesof counselling psychologist (developed in-house, as characterised by Woolfe, 1996, 2002)and counselling psychologist (‘employed’ in theNHS, characterised with reference to dominantdiscourses and required to operate withinframeworks informed by these dominantdiscourses). It may be that we manage thisconflict most successfully by dividing our profes-sional world into these two separate aspects,rather than attempting to search for anycongruence between them.

I experienced a good deal of anxiety at therealisation that the voice of my in-house identitywas at risk of being drowned out completely by amuch louder, more easily heard voice. It is rela-tively easy in this situation to defer to thedominant discourses around you (at leastpublicly) in order to be accepted and under-


stood. Indeed, Corrie reminds us how pervasivedominant discourses can be. In relation to herown research (Corrie & Callanan, 2001), thepractitioners she approached defined researchin terms of large-scale statistical studies, despitetheir participation in a qualitative study. Therequirements and common practices related to aparticular job may also be experienced as pres-sure to privilege dominant discourses overothers. I met with two of my training colleaguesrecently – both of whom now work in in-patientsettings within the NHS. They spoke about howthe roles they are now playing demanded the useof a particular language and precluded the useof others. One remarked ‘when you’re beingasked to present your client work in terms ofwhether someone is safe to be allowed back intothe community (because their bed is needed forsomeone else), to talk about your work in termsof the therapeutic relationship (even if that’show you had been conceptualising it in yourown evidence-based practice) would be just tooprecious, something much more basic is needed’.

Follow our dress code or youcan’t come inWhilst I accept that compartmentalising myprofessional world may ultimately be a necessarycoping strategy in order to benefit from theadvantages of working in the NHS, as a trainee Ilonged for congruence. I wanted to see coun-selling psychology’s inclusive stance towardsevidence-based practice acknow-ledged andmoreover, valued within the NHS. What Ilearned is that we’ve got a long way to go and alot of hard work to do before that happens.

I asked a colleague from the course whatfirst came into her mind when I said the phrase‘evidence-based practice’. She said What Worksfor Whom? by Roth and Fonagy (1996). Herresponse it emerged was motivated by herawareness of the particular interpretation ofevidence-based practice within the NHS. What Works for Whom? is a review ofpsychotherapy research that was commissionedby the Department of Health specifically toinform evidence-based practice. It is perhapsnot surprising to find that the authors do not gobeyond dominant discourses, accepting amedical model of disease and a hierarchy ofresearch evidence which acknowledges

randomised controlled trials (RCTs) as the‘gold standard’.

I imagine that a good number of coun-selling psychology trainees have had a copy ofWhat Works for Whom? on their bookshelf atsome stage of their course. Indeed, it should bethe concern of all practitioners to engage withthe question ‘does psychological therapy work?’Seduced by the appeal of cognitive economy in itsuse of categories which ‘minimise cognitive effortby representing aspects of our world in the most infor-mative but economical way’ (Roth, 1995, p.20),and possibly by the kind of certainty Corrierefers to, I was more than willing to make roomfor Roth and Fonagy’s book on my shelf.However, I found little in it to usefully informmy own therapeutic practice and much in it tochallenge my in-house identity. Indeed, I felt asense of hopelessness at the implication thatunless I could specify my model of therapeuticpractice using the language of the dominantdiscourses, it was unlikely to have any chance ofbeing considered effective anyway.

Whilst I accept that the most importantimplication of the current focus on evidence asoutcome may be in ‘framing our clients’ expec-tations in ways that are detrimental to areflective and collaborative exploration of theiridiosyncratic needs’ (Corrie, this volume), I can’t ignore the heirarchy of approaches thatis invoked either. It is not surprising that theclient, David, requested IPT and in particularperhaps, CBT. In the move towards empiricallysupported therapies, some therapeuticapproaches do appear more frequently as thetreatment of choice over others. Recall herethat empirically supported therapies are clearlyspecified psychological ‘treatments’ that havebeen found to produce statistically significanthealth benefits through controlled research,with clearly defined populations usually delin-eated on the basis of diagnostic systems(Chambless & Hollon, 1998). For example,Kneebone and Dunmore argued that on thebasis of the fit between empirically supportedtherapy criteria and CBT, ‘a number of studiessuggest the type of therapy worthy of trial [in the caseof post-stroke depression] is CBT’ (2000, p.63). Isthis the kind of closer working partnershipbetween research and practice that will bringmost benefit to clients and practitioners?


I felt a good deal of frustration by what I sawlargely as the attempt to demonstrate thesupremacy of one approach over another. Thehighly specific and rigid inclusion criteria of thekind used to establish empirically supportedtherapies began to look like Cinderella’s glassslipper to me. Like the slipper, the criteria arepresented on a velvet cushion for all to try, butonly if you practice a highly specified and struc-tured model of therapy with demonstrable,measurable outcomes, will you come close tomeeting them – only if you are Cinderella willyour foot fit the slipper. Perhaps David’s[mis]conception of therapy was not as wide ofthe mark as we might think. If such ill fittingmethods continue to inform evidence-basedpractice in the NHS, counselling psychologyruns the risk not only of accumulating anevidence base of little value (Corrie, thisvolume), but also the attempt to influence theparticular way (Woolfe, 1996, 2002) we practicethrough the application of homogenising andprescriptive clinical guidelines.

Change the world or frankly,don’t botherIt is of course encouraging to hear the voicescoming from within the NHS who are alsospeaking out in debates about appropriateness inrelation to method. ‘[I]deas about evidence arebeing re-evaluated and expanded’ and we areseeing ‘more of a focus on achieving anevidence-base that encompasses questionsaround process and context’ (Corrie, thisvolume). Indeed, it has been argued for sometime that methodological plurality may be theonly way forward in answering the specific ques-tions emerging from specific contexts in theNHS. Strategies are needed that can takeaccount of ‘the perspectives of [service users],purchasers, service managers, referrers and practition-ers’ (Parry, 1992, p.3). Strategies that arephenomenon-driven rather than method-driven(Corrie, this volume) would offer counsellingpsychologists a way of reconciling differentresearch paradigms under the over-archingframework of researcher reflexivity.

There is a problem though. As ‘scientists’,counselling psychologists have largely rejectedthe task of doing systematic research (Woolfe,1996). Only a few have published their findings,

particularly the findings of qualitative outcomestudies (McLeod, 1999). Undoubtedly this situ-ation is changing all the time and a number ofpublications have included Special Sections withthe focus on qualitative research both within thediscipline – the Journal of Counselling Psychology(October, 1994) – and more generally – ThePsychologist (March, 1995). However, as a traineesearching for published research by counsellingpsychologists, I found McLeod’s observationthat ‘the majority of studies are disseminated aslimited circulation reports and discussion papers, orlodged in college libraries as student dissertations’(1994, pp.5–6) – my own now included – waslargely the case. If we do not make our researchavailable for debate through publication(Woolfe, 1996), or are prevented fromconducting research due to the demands of ourday to day working lives, or we just do not havean interest in conducting research, where doesthat leave us in terms of having a voice in theevidence-based practice debate within the NHS?

Psychoanalytic psychotherapists face asimilar challenge. Holmes argued that as long asevidence-based medicine in the NHS with itsRCT research paradigm remains ‘today’s newGod’ (2000, p.455), psychotherapy may have tocompromise its core values if it is to play aninfluential role in mainstream, publicly fundedmental health care. Similarly Fonagy (2000)sees the way forward for psychoanalyticpsychotherapy through the systematisation ofpsychoanalytic knowledge and the developmentof new and relevant measures, rather than bystepping outside the constraints imposed onhealth practitioners by the NHS and by society.The possible rewards include psychotherapeuti-cally-informed psychiatry and the chance totake part in an integrative revolution (Holmes,2000). Thus, counselling psychologists firstwilling to enter NHS Troy in the wooden horseof current evidence-based practice may eventu-ally be able to burst out and force are-examination of old paradigms. Some,however, caution us against the use of such infil-tration processes.

Spinelli (2001) argued that counsellingpsychology’s current uncertain identity will nothelp it to advance as a profession. In order todistinguish itself from already existing profes-sions in psychology and psychotherapy,


counselling psychology must first ‘clarify justwhat kind of notion of ‘scientist-practitioner’ it adopts,espouses and seeks to develop’ (2001, p.11). He goesfurther, saying that the sort of knowledge that isalready helping us in our understanding of thetherapeutic relationship derives from ‘a qualita-tively-based form of analysis which is unavailable toNatural Science methodologies’ (2001, p.8). Fromthis stance, respect for the personal, subjectiveexperience of the client (Division ofCounselling Psychology, 2001) and the acknowl-edgement of our defining features aspractitioners are best served by a qualitativeresearch paradigm.

As a trainee I wanted to know what coun-selling psychologists have actually done or aredoing in response to these issues. I was aware ofthe challenges posed by clinical governancestrategies in the NHS and aware of the debatestaking place around possible ways forward, buthow are practitioners responding? Given thedearth of published material, speaking anecdo-tally from my two placement years spent in theNHS and through my own research looking atpsychological therapy in primary care, it seemsthat practitioners will ‘go along’ with qualityassurance initiatives (however many forms theyhave to fill in). They are also prepared to askclients to complete pre- and post-therapy ques-tionnaires like the General HealthQuestionnaire (if they really have to). As long asthey can continue to exercise their clinicaljudgement and therapeutic skills in ways thatare congruent with their own core values (whenthey are in the room with clients at least), theycan endure the less meaningful aspects of theirwork.

Overall, the experience of developing anapproach to evidence-based practice in-house,whilst also learning about evidence-based prac-tice as it appears within NHS clinical governancestrategies, proved to be one of ‘storm and stress’for me. Even now, I can accept that compart-mentalisation may be a necessary process forcounselling psychologists working in the NHS –but I still hope for a future characterised bygreater congruence. As Holmes argued forpsychotherapy ‘we need to be able to speak with theentitlement of the healthy infant, rather than thedespair of the abandoned child [ ]; with an ego that isin touch with things as they are, rather than a

nostalgic turning away from reality’ (2000, p.455).However, I do not support Holmes’ view that thisis best achieved by accepting current interpreta-tions of evidence-based medicine and adaptingthe profession to fit them. Instead I hope thatthe actions of counselling psychologists cancontribute to a re-examination of these interpre-tations and can facilitate the move towards amore phenomenon-driven, inclusive stancetowards evidence-based practice in the NHS.

ReferencesAveline, M. (1990). The training and

supervision of individual therapists. In W. Dryden (Ed.), Individual therapy – A handbook. Buckingham: Open UniversityPress.

Chambless, D.H. & Hollon, S.D. (1998).Defining empirically supported therapies.Journal of Consulting and Clinical Psychology,66, 7–18.

Corrie, S. & Callanan, M.M. (2001).Therapists’ beliefs about research and thescientist-practitioner model in an evidence-based health care climate. British Journal ofMedical Psychology, 74, 135–149.

Division of Counselling Psychology (2001).Professional Practice Guidelines. Leicester: TheBritish Psychological Society.

Erikson, E.H. (1968). Identity: Youth and crisis.London: Faber.

Fonagy, P. (2000). Grasping the nettle: Or whypsychoanalytic research is such an irritant. TheBritish Psycho-Analytical Society, AnnualResearch Lecture, 1st March.

Glassman, W. E. (1995). Approaches to psychology.Buckingham: Open University Press.

Holmes, J. (2000). NHS psychotherapy: Past, future and present. British Journal ofPsychotherapy, 16(4), 447–457.

Kneebone, I.I., & Dunmore, E. (2000).Psychological management of post-strokedepression. British Journal of ClinicalPsychology, 39, 53–65.

McCourt, J. (2002). A spirited identity. The Psychologist, 15(7), 354–355.

McLeod, J. (1994). Doing counselling research.London: Sage.

McLeod, J. (1999). Practitioner research incounselling. London: Sage.



Monk, P. (2001). Telling stories: A narrativeanalysis of clients’ accounts of outcomes inpsychotherapy. Unpublished doctoralresearch. University of Surrey, Guildford.

Parry, G. (1992). Improving psychotherapyservices: Applications of research, audit andevaluation. British Journal of ClinicalPsychology, 31, 3–19.

Roth, I. (1995). Conceptual categories. In I. Roth & V. Bruce, Perception andrepresentation: Current issues. Buckingham:Open University Press.

Roth, A. & Fonagy, P. (1996). What works forwhom? A critical review of the psychotherapyoutcome literature. London: Guilford Press.

Rickman, H. P. (1990). Science andhermeneutics. Philosophy of the SocialSciences, 20(3), 295–316.

Spinelli, E. (2001). Counselling psychology: A hesitant hybrid or a tantalisinginnovation? Counselling Psychology Review,16(3), 3–12.

Winyard, G. (1995). Improving clinicaleffectiveness: A co-ordinated approach. In M. Deighan & S. Hitch (Eds.), Clinicaleffectiveness from guidelines to cost-effectivepractice. Brentwood: Earlybrave PublicationsLtd.

Woolfe, R. (1996). The nature of counsellingpsychology. In R. Woolfe & W. Dryden(Eds.), Handbook of counselling psychology.London: Sage.

Woolfe, R. (2002). Letters. The Psychologist,15(4), 169.

CorrespondenceTricia Monk8 Avondale CloseHershamSurrey KT12 4HS.


S CORRIE NOTES it is difficult to disagreewith the concept of evidence-based

practice – in fact it is almost as difficult as disagreeing with the principle ofequal rights or freedom of speech. At firstglance it appears to be unquestionable thatservices provided to those in need should beaudited, monitored and based on up-to-dateempirical evidence. After all we certainly wouldnot like to think that we are part of serviceswhich are not legitimate in some way or do notconform to an acceptable standard. However asa recent commentator discussing the situationin medicine put the matter: ‘…in the past decadeit [evidence-based medicine] has become the corner-stone of practice. Evidence-based medicine is now sorespectable that to question its validity at all isheretical, yet there are parallels here with the emperor’snew clothes.’ (Hampton, 2002, p.549)

We would like to present in our response afurther, (perhaps more critical) development ofsome of the issues raised by Corrie concerningthe fundamental question of consistency ofphilosophical positions underpinning evidence-based practice and counselling psychology.

Our view is that two different philosophicalpositions underpin evidence-based practice andcounselling psychology. These positions arealternatives in that they offer completelydifferent answers to the questions: what isknowledge and how might this knowledge formour practice? This being so it is hard to conceiveof a position from which one can argue for thesimple integration of evidence-based practice to

counselling psychology theory and practice. It isour view that the evidence-based practice move-ment is based on what can be called a realistview, a form of realism which states that if somephenomena – a clinical outcome for example –can be measured it is ‘real’ and if it cannot bemeasured then it is not ‘real’ (Michell, 2003).This position serves those who are addressing aprimarily political agenda around achievingvalue for money in state funded health serviceswithin a social democracy. As Corrie explains,this is the focus of clinical governance andevidence-based practice as evidenced by thedrive towards ‘quality services’, ‘commitment toaudit’ and ‘effective outcomes’. Evidence-basedpractice does not however, reflect the theoret-ical sophistication and diversity of eithermainstream physical science (Kuhn, 1962) orsocial scientists theorising therapy practice(Gergen & Kaye, 1992). This is a crucial point,evidence-based practice is not itself scientific orscience, it is a set of practices and a discourse forframing the activity of professional staffproviding a service. It is absolutely vital that wedo not accept the disciplining power of thismovement and its capacity to determine how,when and where we can criticise it. As Corriesuggests, there is a moral tone implied by therhetoric surrounding evidence-based practice,this is an example of how this form of discoursecan frame both the questions and possibleanswers produced by its critics.

For the medical and allied health professionsevidence-based practice represents a potential

AS

Second Response – Training CounsellingPsychologists: What rolefor evidence-basedpractice?Nicky Hart & Kevin HoganUniversity of Wolverhampton.

threat to professional autonomy, patient-profes-sional relationships and a narrowing of thediscretion of care providers that already seemsdeeply problematical to many (Hampton, 2002;Eddy, 2002). We would suggest that counsellingpsychology is not in this position, nor should weallow ourselves to become so. This is becausesignificant differences exist between the posi-tions of medical and allied health professionalsand counselling psychologists with respect totheir philosophy, client base and most impor-tantly their paymasters.

Training for evidence-basedpracticeWhile Corrie may not have had the space todirectly address the implications for the trainingof counselling psychologists, it is important toconsider this is some depth. Evidence within theliterature for the success of training in theevidence-based approach is as yet, very limitedand the quality of that evidence is poor (Green,1999). An attempt by the CochraneCollaboration to undertake a systematic reviewof educational interventions to teach criticalappraisal to health care professionals, foundonly one article that met the methodologicalcriteria set for the review (Parks, Hyde, Deeks &Milne, 2002). The researchers suggest twopossible causes of this problem. Firstly theyidentify a lack of validated outcome measures.They note that while it is easy to measure knowl-edge only a few instruments capable ofmeasuring developments in critical appraisalskills have been validated. Too few researchershave used such tools and consequently it is verydifficult to interpret their results. Second, giventhat the long-term goal of medical education isto change learners’ behaviours, researchers arecontinuing to struggle when it comes todefining the changes that are expected to resultfrom new training strategies (Hatala & Guyatt,2002). It would be fair to argue that the simpleor rather ‘commonsense’ approach of evidence-based practice is running into a number ofcomplicating factors when applied to training.These problems are also common when theapproach is applied to clinical work.

Another important question for trainers ofcounselling psychologists to consider is whetheror not the existence of an evidence base influ-

ences clinical practice. Research suggests that itdoes not have the impact that supporters ofevidence-based practice might wish. In the faceof clear, well-articulated and disseminatedguidelines the evidence is that clinicians are notapplying them (Bloor, Freemantle, Khadjesari &Maynard, 2003) which is clearly frustrating forsome commentators (Hatala & Guyatt, 2002).Health care settings are real world systems anduninformed assumptions concerning humanbehaviour and the development of organisa-tions that underpin any attempt to implementevidence-based practice will be sorely tested.

Before leaving this topic, two further pointsshould be made in the context of the researchliterature mentioned above. In many studies oftraining in evidence-based practice for doctors,the actual interventions are designed to enhancecritical appraisal skills (Green, 1999). In effectthis has meant that students are taught toappraise research papers and research evidenceand to discuss their reading of the professionalliterature via such approaches as journal clubs.This being so, we might suggest without compla-cency that British psychology graduates havesome familiarity with this approach and indeedthe curriculum of postgraduate training in coun-selling psychology is expressly designed toenhance just these skills (BPS, 2002)

Our second point relates to the difficulty inestablishing clear outcome measures fortrainees’ behaviour in the context of evidence-based practice. We believe the reflectivepractitioner model underpinning counsellingpsychology is itself an answer to these very prob-lems. It should be part of the individual’sprofessional practice to continuously reflect ontheir practice and apply the skills of a scientistpractitioner for each and every client. In orderto serve the philosophy underpinning coun-selling psychology the evidence base mustremain the reflections of counselling psycholo-gist and client upon what they have experiencedon the occasions they have worked together.This being so we do not expect that every coun-selling psychologist would ‘produce’ the samebehaviour with a given client. That however, hasbeen articulated as exactly the goal of evidence-based practice in medicine. In summary we haveevidence that the teaching and diffusion ofevidence-based practice takes place within


complex social systems not rational machines(Dopson, Fitgerald, Ferlie & Grabbay, 2002)which makes the task rather more complex thanthe implicit logic of the evidence-based practiceapproach might suggest.

Evidence-based practice andscienceAs trainers and hopefully educators of coun-selling psychologists we would like to suggestthat we do have a duty to evidence our practiceand to train our psychologists as good qualityresearchers. Hence it is important that ourstudents understand that not only are evidenceand knowledge not the same thing, as Corrrienotes, but evidence-based practice and researchare also not synonymous.

The focus of evidence-based practice is‘evidence of effectiveness’ as cited by Corrie andas she points out we currently inhabit a cultureseemingly obsessed with ‘evaluation and justifi-cation’ and research has come to denote themeans by which we can determine whichclinical intervention works best. This is not thedefinition of research as researchers commonlyunderstand it or indeed the way in whichresearch is prescribed within the new BPS‘Criteria for the Accreditation of PostgraduateProgrammes in Counselling Psychology’ (2003)for all students training to be counsellingpsychologists.

In this document section C4 of theprogramme requirements sets out the criteriaby which the research provision of trainingcourses will be assessed. The emphasis here ison the importance of knowledge and under-standing of a variety of research designs, ‘thetrainee should develop an understanding of a varietyof research designs’ (4.4) and that these shouldinclude both outcome and process research, ‘thetrainee should develop a knowledge of the researchevidence on process and outcomes of psychologicaltherapy relevant to counselling psychology’ (4.1).However the significant aspect of point 4.1 isthe reference to professional relevance.

One of the questions for us as counsellingpsychologists is to consider what kind ofresearch paradigm we see as relevant to ourpractice and philosophy. Corrie very succinctlydemonstrates how ideas about what constituteslegitimate evidence are beginning to move

beyond the simplistic level of outcomemeasures. But as Monk (this volume) illustrates,for those who have to make (and justify) deci-sions about service delivery and spending offunds there is little incentive to look furtherthan a body of evidence that provides quantita-tive information on what therapeuticintervention worked better than another. Ascounselling psychologists we must surely seethat service evaluation is not science and astrainers we are required to train our students tobe effective researchers within the discipline ofcounselling psychology.

In our work as psychologists we draw upon ahuge body of knowledge concerning humanbehaviour; our client experience has suppliedus with a greater understanding of the experi-ence of living and these things together allow usto occupy a privileged position as scientists whocan offer continuous, rich and creative insightinto the human condition. Evidence-based prac-tice runs the risk of reducing and limiting ouropportunities, it is a-theoretical and unscientificin that rather than furthering knowledgethrough the production and testing of theory ituses the discourse of legitimacy to restrict thepossible forms of practice. The question, alsoaddressed by Corrie, then becomes how will wefurther innovate in our practice. If it becomesthe case that only interventions with anapproved evidence-base will be accepted thenhow can we ever try anything new?

Corrie’s argument, that counsellingpsychology research must embrace both quanti-tative and qualitative paradigms is an exampleof how we have been positioned within and bythe evidence-based practice discourse. This isalso demonstrated in the accreditation criteriawhere it is stated that counselling psychologytrainees, ‘develop a knowledge of quantitative andqualitative approaches to research and inquiry’ (4.2).Surely it can be taken as read that both para-digms are critical to our research base and theplatform from which we should be conductingthis debate is a more fundamental one whichasks questions, from outside the discourse,about what we do, how we theorise our work,how we build and test meaningful frameworksof understanding about the process of living forclients and ourselves.


In order to train counselling psychologiststo take up this mantle our task is to produceskilled and reflective, rather than reductionist,researchers who are able to think clearly aboutthe relationship between theory and practice.To gain endorsement from The BritishPsychological Society training courses musttrain students to ‘develop the ability to reflect on theirexperience of being a researcher’ (4.8) and it is herethat we as counselling psychologists have mostto offer. We agree totally with Corrie’s conclu-sion that when reflecting on our practice thereare many questions which arise that wouldconstitute a relevant and interesting researchbase for our profession.

In agreeing with the sentiments expressed byboth Salkovskis (2002) and Moran (1999) wewould argue that within this context the role ofresearch must be more specific. It must provideus with a tool by which we can answer the difficultand challenging questions thrown up by ourpractice. Research must be practice led not theother way around. By using research to test outhypotheses generated by practice we willcontinue the process of theory building andgenerate a truly scientific base for our profession.

The philosophy of counsellingpsychologyIf we consider the definition of counsellingpsychology given in the Training Committee inCounselling Psychology Accreditation Criteria(BPS, 2003) it is clear that our remit as trainersis to produce psychologists who are aware of thewhole context of human experience and rela-tionships, ‘Counselling psychology pays particularattention to the meanings, beliefs, context andprocesses that are constructed both within and betweenpeople and which affect the psychological well-being ofthe person’ (BPS, 2003, 3.7.3, p.4).

The emphasis is on the complexity ofhuman life and the understanding of the impor-tance of creating meaning in order to enhancethe well-being of our clients.

Psychological distress is multi-layered and itis rare that clients present with a single discreteproblem for which we can prescribe an appro-priate intervention. It is also rare that ourclients present with problems that only affectthemselves. Our practice involves skills ofempathy, understanding and humility in order

that we may journey into our clients’ worlds anduse our relationship with them to facilitate hopeand a better outcome for themselves and thosethey care about, ‘Counselling psychologists recognisethe pivotal role of inter-subjective experience andcollaborative formulation between those participatingin deriving understanding and approaches to people’soften profound distress’ (BPS, 2003, 3.7.3, p.5). It isinteresting that a general practitioner writing inthe British Medical Journal recently draws atten-tion to the need for doctors to ‘hear’ theirpatients in a more profound way than thattaught through the obligatory communicationskills sessions in their training.

‘ Is communication really only a ‘skill’, or is itsomething more intrinsic, a reflection of self?Perhaps it is not simply asking the question, therevelatory trick, but the timing, the how. Perhapsthat is the art.’ (de Zulueta, 2003) It is encouraging to think that our philos-

ophy is shared and an alternative discourse tothat of evidence-based practice does existoutside the boundaries of our own profession.

We are not in the business of ‘doing to’ butrather of ‘being with’ and for this there is noclear and accepted evidence base. It is throughcontinual reflection on who we are and how wework as well as the therapeutic process that welearn to be effective counselling psychologists.As trainees will attest, this is a challengingprocess and a skill that is not easy to learn. Itrequires rigour in the form of the systematicapplication of a number of cognitive processes,recording and monitoring of events, thoughtsand feelings, literature searching, hypothesistesting, insight and creativity. It is the applica-tion of knowledge and skill in this way thatmakes us effective psychologists and as trainersit is the development of these skills that that wemust facilitate in our trainees. We do have aduty to ‘develop a commitment to best practice in theinterests of our clients’ (BPS, 2003, C5.1, p.8) butour definition of best practice does not have toconform to those of the commissioners orservice planners.

Politics of EPB: Evidence-based practice as a discipliningformationIt is our proposition, in agreement with Corrie,that the NHS is a state funded health care


system that needs to be organised in such a wayas to manage the tensions of providing healthcare free at the point of consumption in amarket economy. The state needs to be able todetermine that value for money is achieved inthe delivery of services that are fit for purpose.The tension between the autonomy of healthprofessionals employed in such a system andthose charged with managing have been mani-fest in the professional literature for 20 years atleast (Hampton, 2002). Indeed, throughout thespring of 2003, the letters pages of the BMJ havebeen regularly taken up with the argumentssurrounding the relationship between doctorsand managers with frequent reference toevidence-based practice in this debate (e.g.Wilson & Sweeney, 2003). To no small degree,the clash of cultures and agendas and many ofthe arguments surrounding the advance ofevidence-based practice has revolved aroundthe contention from health professionals thatevidence-based practice is a way of advancingthe cause of those who seek to more closelymanage the service.

What we would argue is that this debate isboth sterile and in an important sense for thecounselling psychology profession, irrelevant. Itis a sterile debate because the terms for theargument and hence position from which criticsof evidence-based practice can attack are inher-ently limited. The debate is irrelevant andhence by the way, empowering for counsellingpsychology because the structural position ofthe profession in the context of British health-care professions is radically different from thatof medicine or clinical psychology.

From a social constructionist paradigm theEPB discourse positions and objectifies the criticand therefore the framework within which criti-cism is allowable is already established anddetermined by those who are being criticised(Foucault, 1967). There are many debates thatwe can engage in from the critic’s chair – isprocess or outcome research more meaningful?is qualitative or quantitative methodology morerelevant? – and so on. All are interesting andsuccinctly articulated by Corrie and may have animpact on the current debate on evidence-basedpractice but the question we would ask is do weas counselling psychologists need to be part ofthis debate at all?

Although challenging, it is possible to forceourselves into a different position – one fromwhich we can question our practise and thetheory which underpins it from the position ofan ethical and reflective practitioner andconsider an evidence base that reflects our epis-temological position as counsellingpsychologists. The guidelines which structureour practise and the training of our recruits arebased on an ethics of practice. We are not ahomogeneous profession but rather we cele-brate diversity and have a desire to embracedivergent rather than convergent thinking. Thisseems at odds with the philosophy of evidence-based practice where the aim often seems to beto find an intervention which has been provento be effective every time those circumstancesarise and therefore can be designated as thetreatment of choice.

The special status ofCounselling Psychology and,more particularly, traineecounselling psychologists inthe UKThe important point here is that the impera-tives driving forward evidence-based practiceare not the same for counselling psychology asfor many other health professions in Britain.For example, the circumstances that surroundthe training of clinical and counselling psychol-ogists in Britain are very different. Firstly,because the NHS commissions all of thetraining for clinical psychologists in the UK,normally employing all of the graduates. This isnot true of counselling psychology as, at thecurrent time, the NHS doesn’t commission anycourses in counselling psychology and althoughit does employ several hundred counsellingpsychologists of one kind or another innumerous different settings, that is notcurrently the primary goal for the design orimplementation of counselling psychologycourses in Britain. Not least because a significant proportion of students are trainedvia the independent route and have no partic-ular organisational basis for their training orpractice other than the requirements of theprofessional body. Counselling psychologists asa group are not obliged to undertake courses tofamiliarise themselves with the operation of the


NHS, there is no general requirement that theyundertake placements within NHS contexts,their training does not follow the configurationof the specialties which characterise servicedelivery in the UK as does that of clinicalpsychologists and it is by no means a safeassumption that they would ever practice withinthe NHS either as direct employees or by takingreferrals. Finally and perhaps most important ofall, is the fact that unlike clinical psychologistsour students are not company employees (ofthe NHS) whilst in training. Not only do theynot receive a bursary from the NHS, they get nofinancial aid from nor owe any obligation to anyorganisation – other than their professionalbody. This being so we must not allow thetraining of counselling psychologists to fall preyto the concerns of the NHS when they conflictwith our professional or academic convictions.

The recent publication of a documentsetting out evidence based clinical practiceguidelines for psychological therapies andcounselling (DoH, 2001) serves to illustrate anumber of our points. It is hardly surprising asthe authors of Treatment Choice inPsychological Therapies and Counselling(DoH, 2001) noted ‘…there are forms of therapywhere good quality research has not yet been commis-sioned’ (p.40). But then just as the training ofcounselling psychologists is not publicly fundedin the UK neither does counselling psychologyresearch be it theoretical work, service develop-ment or enhancement undertaken byacademics or practicing professionals, receivesufficient funding. In fact colleagues concernedfor the level and quality of research andresearch training undertaken in clinicalpsychology have made the same point very effec-tively regarding the situation in their profession(Thomas, Turpin & Meyer, 2002). The criteriaset for the review, excluded much of the litera-ture pertinent to the agenda of counsellingpsychology. Indeed the profession itself isomitted from the list of professional disciplinesproviding psychological therapies in the NHS(DoH, 2001, p.7). Evidence-based practiceproduces and reproduces practice(s) in its ownimage and we must guard against this process,particularly as it appears that the voice of coun-selling psychology will have to change if it is notto be ignored. The authors of the report were

forced to point out that ‘the most prevalent inter-ventions are paradoxically the least researched.’(DoH, 2001, p.4). Indicating that research ismost often conducted upon pure forms of inter-vention, using strict inclusion criteria andstandardised measures – unlike practice. Inshort much of our practice is without anevidence base and our evidence base does notapply to very much of our practice. Even werewe convinced by the arguments for evidence-based practice the absence of the requiredevidence base or the means by which to strate-gically and systematically assemble evidence,must raise some questions as to the logic of theenterprise. We are left with the distinct impres-sion that Corrie is very probably correct whenshe argues that there is room ‘for a moreprofound type of enquiry’.

ConclusionThe first key question raised by Corrie is ‘towhat extent is the philosophy of evidence-basedpractice consistent with the underlying valuesystem of counselling psychology?’ This is, for usthe critical question and we have argued thatthey are based on radically different and incom-patible epistemologies and value systems. Intraining counselling psychologists, developingthe value system underpinning the profession isa major goal. It is our view that that the philos-ophy, values and practices inherent in theevidence-based practice approach are funda-mentally incompatible with that value system.Therefore, we will strive to teach students aboutthe evidence-based practice approach but notseek to dictate that they should practice withinsuch a framework. It is vital that we avoidconfronting students with the dilemma thatmust otherwise occur, if they are asked tostruggle with the task of incorporating evidencebased practice into the value system of coun-selling psychology.

Corrie’s second key question – ‘to whatextent should counselling psychologistsembrace or reject evidence-based practice as ameans of enhancing professional effectiveness?’demands an answer because it does seem that byembracing evidence-based practice there issome danger that the profession might have tosacrifice aspects of its values and core philos-ophy. Indeed it would appear that if an attempt


were made to reconstruct the profession alongthe lines demanded by evidence-based practiceit may very well cease to be distinct from anyother professional discipline delivering psycho-logical therapy. Given the current position ofthe profession with its unique status by virtue ofits values, philosophy and independence fromthe NHS we suggest that the profession standapart from the drive for evidence-based practiceand celebrate that difference.

Finally, we would wish to see counsellingpsychology and the other disciplines involved inthe delivery of psychological therapies confrontthe task of developing an evidence base whichprivileges the voice of clients.

ReferencesBloor, K., Freemantle, N., Khadjesari, Z. &

Maynard, A. (2003). Impact of NICEguidance on laparoscopic surgery foringuinal hernias: Analysis of interruptedtime series. British Medical Journal, 326(7389), 578.

British Psychological Society (2002). Regulationsand syllabus for the diploma in counsellingpsychology April 2001–March 2002. Leicester:British Psychological Society.

British Psychological Society TrainingCommittee in Counselling Psychology(2003). Criteria for the accreditation ofpostgraduate training programmes in counsellingpsychology. Leicester: British PsychologicalSociety.

Department of Health (2001). Treatment choicein psychological therapies and counselling:Evidence-based clinical practice guideline.London: Department of Health.

De Zulueta, P. (2003). The body tells a story.Personal views. British Medical Journal, 326,666.

Dopson, S., Fitzgerald, L., Ferlie, E. & Gabbay, J. (2002). No magic target!Changing clinical practice to become moreevidence-based. Health Care ManagementReview, 27(3), 35–47.

Eddy, D.M. (2002). Evidence-based medicine;What it is, why to use it and how toincorporate it into decision making.Formulary, 37(10) 525–530.

Foucault, M. (1967). Madness and civilisation.London: Tavistock

Gergen, K.J. & Kaye, J. (1992). Beyondnarrative in the negotiation of therapeuticmeaning. In S.McNamee & K.J. Gergen(Eds.), Therapy as social construction.London: Sage.

Green, M.L. (1999). Graduate medicaleducation in clinical epidemiology, criticalappraisal, and evidence-based medicine: A critical review of curricula. Acad Med. 74,686–694.

Hampton, J.R. (2002). Evidence-basedmedicine, opinion-based medicine andreal-world medicine. Perspectives in Biologyand Medicine, 45(4), 549–568.

Hatala, R. & Guyatt, G. (2002). Evaluating theteaching of evidence-based medicine.JAMA, 288(9), 1110–1112.

Kuhn, T.S. (1962). The structure of scientificrevolutions. Chicago, IL: University ofChicago Press.

Michell, J. (2003). The qualitative imperative.Positivism, naïve realism and the place ofqualitative methods in psychology. Theory and Psychology, 13(1), 5–31.

Moran, J. (1999). Response to John Rowan’sarticle: ‘A personal view: Concerns aboutresearch’. Counselling Psychology Review,14(3), 45–46.

Parks, J., Hyde, C., Deeks, J. & Milne, R.(2002). Teaching critical appraisal skills inhealth care settings [database on CD-ROM].Oxford, England: Cochrane Library,Update Software; issue 2.

Thomas, G.V., Turpin, G. & Meyer, C. (2002).Clinical research under threat. The Psychologist, 15(6) 286–289

Salkovskis (2002). Empirically groundedclinical interventions: Cognitive-behavioural therapy progresses through amulti-dimensional approach to clinicalscience. Behavioural and CognitivePsychotherapy, 30, 3–9.

Wilson, T. & Sweeney, K. (2003) ‘You just don’tunderstand’. British Medical Journal, 326(7390), 656.

CorrespondenceNicola M.T. Hart & Kevin M. HoganDepartment of PsychologyUniversity of WolverhamptonWolverhampton WV1 1SB.



COUNSELLING OLDER PEOPLEAre you undertaking any research in this area?

Are you aware of any studies in this area?

The University of Salford has been commissioned by the BritishAssociation of Counselling and Psychotherapy to undertake asystematic review of research evidence in the area of counselling older people, the latterbeing defined as those of 60 years and above.

We are using a range of methods to track down potential studies. If you know of anyongoing, published or unpublished work in this area, please let us know.

Many thanks in advance for your help.

Contact Andrew Hill, Senior Lecturer in Counselling, School of Community HealthSciences and Social Care, University of Salford, Allerton Building, Frederick Road, SalfordM6 6PU. Tel: 0161 295 2388. E-mail: [email protected]


IT WAS INTERESTING to be asked to prepare aresponse to this paper, a paper thatconsiders some of the potential benefits

and costs of having an evidence-based approachto practice. My interest in responding wasbecause this has been a subject that as a practi-tioner within the NHS I have had to reflect on,and for which quite possibly I have needed animpetus to gather together my own rationale formy own philosophy of practice in this regard.

I would like to assume that all counsellingpsychologists have no problem with the conceptof improving the services that we provide to ourclients – and by clients I do not only mean thosethat counselling psychologists work therapeuti-cally with. I would also suggest that thoseorganisations that counselling psychologistswork for are our clients too. Many of theseorganisations believe that by using evidence-based practice we do in fact improve the serviceswe provide.

As Corrie and previous respondents havenoted, the idea that the delivery of therapeuticinterventions should be informed by evidenceof effectiveness does not at first sound likeanything counselling psychologists woulddispute. However, we have to recognise that thedefinition of ‘effectiveness’ has not yet beenformulated in a way that is satisfactory to manyof us. For example, if effectiveness is measuredby outcome, then one very important measureof outcome that is underlined within the healthservice is that of a shortening waiting list.However, this is problematic as this same aim ismet with unwanted outcomes as well as thosethat are desired – for example waiting lists are

shortened when clients drop out of therapy,commit suicide or enter into in-patient care. Inthis light I await an acceptable definition of‘outcome’ before I can accept it as criteria.

Is the notion of evidence-based practice consistent withthe underlying value systemof counselling psychology?Corrie’s paper raises the question as to whethercounselling psychologists are clear on how theymight question the extent to which the notionof evidence-based practice is consistent with theunderlying value system of counsellingpsychology. To illustrate what is meant by this,let us examine one of the basic fundamentalassumptions from which all counselling psychol-ogists’ work. The ‘cornerstone’ ofpsychotherapeutic practice is that of attentionto the ‘therapeutic relationship’. This premisepredates the profession of counsellingpsychology within this country (see, forexample, Horvath & Luborsky, 1993; Luborsky,1976; Rogers, 1957).

But where did this foundation stone origi-nate? Much of the thinking around this comesfrom the work of a stalwart team of scientist-practitioners (we will return later to this term)in Philadelphia in the late 70s and early 80s.This team was working with Vietnam veteranswho had problems with substance misuse (see,for example, Woody, McLellan, Luborsky &O’Brien, 1986; Luborsky, McLellan, Woody &O’Brien, 1985). Their aim was to improveservices for these clients and the method thatthey used for this was to carry out a series of

Third Response –Testing the way the windblows: Innovation and asound theoretical basisYvonne WalshNorth East Mental Health Trust.

outcome studies. This team’s work examinedthe contribution of the therapists’ performancein determining outcomes of treatment.Profound differences were discovered in thetherapists’ success with the patients in theircaseloads. There were differences in thecontent and process of counselling among thecounsellors and these differences were associ-ated with the differences in patient outcome.The findings were that therapists who had themost beneficial results had formed the mostpositive relationships with their clients.

This work underlines the notion of theequivalence-paradox (Stiles, Reynolds, Hardy,Rees, Barkham & Shapiro, 1994) that Barkham(1996) discusses. This says that the highlyconsistent findings of non-significant differ-ences in outcome findings among conceptuallydifferent therapies suggests that the specifictype of therapy may be less potent in affectingchange than the therapist factors. What isproposed is that the major agent of change isthe ability to form a warm, supportive workingrelationship (Luborsky et al., 1985, and soforth). Do counselling psychologists as a profes-sion dispute or deny this? I do not believe so.

What I do find wryly amusing is that manycounselling psychologists will cite the work ofWoody et al. (1986) and so forth as substanti-ating the centrality of the therapeutic alliance,helping alliance or working alliance, becausethey have read about their work. They do thisoften without really understanding that byaccepting this premise they are endorsing thenotion of evidence-based empirical nomotheticresearch directing clinical practice. That is tosay, research that relates to the abstract notionof a theoretical frame, encompassing the notionof ‘universality’. This can be contrasted with theuse of research that is idiographic and thereforederived from the individual. If we were then toargue against the acceptance of evidence basedpractice as a tool to define practice within coun-selling psychology we are arguing against theevidence used to substantiate one of our basicfoundation premise for our profession. Thisthen suggests that those resisting evidencebased practice as a standard within counsellingpsychology may in a sense, be arguing againstmuch of what counselling psychology is. This, ofcourse, raises another question.

Is it appropriate forcounselling psychologists touse evidence derived fromnomothetic research?Alongside the use of evidence-based practice toguide the development of practice, Corrie’spaper also raises the need to consider theappropriateness of using evidence derived fromnomothetic research. This is because coun-selling psychology as a profession works with theclient’s world-view as a guide to practice. Itespouses a client-focussed epistemo-logical frame to work within. Thus counsellingpsychologists construct case formulations orcase conceptualisations from evidence derivedfrom the client as to where the endeavour oftherapy should take place (Persons, 1989; Beck,Wright, Newman & Liese, 1993). Accepting anomothetic stance suggests that we accept thatthere are commonalities shared by most if notall minds (no Tabular Rasa here). An ideo-graphic stance celebrates the uniqueness of theindividual. These are sometimes very differentstances. However, my question here, and onethat Corrie usefully considers is: Is it notpermitted (or possible) to combine thestrengths of both of these explanations?

For some counselling psychologists, it maybe that this is precisely the strength of ourprofession. We are able to use evidence-basedresearch and the interpretation of assessmentsand diagnosis that are often made within thisparadigm as well as the ongoing negotiationwith clients of a shared understanding of theclient’s world-view. This endeavour enables astate of congruence to exist between the thera-pist and the client. As we all know, if you are notcongruent with your client you will not get veryfar with therapy.

As well as contributing to our own version ofevidence-based practice, I would suggest thatthis skill of negotiating meaning could be usedwithin the different fora in which we work.Counselling psychologists acknowledge that thisis at the forefront of our practice with clients,can those of us who work with other professions,managers and service commissioners not alsoput it at the centre of our transactions withthem.

Counselling psychologists, as a profession,may have problems with the notion of classifica-


tion and diagnosis leading to the treatment ofmental health ‘disorders’. This notion of thegrouping together of a universality of ‘symp-toms’ within a more nomothetic world-viewdenies the uniqueness of the individual experi-ence and it may be this that underlies theunease of many of us when we considerevidence-based practice. This is of courseimportant to keep in mind.

An alternative thought is that many of usworking in the health service and otherwise,work with other professionals that we respecthighly, and some of these colleagues use thesenotions to their own satisfaction. Would we bejustified in reifying our profession and practiceabove that of these other professionals andsaying not only do we not wish to honour yourworld-view – but we also cannot use theevidence you use as it is derived from conceptsalien to our own world-view. For some of uswanting to incorporate our views into thissystem, I do wonder whether it is possible tohave as much influence to bring about changesin perceptions and practice from outside of anorganisation as it is from within.

If we reject evidence-basedpractice what else must wereject?My reasoning so far has led me to ponder theappropriateness of counselling psychologydismissing the notion of evidence based prac-tice as suggested by some, given the fact that itleads to the development of much of the basisthat our profession works from. It could besuggested that if evidence-based practice werethought to be a flawed notion then we mustreject all that flows from it. I refer here not onlyto the notion of the centrality of the therapeuticalliance, but also for example research carriedout by those such as Rogers, Beck, Freud and soforth who are some of the key theorists in thedevelopment of therapeutic paradigmsespoused by many counselling psychologists.However, this argument does not hold up underclose scrutiny and warns us that we must bewareof throwing the baby out with the bath water.

Corrie’s paper does not argue that evidencebased practice is flawed; it simply suggests thatwe query practice being driven by the need foran evidence-base to work from. It does suggest

that an expansion of what is considered validevidence needs to take place with more focus onachieving an evidence base that encompassesquestions around process and content. This is inaddition to research protocols that include idio-graphic assessment and treatment locatedwithin a case formulation and case conceptuali-sation approach to therapy (Beck et al., 1993;Persons, 1989).

Taking responsibility for ourresearchI would suggest that counselling psychologistscan agree that we cannot dismiss the develop-ment of evidence based practice because manyof the fundaments of our practice and philos-ophy that derive from this type of research. If Iam right, then we have to take responsibility fordeveloping a more sophisticated approach toresearch that incorporates a wider base ofresearch protocols. The complexity of thinkingneeded to develop this sophistication will allowus to enter into what Moran has described as‘profound engagement with a quandary’ (1999,p.45). It also follows that counselling psycholo-gists must then fulfil the commitment made astrainees to become not only consumers but alsooriginators of know-ledge, I would suggest thatwe have an obligation to remedy that which wecriticise.

I am suggesting that if we are to becomeboth consumers and producers of knowledgethen we have a responsibility to challengecontemporary definitions of evidence. Corrie’spoint that we also need to consider our positionin relation to the research of others and ourresponse to their research is well made. Thecapacity of research to be used to influence doesnot necessarily reside with an informed reader-ship. Our responsibility extends both to theundertaking of research and also to its use.Once research is published and in the publicdomain it is open to implementation and inter-pretation by a raft of ‘consumers’ and not all ofthese consumers are well informed and able toaccurately interpret research into practice. Nomatter how good the research is and what itsviability for directing therapeutic input, if thosethat interpret are not informed readers, thenthe benefit that could be derived from theresearch may be transformed into harm.


A note of cautionAs well as the issues mentioned above, the reali-ties of our working lives must be considered.There is a lack of time in some services for thosewho make decisions about implementation ofpolicy to read research. This can lead to practicethat is derived not from research papers, butfrom another’s synopsis of research, orsecondary sources and this can move theconclusions formed by local policy makers awayfrom those intended by the researchers.

An example of this can be seen by turning tothe work of McLellan, Alterman, Woody, Metzger,McKay and O’Brien (1994) who were commis-sioned to prepare a report for the Task Force toReview Services for Drug Misusers. The reportreviewed the international literature onpsychotherapy for substance misuse and maderecommendations for treatment. Using thisreport in addition to a much wider range of infor-mation gathering, the task force produced areport to inform the Government of the dayabout different treatment modalities forsubstance misuse. It led to the publishing of aWhite Paper: Tackling Drugs To Build A BetterBritain (1996). Subsequently the NationalTreatment Agency for Substance Misuse wasdeveloped and ‘Models of Care’, a paper with theequivalent status of a National Service Frameworkfor substance misuse, was published in 2003.

This has led to the publication of a docu-ment that is a resource pack for commissioners,‘Commissioning Drug Treatment Systems’ inwhich the service specifications for ‘structuredcounselling’ within Department of Healthfunded Substance Misuse Services (both inde-pendent sector and NHS) are explicated. Themajority of the document, although couched interms that are very jargon laden, gives a throughover view of service specifications. However,when it describes ‘Services, Care andInterventions Provided’ it moves beyond theresearch literature to define very clearly whatthe counsellor must do. Point 5 in this sectionssays: ‘service providers enhance motivation andreadiness for change by paying special attentionto: …work to enhance clients perception ofhelpfulness of service’. Such a move fromevidence to policy troubles me. Nowhere in theinternational literature is this demonstrated asbeing part of a positive psychotherapeutic inter-

vention. It offends against my notion of theappropriate use of powerful psychological tech-niques. It cannot be acceptable to use them toenhance a client’s perception of the helpfulnessof a service. If the service is helpful this willspeak for itself and if it is not perceived ashelpful we should be exploring the reasons forthis, not using psychological therapies toconvince the client that it is.

Additionally, in Point 6, the document says:‘Structured counselling must be linked to thegoals for behaviour change identified in theoverall care plan’. This may sometimes beappropriate but what if the clients purpose forengaging in counselling is not linked to behav-iour change, but is for example aboutself-development, mood change or any of amyriad of other foci that may be present intherapy? This constraint is not enabling me as acounselling psychologist to practice my profes-sion in a manner that is compliant with thewell-researched and promulgated mass of litera-ture one finds on psychotherapy. It also bearslittle reflection to the discussion on this subjectin the original report prepared by McLellan etal. in 1994 for the specific purpose of informingpsychotherapy with this client group

Shaping change, not justcriticising itIt may be that my interpretation of evidence-based practice is at fault, maybe I have misreadit. However, if I am not part of the debate onthis subject, for instance because I cannot allowmyself to work with those who are constrainedby a more medically-based model, I have nochance to highlight and discuss my concernsand create an opportunity for change.

I would question, maybe somewhat naively,whether the drive for evidence-based practice ishas at its heart ‘control[ling] service deliveryand justify[ing] service rationing’. I am notaware of any research that has been carried outwith this purpose as its goal. If this is happeningthen it reflects the need for researchers to‘police’ their work and be prepared to chal-lenge its use.

Counselling psychologists are inherentlyscientist-practitioners (Woolfe, 1996), we areafter all the branch of psychology thatspecialises in counselling/psychotherapy. As a


first degree we study psychology – a socialscience. We use the theories of psychology(mostly derived from empirical psychology) toguide our practice – developmental theories,learning theories behavioural theories and soforth. How can we deny ourselves the role ofscientist-practitioner without rejecting thisscientifically derived raft of knowledge? Can wenot accept who we are and then strive toimprove on this as we as a profession mature? Asa second-generation counselling psycho-logist Ilook forward to where our future generations ofcounselling psychologists take us – hopefullywithout forgetting where we have come from.

A final thoughtWhen I apply evidence-based research to mypractice, particularly when it originates fromresearchers and practitioners whose robust andrigorous work I know and trust – I know I amdoing more than licking my finger and holdingit up to the wind to see which way it is blowing.Additionally, I am not doing something becauseit feels like it might work. It is grounded insomething more substantial. This does notmean that I will not innovate – just that my inno-vations must be based on a sound theoreticalbasis – if I don’t know where I am going then Idon’t believe I will know when I get there.

ReferencesBarkham, M. (1996). Quantitative research on

psychotherapeutic interventions:Methodological issues and substantivefindings across three research generations.In R. Woolfe & W. Dryden (Eds.), Handbookof Counselling Psychology. Sage: London.

Beck, A.T., Wright, F.D., Newman, C.F. & Liese B.S. (1993). Cognitive therapy ofsubstance abuse. Guilford Press: London.

Department of Health. (1996). Tackling drugs tobuild a better britain: The Government’s 10-year strategy for tackling drug misuse.London: HMSO.

Horvath, A.O. & Luborsky, L. (1993). The roleof the therapeutic alliance inpsychotherapy. Journal of Consulting andClinical Psychology, 16(4): 561–573.

Luborsky, L. (1976). Helping alliances inpsychotherapy. Successful psychotherapy.Cleghorn, J.L.

Luborsky, L., McLellan, T., Woody, G.E. &O’Brien, C.P. (1985). Counsellingpsychologist success and its determinants.Archives of General Psychiatry, 42, 602–611.

McLellan T., Ardt, I.O., Metzger, D., WoodyG.E. & O’Brien C.P. (1993). The effects ofpsychosocial services in substance abusetreatment. JAMA 269 (15), 1953–1959.

McLellan, T., Alterman, A.I., Woody, G.E.,Luborsky, L., Metzger, D., McKay, J.R. &O’Brien, C.P. (1994). Evaluating theeffectiveness of substance abuse treatment. A report prepared for the Task Force to ReviewServices for Drug Misusers. London:Department of Health.

Moran, J. (1999). Response to John Rowan’sarticle: ‘A personal view: Concerns aboutresearch’. Counselling Psychology Review,14(3) 45–46.

National Treatment Agency (2003).Commissioning drug treatment systems: Resourcepack for commissioners. Service specification forTier 3. Care planned counselling. London:National Treatment Agency.

National Treatment Agency for SubstanceMisuse (2003). Models of care. London:National Treatment Agency.

Persons, J. (1989). Cognitive therapy in practice: Acase conceptualisation approach. New York:W.W. Norton.

Rogers, C.R. (1957). The necessary andsufficient conditions of therapeuticpersonality change. Journal of ConsultingPsychology, 21(2), 95–103.

Stiles, W.B., Reynolds, S., Hardy G.E., Rees, A.,Barkham, M. & Shapiro, D.A (1994).Evaluation and description ofpsychotherapy sessions by clients using thesession evaluation questionnaire and thesession impacts scale. Journal of CounsellingPsychology, 41, 175–185.

Woody, G.E., McLellan, T., Luborsky, L. &O’Brien, C.P. (1986). Psychotherapy forsubstance misuse. Psychiatric Clinics of NorthAmerica, 9(3), 547–561.

Woolfe, R. (1996). Counselling psychology inBritain: Past, present and future. CounsellingPsychology Review, 11(4), 7–15.



CorrespondenceYvonne WalshLead Psychologist for Addictions and Dual DiagnosisNorth East Mental Health TrustCentral PsychologyLarkswood CentreThorpe Coombe Hospital714 Forest RoadWaltham Forest E17 3HP.

DIPLOMA IN COUNSELLING PSYCHOLOGYCO-ORDINATORS OF TRAINING DAY

Saturday 17th January 2004 – 10.30 am to 4.30 p.m. at The British Psychological Society,

33 John Street, London.The Board of Examiners for the Diploma in Counselling Psychology are pleased to offer aTraining Day for Co-ordinators of Training of those candidates undertaking theindependent route towards chartered status as counselling psychologists.

This one-day training will provide an information and discussion forum to all those who areinvolved in co-ordinating the training of candidates on the independent route or areconsidering doing so. The day will acquaint Co-ordinators with the new Qualification inCounselling Psychology which is scheduled to replace the current Diploma in CounsellingPsychology in 2004 in time for the 2005 examinations. This new Qualification will focus onlearning outcomes and competences so the programme of the day will focus on planningthe training, assessment and evidence requirements and the standards for submitted work.Speakers will include the Chair of the Board of Examiners, the Registrar and the SeniorExaminer. The day will also provide an opportunity to meet with other Co-ordinators ofTraining, which is one of the requests which emerged from the recent survey of currentCo-ordinators of Training.

The Training Day is supported by the Membership and Professional Training Board. Therewill be a charge of £10 for attendance at the day, with lunch being provided. This trainingday can be counted towards CPD hours.

Venue: The British Psychological Society, 33 John Street, London, WC1N 2AT.

For a full programme and application form please contact Jean Duckworth, The BritishPsychological Society, St Andrews House, 48 Princess Road East, Leicester, LE1 7DR ore-mail: [email protected]


Comprehensive Handbook ofPsychotherapyEditor-in-Chief: Florence Kaslow

Volume 1:Psychodynamic/Object RelationsEditor-in-Chief: Florence KaslowVolume Editor: Jeffrey Magnavita25 Chapters, 622 pp. ISBN: 0-471-38263-9

Volume 2: Cognitive-Behavioural ApproachesEditor-in-Chief: Florence KaslowVolume Editor: Terence Patterson25 Chapters, 636 pp. ISBN: 0-471-38319-8

Volume 3: Interpersonal/Humanistic/ExistentialEditor-in-Chief: Florence KaslowVolume Editors: Robert Massey andSharon Massey27 Chapters, 749 pp. ISBN: 0-471-38626-X

Volume 4:Integrative/EclecticEditor-in-Chief: Florence KaslowVolume Editor: Jay Lebow27 Chapters, 602 pp. ISBN: 0-471- 38627-8

Each volume is individually priced at £92.50with the set of four priced at £370.00. Eachvolume is A4-sized with strong hard covers andbindings; published in 2002 by John Wiley &Sons, Inc., New York.

ISBN: 0-471-01848 (set of four).

This is an impressive collection of essaysoutlining a wide range of therapeuticapproaches covering much of the field andorganised into four volumes devoted in turn topsychodynamic/object relations, cognitive-behavioural approaches, interpersonal/humanistic/existential, and integrative/eclectic. Each volume is organised the same wayinto six sections as follows: Section One:Psychotherapy with Children; Section Two:Psychotherapy with Adolescents and YoungAdults; Section Three: Psychotherapy withAdults; Section Four: Psychotherapy withFamilies and Couples; Section Five: GroupPsychotherapy; and Section Six: Special Topics.

Most chapters include a very helpful intro-ductory summary of the core approachesexplored and have several case examples ofclient work interwoven into the text. There areextensive references and the chapters are wellwritten and presented. All in all a verycommendable addition to the field and onethat, no doubt as intended, offers a snap-shot ofpsychotherapy practices at the start of a newMillennium.

It is, though, essentially a review of developments and progress within NorthAmerican psychotherapeutic practices with over80 per cent of the contributions coming from US-based contributors. In this regard I would suspectthat some leading and noteworthy practitionersand clinicians outside the US may feel somewhatfrustrated that their innovations and practicesmay have been overlooked or neglected. Thatsaid this remains a valuable resource for the widerstudent and practitioner audience.

BBooookkRReevviieewwss

Overall the underlying storyline – across thefour volumes – is the continuing developmentand evolution of psychotherapeutic practicestowards a more eclectic theoretical approachand away from dogma-like attachments to anyone specific orientation to the exclusion ofothers. The writings very much reflect such ajudged integration of concepts and techniquesacross the primary orientations and schools ofthought.

This more allowing and inclusive approachis evidenced too through the many chapters andreferences to the benefits, for client(s) and ther-apist alike, of working within a systemsframework in which the wider relational dimen-sions of the client’s concerns may beconsidered. The criticality of the workingalliance — pretty much irrespective of theorientation adopted and the techniques beingdescribed – is sustained within all four volumesas, by and large, the key factor in progress inworking with the client on their concerns andpreoccupations.

The volumes serve several purposes overand above representing the ‘state of thepsychotherapeutic nation’ as at 2002 as theyoffer the promise of a further opening up ofminds to the approaches, dispositions, beliefs,challenges, and limitations of one’s colleagueswho work in ways different from one’s own.Moves towards such cross-theoretical under-standings, and increased professional tolerance,is made easier as each volume follows the sameinternal structure which makes it simple, forexample, to compare and contrast work withadults or with groups across the various orienta-tions covered. This is a very neat way to developboth theory and practice and, importantly,share insights, surprises and confusions.Readers though should be alert to overload asthere is so much packed into this set that indi-gestion can set in if one tries to cover too muchin one sitting!

Unsurprisingly there is a certain amount ofduplication as some chapters inevitably drawon the same core frameworks to underpin theparticular developmental approach they havenow developed and are promoting. In thisregard the volumes have a role in remindingthe reader of core texts, concepts and orienta-tions that is quite helpful in reasserting the

origins and heritage of contemporary practice.One of the highlights for me is Miller,

Duncan and Hubble’s Chapter 9 – in Volume 4– entitled ‘Client-Directed, Outcome-InformedClinical Work’. This chapter is well worth a readand contains some very interesting points aboutthe outcome efficacy of psychotherapy. It might even aspire to achieving the status of a‘must read’ chapter for budding psycho-therapists and for practitioners with an omniscient tendency!

As the authors note, in considering the ques-tion of which is the most effective therapeuticapproach to adopt, ‘Simply put, practicing ther-apists have yet to find a single therapy model orpackage of techniques that adequately capturesthe realities of day-to-day clinical practice. Theresult is that most are forced into practicing an‘accidental eclecticism’, assembling throughtrial and error bits and pieces from a variety ofapproaches encountered in workshops and onthe job.’ (Vol. 4, p.187)

They continue ‘More importantly was thefinding that the probability of a successfuloutcome in even the most challenging cases (intheir study) could be improved by simplyaccommodating treatment to the client‘sperceptions of the presenting complaint, itscauses and potential solutions, and ideas andexperiences with the change process ingeneral.’ (Vol. 4, p.187)

Reaffirming the centrality of the client-in-it-all is reassuring and somewhat calming in themidst of so many formulations and expert-ledattestations of the worth of this or that approachand derivation of best practice. From my limitedexperience it is so often the simpler and morestraightforward approach – as opposed to theoverly neat, clever, convoluted and technique-rich ones – which best meet and serve theinterests and capabilities of the client.

There is much to admire and value in thiscollection of practice papers, statements of posi-tion, reflections on theory-in-practice andpractice-in-theory. There is, almost inevitably,some repetition between the 104 separate chapters covered, however.

Maybe, as Buetler et al. suggest in Volume 4,‘It should be clear to most observers that nocontemporary theory provides adequate treat-ment for many patients. What is needed are not



new theories and techniques but practicalguidelines that cut across theories and tell ushow to use the procedures that we already haveavailable as well as how to develop new ones thatwork.’

So overall a valuable contribution to thefield and one that should facilitate cross-functional understandings and collaboration,

lots of potential contacts, lots of references andmany interesting approaches and slants onprofessional practice and the dilemmas high-lighted through such work. I am not so sure thatthe collection can claim to be ‘Comprehensive’however.

Michael Walton

Self Help for Nightmares: A Book for Adults with FrequentRecurrent Bad DreamsMary Burgess, Isaac Marks & Michael GillBlue Stallion Publications, 2001. ISBN: 1-904127-00-2. 60pp. Paperback. £5.50.

Self Help for Chronic Fatigue Syndrome: A Guide for Young PeopleTrudie Chadler & Kaneez HussainBlue Stallion Publications, 2002. ISBN: 1-904127-01-0. 68pp. Paperback. £5.50.

The use of self-help materials is synonymouswith cognitive behaviour therapy. In fact, recentresearch has shown that clients can benefit fromusing self-materials while waiting to be seen bypsychologists or indeed as an adjunct duringtherapy.

The two books provide structured and muchneeded guides to help clients manage night-mares and chronic fatigue syndrome. Both arestep-by-step guides to understanding and usingcognitive behavioural strategies, and includeforms, which can easily be photocopied to helpclients manage their problems. The secondbook, in particular, as it is aimed at youngpeople and includes a lot of diagrams, whichserve to make the book more accessible andeasier to read by children.

In all I think that these books are valuableand accessible tools for psychologists and clientsworking with adults and children.

Kasia Szymanska

All book reviews and correspondence regarding book reviews should be sent to Kasia Szymanska, Book Reviews Editor, CPR, Centre for Stress Management, 156 Westcombe Hill, London, SE3 7DH.

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Newsletter SectionLETTER FROM THE CHAIR

I am honoured and a little intimidated to have been chosen to serve as Chair of the Division for thenext year. On taking over from Jill Wilkinson at the AGM, attended by relatively few of the member-ship, I expressed a number of hopes for my year of office, which I should like to reiterate.

First, as Jill said in her last Chair’s Letter, I think we’re quite well advanced in the task of estab-lishing counselling psychology as a recognised discipline both within psychology and in theworkplace. Progress is currently being made, for example, in achieving parity with our clinicalcolleagues in terms and conditions of employment as well as the creation of funded training placesfor those intending to work in the NHS. Structures are being put in place for the creation of semi-autonomous branches of the Division in Wales and Scotland in order to develop counsellingpsychology in those countries. Increasing numbers of counselling psychology posts are beingcreated, including at some senior level.

Necessarily during this phase we have tended to be somewhat inward looking, preoccupied withourselves and our own interests. The first of my hopes therefore is that we shall start to focus beyondthe boundaries of our particular little patch of territory to the wider world, for example of govern-ment policies on mental health and other matters that affect the well being not just of counsellingpsychologists but of other groups and people generally.

I hope to see a reduction in the volume of masters and doctoral research directed at counsellingpsychologists themselves and more directed at areas in which the practice of counselling psychology,defined broadly, might result in some discernible benefit to humanity. In fact I’d like to see moreand better quality research from counselling psychologists period.

I hope that counselling psychology practice will come to be seen as more than simply thedelivery of psychological therapy to individual clients. Counselling psychologists are equipped witha broad range of skills which can enable them to operate not just in the consulting room but at manylevels within many organisations and contexts.

I hope that in the rush towards professional respectability and the security offered by the promiseof statutory registration and a place in the state funded health care system, we won’t sell our souls andwill manage to hang onto our humanistic values, despite the temptation to abandon them.

I hope we can resist being co-opted into uncritical acceptance of the medical model just becauseour salaries are being paid by the NHS. Whilst it would be unwise to remain so stubbornly pure thatwe render ourselves irrelevant, nevertheless we really do have something distinct and valuable tooffer.

I hope we’ll be able to maintain our autonomy in the face of ever increasing regulation, forexample in relation to codes of ethics, compulsory supervision, continuing professional develop-ment and record keeping, whilst still maintaining a commitment to ethical practice. Humanisticvalues honour self-regulation as something we seek to promote in ourselves as well as our clients.

If I can do half as good a job as my predecessor Jill Wilkinson then I’ll be doing pretty well andprofound thanks are due to her from all of us for all her creative hard work on our behalf over thepast year. In relation to this, my final hope is that we shall see more members of the Division comingforward to stand for election to the Division Committee and to join its various sub-committees, the work of which is for the benefit of the whole Division.

Stephen Munt, Chair, Division of Counselling Psychology.

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THE TRAINEE COLUMNThis is the first contribution to what we hope will become a regular space in which traineeCounselling Psychologists can have a say about their experiences. Please send your contributions tothe Editor or to the Trainee Representatives on the Divisional Committee.

EXPERIENCES OF THE CHARTERING PROCESS THEINDEPENDENT WAYI completed Part 1 through a course route at the University of East London. The criteria for comple-tion of this were strict and did not always appear transparent, but I got through it seemingly withouta hitch, enjoying very much the dissertation I completed in addition to Part 1. My peers at UEL were great; always encouraging and supportive to each other, enabling us all to facethe down times when they came, which of course they did. Toward the end, people’s personal diffi-culties changed the nature of the course which seemed to have been literally transformed into asurvival story for a few people. Feeling very tired toward the end of the course, and the fact thatthere was a new, as yet not accredited course being set up for Part 2 made me doubt the wisdom ofstaying at UEL to do this. I also wanted to taste more widely the world of work and doing the inde-pendent route enabled me to do this, giving me more flexibility alongside my other interests andcommitments. However, I was aware of some of the difficulties of studying independently as severalyears earlier I had converted my Health Sciences degree through the Open University and there-fore appreciated some of the problems of being isolated from a peer group.

It felt like a bold decision to strike out on my own, having consulted with the Division ofCounselling Psychology. I managed to find a co-ordinator of training relatively easily, but in themean time had phoned several people in the Directory before approaching Lyndsey personally. At that initial stage there were several of us who met together. My own feelings swung wildly aboutwhat I was embarking on. I was not entirely happy about the independent route, mainly because ofthe thought of submitting all my work at once, but the advantages of flexibility and being able tochoose my own workshops and courses really appealed; it would also be good to meet with a broadercross-section of therapists and other applied psychologists.

A part of the nature of Part 2 is a move toward integration in practice and on reflection I initially fought against some of these ideas, wrestling with the notion of how this is done. What Inow realise having just got to the end of my final essay and awaiting the results, due in about six toeight weeks, is that of course it was a process. This process of struggle was one that many of ourclients grapple with both within a therapeutic relationship and within their own lives and retro-spectively I think that continuing in therapy would also have been helpful to me during Part 2.However, financial costs have to be budgeted for and doing the Diploma independently means onedoes not qualify for a student card and discounts; finances have to be managed carefully and respon-sibly and I did not have an income for some months.

The question of the process of integration is one that I became increasingly interested in havingworked through this myself, and I would value comments from people who have studied Part 2through both routes regarding this. It is a subject about which I was asked at the Information Day atJohn St last October and I am still unsure of how or even when it happened. I know I found usefulboth a good quality undergraduate level course and a breadth of reading helpful to the process, alsobeing with a range of therapist colleagues who provided differing perspectives. Not least, of course, Iknow I have learnt so much from the many clients with whom I have worked and, importantly, forwhom I have received regular supervision. During Part 2 I have had three different jobs and theseprovided me with both a wider perspective and different levels of understanding in terms of thepsychological theories that underpin the work I do. More latterly I believe an appreciation for socialconstructivist ideas has also contributed to an integration of theory and practice for me personally.

Returning to the nitty gritty of the actual process of chartering, when I first started Part 2 mymotivation felt very low. I had just gained my masters in Counselling Psychology and now was on my

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own. I knew I could do it; normally I have very high levels of motivation and having changed careerI also felt pretty determined. However, I was missing peers with whom I could share experiences overthe client studies and even though my co-ordinator was very supportive I was feeling tired havingcompleted my dissertation. When I had progressed for about six months, having agreed my Plan ofTraining with the Registrar, my co-ordinator told me she had another trainee who was equally deter-mined to progress through to chartership working to the same timescales as myself. This became avery facilitative partnership. Both of us were very busy people but we were able to provide each otherwith support when the going became tough for whatever reason. We were able to e-mail or ’phoneeach other and even though there were no ‘deadlines’ for the completed client studies and processreports, this contact was motivational in helping each of us to remain focused.

When the time for submission came this January, I did not find it easy submitting 18,000 wordsof client studies and process reports simultaneously, and my log book! It was approximately 18 months of work and, like a doctoral thesis (I believe!), I realised I had become quite attached toit all. I could have reworked all of it several times over should I have had the time, but one obser-vation I made that felt very different from my Part 1 course route, was that there is no indicationrequired of the order in which the work was completed. Bearing in mind my own personal devel-opment that happened during Part 2, I am also aware this is likely to be seen in my submitted work.This made me wonder whether this is something that is taken into account by the examinationboard. Reflecting on both Part 1 and Part 2, and despite having experienced well over the obliga-tory 40 hours of personal therapy during Part 1, I believe I developed more as a person during thelatter part of my training and feel certain that this progression and personal development will beseen in my examined work.

On reflection of both parts of the Diploma (was it really only a diploma?!) the advantages ofdoing the course route were the gradual attainment of targets, pieces of work, and workshop andseminar hours that contribute to the log book and, of course, peer support. Part 2 independentlyseemed to be for me much more of a stop-start process, depending on what other demands werebeing imposed on my life. This both enabled and created flexibility (necessary attributes inCounselling Psychologists) but means that people doing the independent route from the beginninghave to seek out a co-ordinator of training, determine their own deadlines, in fact take responsibilityfor their overall pattern and Plan of Training. This is all underpinned and agreed with the Registrarat the beginning of the process and I always appreciated the speedy responses from both theRegistrar and others at the Division of Counselling Psychology to any queries I raised. I have been fortunate; all those from whom I have sought help in whatever capacity havebeen very willing to provide me with advice or information where they have been able. This hasenabled a smooth but flexible process that has taken me through Part 2 in parallel with my university course colleagues.

Whilst I have not found the Independent Route an easy option, at times throughout the processI have fought it, accepted it and finally appreciated it for the changes it has wrought in me, I haveprogressed through it to the end. My old course colleagues are also now finishing and I hope to havesome kind of a reunion to discover how the process of doing Part 2 in such different ways haschanged us both as people and practitioners. I cannot quite believe I have finished studying, but onlooking forward to continuing professional development I know this is only the first part of thatprocess. Interestingly for me, the process has not put me off thinking about doing a ‘top-up’ doctorate, but for now I want a break from studying. I want to develop further as a practitioner and therapist but also would be actively looking within my work for an area I might wantto research when the time is right.

Be encouraged, it is possible to enjoy doing the Diploma independently, but on occasion it canfeel like a trial by fire. Isn’t that a little of what therapy is about?

Sally Greenfield, Independent Route Trainee Representative.

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CORRESPONDENCE

Dear Editor In reading the Letter from the Chair, May 2003, on Statutory Registration, I felt it important to respondas I have recently experienced living temporarily in a country which has had statutory registrationfor a number of years.

In Norway the title of Psychologist is protected by law, meaning that no one can be called aPsychologist unless they have satisfied the authorities that they have completed the necessarytraining which is to Masters, or Doctoral level, plus a specialist training. It is also compulsory forNorwegian Psychology students to undergo a year in Philosophy before embarking on a Psychologycourse.

According to the information I have, Psychology came relatively early to Norway. The Universityof Oslo established an Institute of Psychology in 1909 and from 1948 a full doctoral programme wasoffered. In 1973 the Parliament of Norway approved a law requiring standards and licensure forPsychologists. The standards were revised in 1987 and are used to accredit foreign-educatedPsychologists applying to work in Norway.

The concern expressed in the Letter from the Chair is that Psychologists may feel devalued by beingplaced on a register with other health professionals whose training is seen not to be equivalent to ourown. It is not yet clear where Psychotherapy sits, as their training may exceed our own. At the momentthey are only regulated by their own bodies. Would they be happy to share a register with us?

The list in Norway is far more inclusive, in fact any one related to health personnel includingmedical secretaries and care workers have to be registered. The point of emphasis here is not status,but training that informs the public. From communicating with fellow Psychologists in Oslo, they donot feel devalued by sharing a register, quite the opposite; there is a sense of inclusion. Withoutregistration you are unable to use the title Psychologist. There is some prejudice against apsychotherapist practicing with only three or fours year training. There is no regulation for coun-sellors or psychotherapists. Psychology in Norway is seen as a high status profession. The NorwegianPsychological Association operates much the same way as in the UK, however it does not grant alicence.

What is it that makes us paranoid of what others think of us as a profession? Who are these other‘high status’ professions who would see us as being anything less than psychologists. I find it hard tothink of psychology as being any better or worse than any other helping profession. Perhaps thedifference in Norway is that there is a culture of equality. We do a job that we are trained to do asskilled, scientist-humanistic practitioners. If we think of ourselves as elitist, then we are entering thegame of the so-called ‘high status’ professions. The Counselling Psychologists I have come intocontact with in the UK (there are none in Norway I am aware of) have a strong ethical belief thatwhat we do as Counselling Psychologists helps the well-being of our clients. That belief in ourselvesis implicit, regardless which professions we share the register with.

The system in Norway appears to be open and transparent. What is it that we fear of statutoryregistration, a ‘dumbing down’ – or is it more a question of snobbery? Is it too big a task for thegovernment to create a more inclusive list?

Anna Karczewska Slowikowska, BSc MSc (Counselling Psychologist in Training) (Editor’s note – this letter has been edited)

Dear Editor

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CONFERENCE DIARY

Format of events listed is:date: eventvenuecontact

SEPTEMBER 2003

17–19: British Association for Counselling andPsychotherapy Annual Training ConferenceThe Moat House Hotel, Stratford-upon-Avon.Events Team, British Association forCounselling and Psychotherapy, 1 Regent Place, Rugby, Warwickshire CV21 2PJ.Tel: 0870 443 5241E-mail: [email protected]: www.bacp.co.uk

NOVEMBER 2003

13–15: International Coach Federation 8th Annual International Conference: ‘A Model of Excellence’Denver, Colorado, United States.International Coach Federation, 1444 I Street,NW, Suite 700, Washington, DC 20005-6542USA.Fax: +1.202.216.9646 or +1.888.329.2423E-mail:[email protected]: www.coachfederation.org/conference/international/index.htm

Please send details of all appropriateconferences to me:

By post: People in Progress Ltd5 Rochester Mansions, HoveEast Sussex BN3 2HA.

By fax: 01273 726180.

By e-mail: [email protected]

I look forward to hearing from you.

Jennifer Liston-Smith

A response to Anna Karczewska SlowikowskaIt was heartening to receive such a positive account of statutory regulation in Norway. I was still leftwondering, however, how the author’s non-health-related psychology colleagues found the system.

I noted that it is the term ‘Psychologist’ that is protected in Norway. Apparantly the precise UKprotected title has yet to be decided. One alternative to ‘Psychologist’ which is being discussed, isthe title ‘Psychological Practitioner’.

Professor Jill Wilkinson

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TALKING POINTA series of short pieces by invited Counselling Psychologists on subjects of topical interest anddebate. Responses to the views expressed in ‘Talking Point’ are welcomed: write to the Editormarking your letter ‘for correspondence’.

A QUESTION OF IDENTITYSheelagh Strawbridge

My starting point for this contribution to debate is Alan Bellamy’s thought provoking editorial inthe February edition of CPR. Alan drew attention to the ‘sometimes uncomfortable place’ that weoccupy as counselling psychologists and in doing so focused on important issues of identity. Hecommented that ‘we honour our place within psychology’ but find little to support our work in the‘established canon of psychological research’ and that we ‘struggle to maintain a place for a human-istic vision in workplaces dominated by biomedical or mechanistic views of what it is to be human’.Of course, the discomfort is, in large measure, the outcome of success. Becoming an establisheddiscipline of professional psychology, as well as opening up career paths, has brought pressure toconform both to dominant workplace ideologies and to the ‘canon’. This can lead to self-doubt, e.g.are we adequately trained; do we fall short on the skills demanded by employers, notably the NHS;even, whether we are proper psychologists, and so to a questioning of identity. Whilst I believe it isnecessary to regularly evaluate our competences and I do not see our professional identity as cast instone, I think it is important to re-examine and re-affirm core values in order to resist the predictablyde-radicalising effect of success.

I have struggled with some of the issues relating to work contexts in my own interventions in theongoing debate about diagnostic categories and in my reflections on ‘McDonaldisation’. I want hereto turn to the ‘humanistic vision’ of our discipline and its implications. I think this places values,ethics and politics at the heart of our identity and practice. Recent work for a book chapter(Strawbridge, in press) has prompted me to consider this further and is the basis of the followingthoughts.

Ethics is one of the central pillars of professionalisation. Tjeltveit states, ‘When psychotherapistsassert that they are professionals, they announce, they profess, they make public testimony that they possessspecialised knowledge and technical skills that help people with psychological problems’ (1999, p.255). A promise is made that the profession can be trusted to act in other than its own interests, so anideology of public service and altruism is espoused. Hence the very assertion of professional statusimplies both competence, in specialised knowledge and skills (in our case based in psychology), andethical commitment. Of course, such claims are made by a profession on its own behalf and are asmuch about the monopolisation of particular forms of expertise as about altruism. There are manycritiques of professionalisation, but that is not my focus here.

All professional bodies governing therapeutic practice commit practitioners to ethical standardsand codes of practice. Their main concern, in the context of self-regulation, is to protectclients/patients from bad practice, and with the ethos and conditions within which therapy takesplace. To this end there is significant agreement across such codes about basic principles and stan-dards of conduct. Ethical issues are seen largely as relating to aspects of conduct, such as themanagement of boundaries and the non-exploitation of clients, and to dilemmas arising in situa-tions where values conflict, e.g. those of client autonomy and client safety. These are important areasof ethical thinking. Nonetheless, such issues, relating to the standards and conditions of practice,may be seen as external to the actual process of therapy, which is often, though not always, conceivedin psychological rather than ethical terms.

However, the BACP has recently developed a fundamentally changed ethical framework and theBPS is currently engaged in a similar task. Both organisations are moving away from an approach toprofessional conduct based on sets of rules towards one based on values and principles. This will

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entail a different attitude in thinking about ethics. It will take time to establish but, in my view, thechange is quite profound. Ethical thinking and reasoned judgements based on values and princi-ples will be expected and there will be less specific guidance in the form of rules. Interestingly theBACP framework, which draws as much on virtue ethics as duty ethics, is explicit in requiring prac-titioners to cultivate personal qualities, such as empathy, sincerity and respect as a matter of ethicalresponsibility as well as in the context of technical competence. This emphasis on personal qualities andvalues invokes the ‘humanistic vision’ and re-orients the approach to professional ethics in a waythat makes ethical thinking central to the process of therapy. It does so precisely by drawing attentionto the personal and moral qualities of the practitioner and stressing the personal dimension and thequality of the relationship in therapy.

Of course there are differing aspects of, and ways of characterising ethics. Gernot Bohme (2001)usefully distinguishes three: 1. A branch of academic philosophy, an area of knowledge of a specific kind with its own methods

and schools;2. Connected with the idea of philosophy as a mode of living or a way of life;3. Practical wisdom.

The second and third of these characterisations have to do with what Bohme calls ‘the art ofdealing with serious questions’. Therapy can clearly be linked with the second, where ethical ormoral questions are seen as arising when matters become serious for each of us individually. Bohmeargues that how we decide those questions determines who we are and how we regard ourselves.They are questions that have to do with ‘being-human-well’ or virtue ethics. The third characterisa-tion of ethics, as practical wisdom, centres on public as distinct from personal concerns. Here thebasic values of communal life are at issue and arguments involve the formation of public opinion asa background for social regulation. So ethical or moral questions arise when matters become seriousfor a community and affect how it regards itself and what it becomes. In this aspect it is easy to seethe interrelationship of ethics and politics.

I believe that things are certainly becoming serious in relation to the question of our identity ascounselling psychologists and that some of the issues we are struggling with focus attention on therelationship between ethics, politics and psychology. I think these questions are of central relevanceand that it is useful to see them, in Bohme’s terms, as questions of ‘ethics as practical wisdom’ thatinvolve us collectively as a professional community.

Engaging with clients about issues relating to who they are and how they regard themselves isclearly an ethical activity as defined (under 2) above. At the same time, psychological theories,explicitly or implicitly, contain normative notions about the nature of persons, their well-being andpotential, and debates between theoretical approaches and models of therapy can be seen asdebates within psychology. In my view the humanistic vision of counselling psychology can bringthese together. It embraces the fundamentally ethical character of therapy, including the centralityof personal qualities and relationship and seeks to integrate psychological understanding andinquiry within it. Indeed the ethical notion of ‘being-human-well’ can link with the psychologicalnotion of ‘human potential’ and provide a positive alternative to medicalised notions that patholo-gise. However, the established canon of psychological practice and research, grounded in a naturalscience model, is often at odds with this vision, drawing us back into an emphasis on ‘technicalexpertise’ that undermines our commitment to ‘being-in-relation’, despite the wealth of evidencedemonstrating the therapeutic significance of the practitioner-client relationship.

It is possible, therefore, to imagine ethical and psychological inquiry as complementary. Indeed,deepening our understanding of acceptance, empathy and congruence requires this as theseconcepts relate to psychological attributes and skills of the therapist, to her or his ethical virtues andto the declared values of therapeutic practice. Moreover, whatever the approach, in the specificityof each therapeutic relationship, questions arise which have both ethical and psychological aspects,such as: ‘What does it mean to encounter this person?’; ‘What is my responsibility to this particularother?’; ‘How will I use my professional power in this specific relationship’; ‘How will aspects of my

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self and my values enter this relationship through, for example, disclosing aspects of my personalexperience?’; ‘When and how will I offer or withhold insights, interpretations or specific tech-niques?’.

I believe that our humanistic vision encompasses all this and that it entails a human scienceapproach to psychology. This does not mean adopting humanistic psychology as our model. Thoughthis has much of value to contribute, it is one perspective in a rich tradition of psychologicalapproaches. I want to sketch something of what I think a human science approach does mean.

As Hacking argues, even psychiatric classifications with a possible biological basis, such as schiz-ophrenia, are ‘interactive’, always open to revision because ‘people classified in a certain way change inresponse to being classified’ (1999, p.123). Moreover, the very range of competing psychological theo-ries and therapeutic approaches suggests that theoretical concepts, relating to such things as thenature of persons, their well-being, potential and pathology, are value laden. A human science perspective emphasises this interactive and value laden nature of psychology. Intune with the attitude of George Kelly (e.g. 1963), it adopts the view that human beings (includingpsychologists and their clients) are natural inquirers. One of the few things I remember from myundergraduate studies is a statement, I think by George Miller, about psychology only being of useif it can be given away. I think for us, as therapists, this implies engaging with clients in a spirit of co-operative inquiry. We can draw upon our self-awareness, psychological understanding, interpretativeconcepts and a range of techniques in offering resources, undogmatically, to our clients. I like MillerMair’s idea of psychology in an intermediary mode which is ‘to do with touching and being touched, person-ally. It is to do with communications which refresh and bring a person to life, open them up to new possibilities.’(1989, p.44) I also that think the radical cutting edge of counselling psychology lies in this visionand that it focuses the political dimensions of practice. In this context, I have learnt much fromPaulo Freire’s writings on education and believe that in therapy, like education, there is no neutralground. It is either about ‘domestication’ or ‘liberation’ (see Freire, 1972).

Recognising the range of psychological theories and approaches makes a link with postmod-ernist thinking and this stimulates political critique. Postmodernism stresses that knowledge isalways limited within perspectives. This being so, such perspectives must be made transparent andtheir implicit values examined. Studies within psychology, which are beginning the self-reflective critique of the discipline (e.g. Burman, 1994; Fox & Prilleltensky, 1997), emphasise thepolitical role that psychological theories play in constructing and maintaining socio-political struc-tures and power relationships. More specifically, studies of the discourses of psychopathology andpsychotherapy pose a considerable ethical and political challenge to established therapeutic prac-tice (e.g. Parker et al., 1995; Parker, 1999; Fee, 2000; Hook & Eagle, 2002). They show how, whateverthe model (bio-medical/psychiatric, cognitive-behavioural, psychoanalytic or humanistic) theoriessituate clients and their problems within normative discourses that, for example, set standards ofmental health, adjustment, development or self-realisation. Moreover, if taken as truths, rather thanas useful fictions or maps, they position the therapist as expert and privilege the language of themodel over the everyday language of clients. In doing so they often oppress the people they intendto help. It is worth remembering James Hillman’s comment on the power of psychological perspec-tives: ‘Once one has been written into a particular clinical fantasy with its expectations, its typicalities, itscharacter traits, and the rich vocabulary it offers for recognising oneself, one then begins to recapitulate one’s lifeinto the shape of the story. One’s past too is retold and finds a new internal coherence, even inevitability, throughthis abnormal story.’ (1983, p.15)

So, in short, I think that our humanistic vision entails a human science view of psychology. It encourages us to focus on being-in-relation and co-operative inquiry. It concentrates awareness onthe limited applicability of technical-rational knowledge in therapy, the centrality of ethical andpolitical values and the significance of critique. Developing this vision is important in maintaininga secure sense of identity, particularly in situations where we find ourselves in conflict with established practice.

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ReferencesBohme, G. (2001). Ethics in context: The art of dealing with serious questions. Cambridge: Polity.Burman, E. (1994). Deconstructing developmental psychology. London: Routledge.Fee, D. (Ed.) (2000). Pathology and the postmodern: Mental illness as discourse and experience. London:

Sage.Fox, D. & Prilleltensky, I. (Eds.) (1997). Critical psychology: An introduction. London: Sage.Freire, P. (1972). Cultural action for freedom, and pedagogy of the oppressed. Harmondsworth: Penguin.Hacking, I. (1999). The social construction of what? Cambridge Mass. & London: Harvard University

Press.Hillman, J. (1983). Healing fiction. New York: Spring.Hook, D. & Eagle, G. (Eds.) (2002). Psychopathology and social prejudice: Cape Town: UCT Press.Kelly, G. (1963). A theory of personality: The psychology of personal constructs. New York: Norton.Mair, M. (1989). Between psychology and psychotherapy: A poetics of experience. London: Routledge.Parker, I. (Ed.) (1999). Deconstructing psychotherapy. London: Sage.Parker, I., Georgaca, E., Harper, et al. (1995). Deconstructing psychopathology. London: Sage.Strawbridge, S. (in press). Ethics, psychology and therapeutic practice. In D. Hill & C. Jones

(Eds.), Forms of ethical thinking in therapeutic practice. Milton Keynes: Open University Press.Tjeltveit, A.C. (1999). Ethics and values in psychotherapy. London: Routledge.

DIPLOMA IN COUNSELLING PSYCHOLOGYINFORMATION DAY

Saturday 18th October 2003 – 10.30 am to 4.30 p.m. atThe British Psychological Society,

33 John Street London.The Board of Examiners for the Diploma in Counselling Psychology are pleased to offerthe third annual Information Day on Saturday 18th October 2003 to which all with aninterest in the independent route are warmly invited.

This one-day seminar aims to provide an information and discussion forum to all those whoare undertaking, considering undertaking, or are otherwise interested in the Independentroute to Chartered status as a Counselling Psychologist. The day aims to address the needsof both current and potential trainees and the programme will focus on enrolment,regulations, training requirements and submitting work for examination. Speakers willinclude the Chair of The Board of Examiners, The Registrar, The Senior Examiner, TheStudent Representative from the Division Committee and the day will also provide anopportunity to meet with others who are undertaking the Diploma.

The Seminar is supported by the Division Committee and there is a nominal charge onlyof £10 for attendance at the day. with lunch being provided.

Venue: The British Psychological Society, 33 John Street, London, WC1N 2AT.

For a full programme and application form please contact Jean Duckworth, The BritishPsychological Society, St Andrews House, 48 Princess Road East, Leicester, LE1 7DR ore-mail: [email protected]

Notes for Contributors toCounselling PsychologyReviewSubmissionsThe Editorial Board of Counselling Psychology Review invites contributions on any aspects of counselling psychology. Papersconcerned with professional issues, the training of counselling psychologists and the application and practice of counsellingpsychology are particularly welcome. The Editorial Board would also like to encourage the submission of letters and news of forthcoming events.

Manuscripts should be typewritten, double spaced with 1" margins on one side of A4 paper. Each manuscript should include a word count at the end of each page and overall. Sheets should be numbered. On a separate sheet include author’s name,any relevant qualifications, address, telephone number, current professional activity and a statement that the article is notunder consideration elsewhere and has only been submitted to Counselling Psychology Review. As articles are refereed, the restof the manuscript should be free of information identifying the author. Authors should follow The Society Guidelines for the Useof Non-Sexist Language contained in the booklet Code of Conduct, Ethical Principles and Guidelines. Four copies of the manuscriptshould be submitted with a large s.a.e. A copy should be retained by the author.

Bibliographic references in the text should quote the author’s name and the date of publication thus: Davidson (1999). All references should be listed at the end of the text and should be double spaced in APA style. A guide to the presentationof references using the APA style is given in The British Psychological Society Style Guide, available at £3.50 per copy from The British Psychological Society, St Andrews House, 48 Princess Road East, Leicester LE1 7DR, UK.

Low-quality artwork will not be used. Graphs, diagrams, etc., should be supplied in camera-ready form. Each should have atitle. Written permission should be obtained by the author for the reproduction of tables, diagrams, etc., taken from othersources.

All manuscripts should include an abstractThe abstract should be no longer than 250 words (depending on the length of the paper). It needs to be double spaced, on a separate sheet and headed ‘Abstract’. The British Psychological Society’s Style Guide provides the following informationon writing abstracts:

The purpose of the abstract is to allow the reader to assess the content of the article prior to reading the full text. In addition to appearing immediately below the author’s name, the abstract will be used for indexing and information retrievalby such services as Psychological Abstracts. It should, therefore, be written so that it can be understood independently of thebody of the paper (p.6).

Proofs of articles are sent to authors for the correction of typesetting errors only. The Editor needs the prompt return of proofs.

Contributors should enclose a PC-compatible 3.5" disk with the document saved both in its originalword-processing format and as an ASCII file. All diagrams and other illustrations should be saved intheir original format and as a TIFF or an EPS.

Other submissionsBook reviews, letters, details about courses and notices of forthcoming events are not refereed but evaluated by the Editor.However, book reviews should conform to the general guidelines for academic articles. Contributors should enclose two hard copies.

Deadlines for notices of forthcoming events, letters and advertisements are listed below:For publication in Copy must be received byFebruary 5 NovemberMay 5 FebruaryAugust 5 MayNovember 5 August

All submissions should be sent to: Dr Alan Bellamy, Editor, Counselling Psychology Review, Brynmair Clinic, GoringRoad, Llanelli, Carmarthenshire, SA15 3HF.

Book reviews should be sent to: Kasia Szymanska, Book Reviews Editor, Centre for Stress Management, 156 Westcombe Hill,London SE3 7DH.

ISSN 0269–6975

© The British Psychological Society 2003

St Andrews House, 48 Princess Road East, Leicester LE1 7DR

Printed and published in England by The British Psychological Society

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