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Sir Galahad and Saving the Nation

Andrew Reeves recounts his personal journey from counsellor to researcher and editor and explains that research could be a priority for us all.

When I first qualified as a counsellor I really did not see the relevance of research to my work. I was aware it existed, although I was not encouraged or facilitated by my course to explore the world of research to any great degree. Rather, the ‘real’ work took place in the consulting room with clients, and the ‘task’ of counselling and psychotherapy was only the facilitation of the therapeutic process, rather than the asking of bigger questions. As Editor of an international peer-reviewed counselling and psychotherapy research journal I am a little ashamed to admit to this reality, but a reality it was all the same. The purpose of this article though is about my journey from practitioner to practitioner-researcher, and from practitioner-researcher to an editorial role, and the relevance of that potentially to other counsellors and psychotherapists who still view research with, at best, a degree of boredom and, at worst, suspicion and derision.

My journey begins in practice, with a client I shall call Isobel. I have written about Isobel elsewhere (Reeves, 2010), but to summarise here: Isobel was a middle-aged, white, female client who I saw for several months within the secondary mental health service in which I was based. Estranged from her family, struggling with alcohol dependency and depression, this was the first time Isobel had been offered any form of therapy in her 30-year psychiatric history. Admitted compulsorily on many occasions, and voluntarily on many more, Isobel was more used to a psychopharmachological approach to her distress, rooted within a context of compulsion and obedience. She talked of suicide on many occasions, but also of her growth, increasing self-confidence and self-belief, and re-engagement with a society and culture she had felt disconnected from for many years.

It is therefore hard to convey the sense of personal and professional catastrophe I experienced on hearing the news of her suicide following one of our sessions. She had left the room saying she felt ‘good; very, very good’, but that night decided to end her life with an overdose of anti-depressants and vodka; an irony in those things that had brought her so much despair in living had been used, perhaps, to bring her relief and peace. I was left devastated. My employing organisation was excellent, supervision available and supportive, personal therapy facilitative and colleagues and peers interested and empathic. All were certainly important in me starting to put my pieces back together again. However, none never quite said what I wanted to hear; I still felt isolated, incompetent and alone in my grief.

Quite by accident I later came across writings by Richards (1999; 2000). These were quite revelatory in that suddenly, and without expectation, I read that other therapists felt similar things to me, and their stories of working with suicide resonated with some of what I felt. Isolation, incompetence and aloneness became much more accessible to me, and became concepts I could reflect on as well as feel. Reading these studies fundamentally allowed me to make a different sense of my own experience and contextualise it within a different frame: one that was shared with others, rather than a weight to be carried alone.

For me that is what ‘good’ research is about: something that provides me, as a practitioner, with a frame in which I can reflect on and conceptualise different aspects of counselling and psychotherapy in a way that is shared – connected with – others, as opposed to one informed by my own world-view or that of those immediately around me. Certainly my experience is that counselling and psychotherapy can be very individualistic tasks if we allow them to be. While we might spend a great deal of time with others, we do so within a particular context or relationship. The opportunities to engage with other therapists typically have to be created, rather than fall into our laps, and it is too easy to look back and realise just how long it has been since there was any meaningful discourse with others, beyond supervision, that allowed for critical reflection, challenge and questioning the basic tenets of what we do, and why. It is my assertion here that research can provide us with that space.

I was so inspired (not a word I use lightly) by Richards’ work that I began my own early research. Initially a small-scale study, The experiences of counsellors who work with suicidal clients (Reeves and Mintz, 2001). I was very aware of asking question I needed the answers to. I cannot claim at this stage any altruistic motivation; I was too taken with trying to heal myself. This small-scale qualitative study was startling for me for two primary reasons: first, participants talked of their experiences that so closely mirrored my own that my motivation was further fuelled; and second, I could do research.

The next part of my journey into the world of research came when I was appointed as Editor to Counselling and Psychotherapy Research (CPR), the international peer-review journal of the British Association for Counselling and Psychotherapy (BACP). Journals such as CPR provide the forum for the dissemination of research findings, and thus contribute to the evolution of an evidence base. While there is much research that takes place in counselling and psychotherapy, often through the structure of academic programmes, comparatively little ever sees the light of day because the ‘next step’ (ie dissemination) is not taken. This is such a missed opportunity. I have now been doing this for nearly five years and enjoy it immensely. If I were to summarise my experience of the profile of papers received for CPR:

The majority of papers are submitted by counsellors and psychotherapists, with an increasing number from psychologists, academics, mental health workers and psychiatrists
Approximately half originate from the UK, with the rest from Europe, North America, Australia, New Zealand and Asia
A range of research methods is employed, including quantitative, qualitative, mixed-methods and case studies
Some papers provide a commentary of particular aspects of research in counselling and psychotherapy
All papers make discrete implications for practice, as well and including a reflexive position (where appropriate)
Most positively, an increasing number of papers are submitted by new researchers, (ie people who have never published in a journal previously).

What is hopeful is that, year on year, submissions are increasing and, as stated, include a significant number from practitioners who have never before published their work. My own experience has been that the peer review process that is part of submitting to many journals can provide an invaluable learning process, where the ability to present information in a succinct and accessible way for a particular audience is developed.

So what of the fears that might ‘get in the way’ of undertaking research? It is worth at this stage perhaps spending a moment or two reflecting on a few assumptions I hear from practitioners about research: it is too expensive to do; it won’t change anything; it is what others do (usually professors in universities); and it has nothing to do with me.

It is too expensive to do

There is no doubt that the large-scale, ‘gold-standard’ randomised controlled trials (RCTs) are prohibitively expensive for any individual practitioner to even consider contemplating, and that doesn’t even take into account the logistical intricacies, which would be the first hurdle. Cooper (2011) has offered an eloquent and compelling argument as to why counsellors and psychotherapists should open their hearts and minds to RCT outcomes. I would certainly agree and believe, like Cooper, that they have the potential to contribute to a much-needed growing evidence-base for counselling and psychotherapy. Fundamentally, whether we like it or not, in the current fiscal-orientated climate a strong evidence-base is what we need. Without it counselling and psychotherapy run the risk of being sidelined in the provision of services and, more importantly, the available choices for potential clients become diminished.

This raises an important question about the nature of the relationship between practitioners and research. I do not argue here that all counsellors and psychotherapists should necessarily become practitioner-researchers; rathe,r as a benchmark, we should all at least become critical and informed consumers of research. If this benchmark was achieved, we would be in a position to access and critically engage with the research evidence we might not necessarily be able to ‘do’ ourselves, but that has the potential to profoundly inform and shape the future face of therapy. Surely that can only be a good thing?

It won’t change anything

This is a difficult one to argue, because essentially we need to be clear about how we are measuring ‘change’. The dominance of a positivist world-view that everything is measurable and there are single truths can somewhat put a dent in a ‘wishy-washy’ belief that there are some things best not measured, but rather heard, and that ‘truths’ come in all shapes and sizes. The epistemological mud-slinging that can take place between the different research camps does little to further this argument. That said, counselling and psychotherapy is all too familiar with the ‘my orientation is better than yours’ approach to a particularly unsophisticated exploration of difference. Rather, if we see that all ways of viewing the world, and thus all ways of constructing research, have something to contribute to the bigger picture, then we position ourselves in a stronger place. An example of this is the increasing trend of embedding qualitative studies within the context of RCTs to help us understand particular aspects of that being studied in a different way.

Going back to the nature of change however, my own research has profoundly and irrevocably changed the way in which I see counselling and psychotherapy with suicidal clients, and others have kindly reported the same is true for them also. Was my intention when conducting research to change the world and find a single truth? Mostly not; instead it was to contribute to knowledge and understanding by offering different perspectives on a familiar phenomenon. It is worth noting here that during my doctoral research, when still hurting from Isobel’s actions, a research participant said to me:  “I was wondering, is this a personal journey, are you Sir Galahad on his horse riding out to save the nation because you felt such a failure in yourself? And I wondered about that. I didn’t in any way feel judgmental I just felt, oh, what’s that about? This poor man has to tell the nation, to protect the nation…”. She continued: “What I was left with was the fact that it was something that you were passionate about… which is a strange use of words… but from your experience you had been through with your client, you didn’t want any of us… you were quite protective… you didn’t want any of us going through what you had been through.” (Reeves, 2010 p 169)

She was right (at the time): I had wanted to change the world and ‘save the nation’ as a means of saving myself. My biggest insight through my research was of embracing uncertainty again. Change can happen with a capital ‘C’ and when it does it makes the headlines. Perhaps the most profound change however, is that which happens with a lower-case ‘c’; where we are encouraged to look at the world slightly differently having seen it through the eyes of another.

I would hope the findings of my research into working with suicidal clients, undertaken over several years, have touched others in their work. I am not so deluded to imagine they have brought about change with a capital ‘C’, but I have tried to speak a little of the challenges counsellors and psychotherapists face when supporting a suicidal person. To summarise some of the main findings:

Therapists can feel a range of profoundly difficult feelings when working with suicidal clients, including: fear; anxiety; anger; a sense of incompetence; and trauma
Therapists are generally not well-equipped by their core training to work effectively with suicidal clients
Supervisors, in turn, are generally not well-equipped by their supervision training to support supervisees effectively in their work with suicidal clients
When therapists disagree with organisational policy regarding how they should work with suicidal clients, they are generally more likely to disregard policy than challenge it, continuing to work in their preferred way
While risk-factors, as identified through research, can positively influence policy development, they have limited use for therapists in informing decisions with individual clients
Therapists will often not disclose concern about suicidal potential to others (eg General Practitioners, mental health services) because they lack faith in the quality or nature of the response the client will receive
Countertransferential feelings, particularly around the therapist’s individual views about suicide, can be acted out in sessions with clients if not acknowledged and considered in supervision
Therapists, regardless of theoretical orientation, are more likely to use reflective responses with suicidal clients than explorative ones; this then limits the potential for therapist and client to understand both the nature of the suicidal feelings and the degree of risk they represent
Therapists, regardless of their core training, can fear asking the ‘suicide question’ (ie “Do you have thoughts of suicide or self-harm?”) for fear of putting the thought into the client’s mind where it did not exist before
While therapists use a range of knowledge and skills to help inform their understanding of a client’s suicide potential, they are less willing or skilled at detailing what their thinking was informed by, instead referring to it as ‘gut feeling’ or ‘intuition’
When given time and structure (in this instance a one-day training programme in working with suicidal clients was developed for therapists and evaluated), therapists can be supported to raise self-awareness and develop skills for working with clients at risk.

These findings are detailed in various papers published over the years but, with others, are summarised in Reeves (2010).

It is what others do (usually professors in universities)

There is no doubt that we are lucky in the world of counselling and psychotherapy to have many gifted professors and academics working in excellent universities who make significant contributions to the development of our work through research. I neither wish to deny it, nor detract from it. I wish instead to challenge the assumption I hear at regular intervals that, by virtue of being a practitioner, we are therefore precluded (or excluded) from dipping our own toes in the research lake. The lake is vast and deep and its waters barely chartered. As counsellors and psychotherapists we are, I suspect, an inquisitive bunch, and yet for reasons perhaps based on fear or uncertainty we too often don’t allow ourselves to ask questions in a way that might constitute ‘research’. Instead we seem to remain suspicious of it, leaving it to others to do instead.

I would argue that we all have a contribution to make to an emerging evidence-base for counselling and psychotherapy. The possibilities that exist in developing practice-based evidence (where evidence is derived from practice rather than outside of it), and Practice Research Networks (PRNs) where practitioner-researchers collaborate to generate data and support each other through the process of analysis, are profound. In this way we can make research something we all do, rather than just a few.

Certainly I have tried to integrate my own work with clients into my work as a researcher, and vice versa. This has been on several levels:

Introducing research findings into sessions, sometimes offering references for articles or books, when we both believe research has something to say about or contribute to their own experience or difficulty

Talking to clients about my own research findings. This is particularly true (and useful) when working with suicidal clients. Being able to talk to them of others’ experiences – both clients and therapists – can be profoundly helpful in making inaccessible distress and shameful feelings much more accessible and ‘real’. It helps open doors and can provide a structure within which we can both feel our way

Using outcome measures, such as CORE-OM and the Association for University and Collage Counsellors (AUCC) scales. While measures such as CORE were traditionally developed for benchmarking clinical change at a service level, my own experience is that it can additionally provide invaluable information to help me reflect on my own practice – my strengths and areas for development – as well as proactively using CORE information with clients, in sessions, to help them ‘benchmark’ their own experience of change.

It has nothing to do with me

While similar to the points made above, this position comes from a more philosophical as opposed to pragmatic standpoint; that is, research does not have a place in counselling and psychotherapy. I recently attended a conference for counselling and psychotherapy students. During an otherwise excellent keynote the presenter made reference to some research. He followed this up with the statement, “but research has nothing to do with us”, at which point the audience laughed in recognition of a shared truth. It made me both sad and concerned for the future of our profession. If future practitioners are already professionalised into a belief that research is not relevant to their day-to-day practice, then the progress many have been making recently in challenging that perspective could be quickly undone.

Final Thoughts

As I hope I have demonstrated in my musings here, I would never have imagined when I first qualified as a counsellor that I would become a researcher, and work on a research journal. Now I am here, I cannot imagine a time when research would not have a place in my work. I have written before that, for me, research (doing or reading) is as important as supervision, personal therapy and other professional networking. It forms part of a life-blood of ethical and reflective practice; a foundation on to which everything else I do is built. Following Isobel’s death I unconsciously embarked on a quest to save the nation, and a quest for certainty. I have long since given that up. Every research participant with whom I worked on my research, and there have been several hundred, played an important part in that growth; I remain profoundly grateful.

Andrew Reeves is a counsellor and supervisor at the University of Liverpool Counselling Service. He is a freelance trainer and writes books and articles on a variety of counselling and psychotherapy related activities. He is Editor of Counselling and Psychotherapy Research journal.
The University of Liverpool, Liverpool, Merseyside, L69 7WX, UK A.Reeves@liverpool.ac.uk

References
Cooper, M. (2011) Meeting the demand for evidence-based practice Therapy Today. 22(4):10-16
Reeves, A. and Mintz, R. (2001). Counsellors’ Experience of Working with Suicidal Clients: An Exploratory Study Counselling and Psychotherapy Research 1(3):172-76.
Reeves, A (2010) Counselling Suicidal Clients London: SAGE
Richards, B. (1999) Suicide and internalised relationships: a study from the perspective of psychotherapists working with suicidal patients British Journal of Guidance and Counselling 27(1): 85-98.
Richards, B. (2000) Impact upon therapy and the therapist when working with suicidal patients: some transference and countertransference aspects. British Journal of Guidance and Counselling 28(3):325-337.