An investigation of client preferences using the Therapy ...



Metatherapeutic communication: An exploratory analysis of therapist-reported moments of dialogue regarding the nature of the therapeutic workFani PapayianniGlasgow Caledonian UniversityMick CooperUniversity of RoehamptonFani Papayianni (corresponding author), Department of Psychology, School of Life & Health Sciences, Glasgow Caledonian University, Cowcaddens Road, Glasgow G4 0BA, Scotland; 0141 331 8141; fani.papayianni@gcu.ac.uk.Mick Cooper, Department of Psychology, University of Roehampton, Holybourne Avenue, London SW15 4JD, 07734-558155, mick.cooper@roehampton.ac.ukReferencePapayianni, F., & Cooper, M. (2018). Metatherapeutic communication: an exploratory analysis of therapist-reported moments of dialogue regarding the nature of the therapeutic work. British Journal of Guidance & Counselling, 46(2), 173-184. doi: 10.1080/03069885.2017.1305098Metatherapeutic communication: An exploratory analysis of therapist-reported moments of dialogue regarding the nature of the therapeutic workThe purpose of the study was to investigate the nature of metatherapeutic communication (MTC), defined as dialogue between therapists and clients on the nature of the therapeutic work and the means by which it can be of greatest help to clients. Twelve counselling psychologists, working pluralistically with 35 clients experiencing depression, described on post-session forms moments of negotiation and collaboration around the therapeutic work. Two main dimensions of MTC were identified: the subject matter of the MTC and the temporal focus of the MTC. In addition, MTC varied by the time at which it took place. These findings provide a framework for understanding the nature of MTC in counselling and psychotherapy, and the opportunities for implementing it in practice.Key words: therapeutic alliance, shared decision making, metatherapeutic communication, pluralistic counselling, collaboration.IntroductionMetatherapeutic communication (MTC) has been defined as ‘the process of talking to clients about what they want from therapy, and how they think they may be most likely to achieve it’ ADDIN EN.CITE <EndNote><Cite><Author>Cooper</Author><Year>2012</Year><RecNum>3404</RecNum><Pages>7`, italics added</Pages><DisplayText>(Cooper &amp; McLeod, 2012, pp. 7, italics added)</DisplayText><record><rec-number>3404</rec-number><foreign-keys><key app="EN" db-id="0swazwvvzv2zzfe0fs75dwsza2wreftvrrpv" timestamp="0">3404</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Cooper, Mick</author><author>McLeod, John</author></authors></contributors><titles><title>From either/or to both/and: Developing a pluralistic approach to counselling and psychotherapy</title><secondary-title>European Journal of Psychotherapy and Counselling</secondary-title></titles><pages>5-18</pages><volume>14</volume><number>1</number><dates><year>2012</year></dates><urls></urls></record></Cite></EndNote>(Cooper & McLeod, 2012, pp. 7). This concept builds on Rennie’s (1994) notion of metacommunication: moments where participants in the therapeutic dyad discuss what actually has been said or done. Metatherapeutic communication is a form of metacommunication which focuses specifically on the way that therapy is, has been or could be done ADDIN EN.CITE <EndNote><Cite><Author>Cooper</Author><Year>in press</Year><RecNum>4373</RecNum><DisplayText>(Cooper, Dryden, Martin, &amp; Papayianni, in press)</DisplayText><record><rec-number>4373</rec-number><foreign-keys><key app="EN" db-id="0swazwvvzv2zzfe0fs75dwsza2wreftvrrpv" timestamp="1432966119">4373</key></foreign-keys><ref-type name="Book Section">5</ref-type><contributors><authors><author>Cooper, Mick</author><author>Dryden, W.</author><author>Martin, K</author><author>Papayianni, F</author></authors><secondary-authors><author>Cooper, Mick</author><author>Dryden, W.</author></secondary-authors></contributors><titles><title>Metatherapeutic communication and shared decision-making</title><secondary-title>Handbook of pluralistic counselling and psychotherapy</secondary-title></titles><keywords><keyword>Existential: 5 schools: pluralistic</keyword></keywords><dates><year>in press</year></dates><pub-location>London</pub-location><publisher>Sage</publisher><urls></urls></record></Cite></EndNote>[reference deleted to maintain anonymity of authors], with the aim of optimising its helpfulness to the individual client. This distinguishes it from other forms of metacommunication, such as working in the ‘here-and-now’ or transference work. Metatherapeutic communication also differs from these other forms of metacommunication in that it necessitates an ‘adult’ to ‘adult’ mode of relating ADDIN EN.CITE <EndNote><Cite><Author>Berne</Author><Year>1961</Year><RecNum>208</RecNum><DisplayText>(Berne, 1961)</DisplayText><record><rec-number>208</rec-number><foreign-keys><key app="EN" db-id="0swazwvvzv2zzfe0fs75dwsza2wreftvrrpv" timestamp="0">208</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Berne, Eric</author></authors></contributors><titles><title>Transactional Analysis in Psychotherapy</title></titles><keywords><keyword>Humanistic psychology</keyword></keywords><dates><year>1961</year></dates><pub-location>New York</pub-location><publisher>Grove Press</publisher><urls></urls><custom2>3</custom2></record></Cite></EndNote>(Berne, 1961). The concept of MTC derives from the pluralistic approach to therapy [reference deleted to maintain anonymity of authors]: a collaborative, integrative therapeutic framework that emphasises client-therapist dialogue as a means of tailoring therapy to the client’s individual preferences and wants. The concept of MTC is related to shared decision making, as developed in the wider healthcare field. This is a relational decision making process that contrasts with both the traditional paternalistic model of medical decision making, and also a more laissez-faire ‘informed model’ approach in which the patient is left to make decisions on their own ADDIN EN.CITE <EndNote><Cite><Author>The?Health?Foundation</Author><Year>2012</Year><RecNum>4426</RecNum><DisplayText>(The?Health?Foundation, 2012)</DisplayText><record><rec-number>4426</rec-number><foreign-keys><key app="EN" db-id="0swazwvvzv2zzfe0fs75dwsza2wreftvrrpv" timestamp="1436809579">4426</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>The?Health?Foundation</author></authors></contributors><titles><title>Helping people share decision making</title></titles><dates><year>2012</year></dates><pub-location>London</pub-location><publisher>The Health Foundation</publisher><urls></urls></record></Cite></EndNote>(Da Silva, 2012). Shared decision making is a dialogical, partnership approach ‘in which clinicians and patients work together to select tests, treatments, management, or support packages, based on clinical evidence and patients’ informed preferences’ ADDIN EN.CITE <EndNote><Cite><Author>Coulter</Author><Year>2011</Year><RecNum>4176</RecNum><Pages>??</Pages><DisplayText>(Coulter &amp; Collins, 2011, p.??)</DisplayText><record><rec-number>4176</rec-number><foreign-keys><key app="EN" db-id="0swazwvvzv2zzfe0fs75dwsza2wreftvrrpv" timestamp="1417864204">4176</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Coulter, A</author><author>Collins, A</author></authors><tertiary-authors><author>The Kinds Fund</author></tertiary-authors></contributors><titles><title>Making Shared Decision-Making a Reality:?No decision about me, without me?</title></titles><dates><year>2011</year></dates><pub-location>London</pub-location><publisher>The Kinds Fund</publisher><urls></urls></record></Cite></EndNote>(Coulter & Collins, 2011, p.vii). However, while shared decision making is an explicit process, MTC may be more implicit. It may be less focused around specific treatment decisions. For instance, it may involve reviewing a client’s experiences of a session ADDIN EN.CITE <EndNote><Cite><Author>Cooper</Author><Year>in press</Year><RecNum>4373</RecNum><DisplayText>(Cooper, Dryden, Martin, &amp; Papayianni, in press)</DisplayText><record><rec-number>4373</rec-number><foreign-keys><key app="EN" db-id="0swazwvvzv2zzfe0fs75dwsza2wreftvrrpv" timestamp="1432966119">4373</key></foreign-keys><ref-type name="Book Section">5</ref-type><contributors><authors><author>Cooper, Mick</author><author>Dryden, W.</author><author>Martin, K</author><author>Papayianni, F</author></authors><secondary-authors><author>Cooper, Mick</author><author>Dryden, W.</author></secondary-authors></contributors><titles><title>Metatherapeutic communication and shared decision-making</title><secondary-title>Handbook of pluralistic counselling and psychotherapy</secondary-title></titles><keywords><keyword>Existential: 5 schools: pluralistic</keyword></keywords><dates><year>in press</year></dates><pub-location>London</pub-location><publisher>Sage</publisher><urls></urls></record></Cite></EndNote>[reference deleted to maintain anonymity of authors]. With respect to clinical outcomes, evidence is limited on the effectiveness of MTC and shared decision making processes, per se. There is nevertheless supporting evidence indicating that the idea of processing the therapeutic relationship in the here-and-now can strengthen the therapeutic alliance and thus the effectiveness of therapy (Hill & Knox, 2009). In addition, there is an extensive body of data to indicate that clients do better in therapy where they are in agreement with their therapists on the goals and tasks of therapy PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5UcnlvbjwvQXV0aG9yPjxZZWFyPjIwMTE8L1llYXI+PFJl

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ADDIN EN.CITE.DATA (Horvarth, Del?Re, Fluckinger, & Symonds, 2011; Tryon & Winograd, 2011). In addition, clients who participate in a therapy that is consistent with their preferences, as opposed to clients who participate in a non-preferred therapy, show significantly greater clinical outcomes and satisfaction, and significantly lower dropout rates at a ratio of almost one-to-two (Lindhiem, Bennett, Trentacosta, & McLear, 2014 ADDIN EN.CITE <EndNote><Cite><Author>Swift</Author><Year>2011</Year><RecNum>4102</RecNum><DisplayText>(Swift, Callahan, &amp; Vollmer, 2011)</DisplayText><record><rec-number>4102</rec-number><foreign-keys><key app="EN" db-id="0swazwvvzv2zzfe0fs75dwsza2wreftvrrpv" timestamp="1411802904">4102</key></foreign-keys><ref-type name="Book Section">5</ref-type><contributors><authors><author>Swift, Joshua K.</author><author>Callahan, Jennifer L.</author><author>Vollmer, Barbara M.</author></authors><secondary-authors><author>Norcross, J C</author></secondary-authors></contributors><auth-address>Swift, Joshua K., Department of Psychology, University of Alaska Anchorage 3211 Providence Drive SSB214, Anchorage, AK, US, 99508, Joshua.Keith.Swift@</auth-address><titles><title>Preferences</title><secondary-title>Psychotherapy relationships that work</secondary-title></titles><pages>301-315</pages><edition>2nd</edition><keywords><keyword>client preferences</keyword><keyword>evidence based practice</keyword><keyword>therapeutic practices</keyword><keyword>Client Attitudes</keyword><keyword>Preferences</keyword><keyword>Therapeutic Processes</keyword></keywords><dates><year>2011</year></dates><pub-location>NY</pub-location><publisher>Oxford University</publisher><urls></urls><remote-database-name>psyh</remote-database-name><remote-database-provider>EBSCOhost</remote-database-provider></record></Cite></EndNote>; Swift, Callahan, & Vollmer, 2011). Research also indicates that shared decision making interventions increase service users’ satisfaction and involvement with care; their sense of self-efficacy, self-confidence and self-management; and are desired by a majority of clients PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5UaGUgSGVhbHRoIEZvdW5kYXRpb248L0F1dGhvcj48WWVh

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ADDIN EN.CITE.DATA (Ahmad, Ellins, Krelle & Lawrie, 2014; Da Silva, 2012; Makoul & Clayman, 2006). Finally, evidence for the importance of MTC comes from research into the therapeutic alliance, which indicates that therapeutic outcomes are closely related to the degree of concordance between therapists and clients on the goals and tasks of therapy (Bordin, 1979; Horvarth, Del Re, Fluckinger & Symonds, 2011). Guidelines have been developed for the use of MTC in counselling and psychotherapy ADDIN EN.CITE <EndNote><Cite><Author>Cooper</Author><Year>in press</Year><RecNum>4373</RecNum><DisplayText>(Cooper et al., in press; Cooper &amp; McLeod, 2011)</DisplayText><record><rec-number>4373</rec-number><foreign-keys><key app="EN" db-id="0swazwvvzv2zzfe0fs75dwsza2wreftvrrpv" timestamp="1432966119">4373</key></foreign-keys><ref-type name="Book Section">5</ref-type><contributors><authors><author>Cooper, Mick</author><author>Dryden, W.</author><author>Martin, K</author><author>Papayianni, F</author></authors><secondary-authors><author>Cooper, Mick</author><author>Dryden, W.</author></secondary-authors></contributors><titles><title>Metatherapeutic communication and shared decision-making</title><secondary-title>Handbook of pluralistic counselling and psychotherapy</secondary-title></titles><keywords><keyword>Existential: 5 schools: pluralistic</keyword></keywords><dates><year>in press</year></dates><pub-location>London</pub-location><publisher>Sage</publisher><urls></urls></record></Cite><Cite><Author>Cooper</Author><Year>2011</Year><RecNum>2748</RecNum><record><rec-number>2748</rec-number><foreign-keys><key app="EN" db-id="0swazwvvzv2zzfe0fs75dwsza2wreftvrrpv" timestamp="0">2748</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Cooper, Mick</author><author>McLeod, John</author></authors></contributors><titles><title>Pluralistic Counselling and Psychotherapy</title></titles><keywords><keyword>pluralistic framework: 0 general</keyword></keywords><dates><year>2011</year></dates><pub-location>London</pub-location><publisher>Sage</publisher><urls></urls></record></Cite></EndNote>[reference deleted to maintain anonymity of authors; reference deleted to maintain anonymity of authors], as well as for shared decision making in the wider healthcare field ADDIN EN.CITE <EndNote><Cite><Author>Coulter</Author><Year>2011</Year><RecNum>4176</RecNum><DisplayText>(Coulter &amp; Collins, 2011)</DisplayText><record><rec-number>4176</rec-number><foreign-keys><key app="EN" db-id="0swazwvvzv2zzfe0fs75dwsza2wreftvrrpv" timestamp="1417864204">4176</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Coulter, A</author><author>Collins, A</author></authors><tertiary-authors><author>The Kinds Fund</author></tertiary-authors></contributors><titles><title>Making Shared Decision-Making a Reality:?No decision about me, without me?</title></titles><dates><year>2011</year></dates><pub-location>London</pub-location><publisher>The Kinds Fund</publisher><urls></urls></record></Cite></EndNote>(Coulter & Collins, 2011). However, very little evidence is available regarding the actual forms of MTC that therapists have with their clients. Developing such knowledge is essential in being able to deepen an understanding of MTC and the particular ways it might be facilitated in real therapeutic settings. Such an understanding could then be used to develop research and training in MTC practices. Hence, the aim of this study was to map out MTC as it is reported - by therapists' self-accounts - to take place in actual therapeutic encounters In this respect, we develop, for the first time, an initial framework for MTC; such information will then need to be populated with more rigorous data in order for a more thorough understanding of this phenomenon to occur. MethodDesign This was a mixed methods investigation, in which we thematically analysed sections of therapists’ post-session notes to identify--and count--the forms of MTC being conducted. The data came from an open-label, non-randomised trial of pluralistic therapy for depression [reference deleted to maintain anonymity of authors]. Ethical approval was obtained from the relevant universities’ ethics committees. Participants in the current study: TherapistsData for our current study came from 12 therapists who worked with between one and five clients each (M = 2.9). Seven therapists were female (58.3%) and five were male (41.7%); two (13.3%) were qualified counselling psychologists with an average of 20 years of experience as practitioners and the remainder ten (86.7%) were counselling psychologists in training in their penultimate or final year of their doctoral studies. One therapist was of mixed ethnicity and the others identified as White. All therapists had been trained in humanistic therapies, as well as psychodynamic or cognitive behaviour approaches. All therapists also had additional training in the pluralistic approach to therapy [ ADDIN EN.CITE <EndNote><Cite><Author>Cooper</Author><Year>2007</Year><RecNum>1741</RecNum><DisplayText>(Cooper &amp; McLeod, 2007, 2011)</DisplayText><record><rec-number>1741</rec-number><foreign-keys><key app="EN" db-id="0swazwvvzv2zzfe0fs75dwsza2wreftvrrpv" timestamp="0">1741</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Cooper, Mick</author><author>McLeod, John</author></authors></contributors><titles><title>A pluralistic framework for counselling and psychotherapy: Implications for research</title><secondary-title>Counselling and Psychotherapy Research</secondary-title></titles><periodical><full-title>Counselling and Psychotherapy Research</full-title></periodical><pages>135-143</pages><volume>7</volume><number>3</number><keywords><keyword>pluralistic framework: 0 general</keyword></keywords><dates><year>2007</year></dates><urls></urls></record></Cite><Cite><Author>Cooper</Author><Year>2011</Year><RecNum>2748</RecNum><record><rec-number>2748</rec-number><foreign-keys><key app="EN" db-id="0swazwvvzv2zzfe0fs75dwsza2wreftvrrpv" timestamp="0">2748</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Cooper, Mick</author><author>McLeod, John</author></authors></contributors><titles><title>Pluralistic Counselling and Psychotherapy</title></titles><keywords><keyword>pluralistic framework: 0 general</keyword></keywords><dates><year>2011</year></dates><pub-location>London</pub-location><publisher>Sage</publisher><urls></urls></record></Cite></EndNote>reference deleted to maintain anonymity of authors]; and one was co-founder of this approach. All therapists committed, for the purposes of the trial to working in a pluralistic way, and received monthly individual supervision from the other co-founder of the pluralistic approach to therapy. ClientsData were available from 35 clients, all of whom met criteria for moderate or more severe levels of depression, scoring ten or more on the Patient Health Questionnaire-9 (PHQ-9) (Kroenke, Spitzer & Williams, 2001) at assessment. The mean age of these 35 clients was 31.9 (SD = 12.1). They were predominantly female (n = 24, 68.6%) and of a White European ethnic origin (n = 26, 74.3%). On average, the clients had 15.1 sessions of therapy (SD = 7.9). Twenty-two of the clients had planned endings (62.9%) and 13 had unplanned endings (37.1%). In terms of clinical outcomes, using formula from the Improving Access to Psychological Therapies programme ADDIN EN.CITE <EndNote><Cite><Author>Gyani</Author><Year>2013</Year><RecNum>3749</RecNum><DisplayText>(Gyani, Shafran, Layard, &amp; Clark, 2013)</DisplayText><record><rec-number>3749</rec-number><foreign-keys><key app="EN" db-id="0swazwvvzv2zzfe0fs75dwsza2wreftvrrpv" timestamp="1397461822">3749</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Gyani, A</author><author>Shafran, R</author><author>Layard, R</author><author>Clark, D M</author></authors></contributors><titles><title>Enhancing recovery rates: Lessons from year one of IAPT</title><secondary-title>Behaviour Research and Therapy</secondary-title></titles><periodical><full-title>Behaviour Research and Therapy</full-title></periodical><pages>597-606</pages><volume>51</volume><number>9</number><dates><year>2013</year></dates><urls></urls><electronic-resource-num>10.1016/j.brat.2013.06.004</electronic-resource-num></record></Cite></EndNote>(Gyani, Shafran, Layard, & Clark, 2013) 14 clients reliably recovered (40%), 11 further clients reliably improved (31.4%) and 4 clients reliably deteriorated (11.4%). The other six (17.1%) did not show any reliable changes. MaterialsTherapist note form. Therapists were asked to complete a Therapist Note Form at the end of each session, excluding the assessment session. This consisted of open response sections on the process of therapy (main episodes, extra-therapeutic events, ideas for next time), a ‘pluralistic analysis’ (aims, methods, outcomes), overall session ratings, and self-ratings of competence. The therapists were also asked to: ‘briefly describe any moments of negotiation or collaboration around the goals, tasks and methods of therapy (and indicate when in the session they occurred)’. Data for the present analysis comes from the open-ended responses to this question; each response that therapists gave on the Therapist Note Form was treated as a meaning unit. The limitations of this method will be examined in the Discussion section of our paper. ProcedureClients were recruited through public health centres or through the universities’ established counselling services. Interested individuals were sent an information sheet and then invited to an assessment interview. If individuals consented to participate, they were offered up to 24 free sessions of therapy with the same therapist who had conducted their assessment. At the start of each session, clients completed the PHQ-9, the Generalized Anxiety Disorder 7-item Scale ADDIN EN.CITE <EndNote><Cite><Author>Spitzer</Author><Year>2006</Year><RecNum>4163</RecNum><Prefix>GAD-7`, </Prefix><DisplayText>(GAD-7, Spitzer, Kroenke, Williams, &amp; L?we, 2006)</DisplayText><record><rec-number>4163</rec-number><foreign-keys><key app="EN" db-id="0swazwvvzv2zzfe0fs75dwsza2wreftvrrpv" timestamp="1413541121">4163</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Spitzer, Robert L</author><author>Kroenke, Kurt</author><author>Williams, Janet BW</author><author>L?we, Bernd</author></authors></contributors><titles><title>A brief measure for assessing generalized anxiety disorder: the GAD-7</title><secondary-title>Archives of internal medicine</secondary-title></titles><periodical><full-title>Archives of internal medicine</full-title></periodical><pages>1092-1097</pages><volume>166</volume><number>10</number><dates><year>2006</year></dates><isbn>0003-9926</isbn><urls></urls></record></Cite></EndNote>(GAD-7) (Spitzer, Kroenke, Williams, & L?we, 2006), and an individualised goals form ADDIN EN.CITE <EndNote><Cite><Author>Cooper</Author><Year>2014</Year><RecNum>4011</RecNum><DisplayText>(Cooper, 2014)</DisplayText><record><rec-number>4011</rec-number><foreign-keys><key app="EN" db-id="0swazwvvzv2zzfe0fs75dwsza2wreftvrrpv" timestamp="1401952798">4011</key></foreign-keys><ref-type name="Report">27</ref-type><contributors><authors><author>Cooper, Mick</author></authors></contributors><titles><title>Strathclyde pluralistic protocol</title></titles><keywords><keyword>pluralistic therapy</keyword></keywords><dates><year>2014</year></dates><pub-location>London</pub-location><publisher>University of Roehampton</publisher><urls></urls></record></Cite></EndNote>(Cooper, 2014). After the end of each session, they completed the Helpful Aspects of Therapy form (HAT) (Llewelyn, 1988), the Session Rating Scale (SRS) (Duncan, Miller, Sparks & Claud, 2003) and the Session Effectiveness Scale (SES) (Elliott, 2000). Therapists typically completed their Therapist Notes Forms at the end of each session. Therapists were instructed to conduct a review of the therapeutic work at session four and session ten, or at another agreed time. The therapists were asked to deliver pluralistic therapy in accordance with a treatment manual (McLeod & Cooper, 2012). This specified four general phases of therapy. In the first phase, therapists were encouraged to develop a collaborative relationship with clients, eliciting their ‘stories’, helping them to identify their strengths and resources, and agreeing with them goals for therapy. In the second phase, therapists were encouraged to establish a collaborative case formulation and a plan of work. In the third phase, therapists were encouraged to engage with clients in ways that would facilitate change in the direction of their goals. In the fourth phase, therapists were encouraged to bring the therapy to an end by reviewing and consolidating progress with their clients, and anticipating and preventing relapse. Within each session, therapists were encouraged to engage in on-going MTC with clients regarding their progress, and process and outcome ratings were used to facilitate collaborative alignment with clients’ goals and tasks. Therapists were encouraged to draw on, as and where competent, a wide range of therapeutic methods of potential help to their clients. These included cognitive interventions, working with feelings, and helping clients develop a coherent understanding of their difficulties. Therapists self-rated their adherence to pluralistic practice using a pilot version of an adherence rating scale. Data analysis Therapists’ descriptions on the Therapist Note Form of moments of negotiation or collaboration around the goals, tasks and methods of therapy were extracted and explored, using template analysis. This method involves the development of a coding template which summarises the themes the researchers have identified as important in a given data set, and organises them in a useful and meaningful manner (King, 2012). Emphasis is given in hierarchical coding, and in the use of broad themes and narrower, more specific ones as necessary (Brooks, McCluskey, Turley & King, 2015). The main procedural steps in carrying out template analysis are described as follows (King, 2012): The first author familiarised herself with the meaning units to be analysed. The first author carried out preliminary coding of the data, identifying and marking segments that were perceived as relevant to the subject under investigation. At this point the second author reviewed the initial codes and themes offering feedback.After a sub-set of accounts had been coded, themes were identified to include the relevant material and organised into an initial template by the first author. The themes identified in the selected accounts were then grouped into a smaller number of higher-order codes which described broader themes in the data. At this point the second author reviewed the initial coding template, proposing changes that were discussed and incorporated. The first author developed the coding template?by applying it to the full data set, applying changes to the template as appropriate. At this point the themes and subthemes were reviewed by both authors and it was decided that the principal themes would be better considered as dimensions, as they represented two intersecting features of metatherapeutic communication and then a third clinical dimension. Clear labels were given to each dimension and each meaning unit was coded once, or more than once, at each of the three dimensions (e.g., a meaning unit could be coded as ‘Start of session + Goals + Current session’ and also ‘Start of session + Methods + Current session’). A third colleague also reviewed the finding so far with some changes proposed. The first author used the final coding template to interpret?and?write up?the findings. These were then reviewed by the second author with changes proposed and implemented. The study was carried out within a positivist frame, in which we assumed that moments of metatherapeutic communication are real events that take place within the therapeutic work. As will be discussed later on, one of the limitations is that we attempt to examine these moments through the subjective experiences of our therapists, which will inevitably differ from what might be viewed from an external, observer position.In order to ensure analysis was not systematically distorted by the first author's assumptions or preconceptions, a?quality and reflexivity?check was carried out during the different coding stages through the presence of the second author as well as a third colleague with expertise in the field, as described above.To be coded as instances of MTC, the therapists’ responses on the Therapist Note Form needed to meet the following criteria: 1. Explicit verbal communication was reported to have taken place between therapists and clients; 2. The communication was described as being about the way in which the therapy was, has been, or could be conducted; and 3. Both parties were described as being involved in the communication. We excluded responses that were: 1. General descriptions of collaborative activity; 2. Non-specific, session-wide descriptions. Where appropriate, the data was coded into more than one dimension or sub-dimension within that dimension. To standardise across sessions, we chose a simple and transparent rubric for determining what was the start and end of sessions: Given each session lasted approximately 50 minutes (predetermined in the context of the project), we defined the ‘start of the session’ as the first ten minutes and the ‘end of the session’ as the last ten minutes, with ‘within session’ coded as the 11th-39th minutes, as reasonable time-frames to represent start; middle; and ending periods within a single session. Where there was no indication of the time that the MTC took place we coded this as ‘within session’. The data were only coded as being at review sessions when this was explicitly stated. The data were coded as being ‘for current session’ if it was clearly indicated that it was for that session. It was coded as ‘for therapeutic work’ if it was indicated that it was for the ongoing course of therapy, which could include previous sessions.Quantitative data counts are primarily presented descriptively. However, we used chi-square tests to examine if there were significant interactions across the dimensions that were identified. However, these must be treated with substantial cautious as there were a number of empty cells. ResultsPreliminary analysisTherapist Note Forms were missing for 71 of the total 529 sessions (13.4%). In total, therefore, we had Therapist Note Forms for 458 sessions. However, for 84 of these sessions (18.3%), therapists had not given any response to the open-ended question regarding moments of negotiation or collaboration. This left 374 Therapist Note Forms with relevant answers.In 208 instances, the meaning units on the Therapist Note Forms were coded as not valid descriptions of MTC. In 132 instances, this was because the therapists gave general descriptions of collaborative activities, rather than describing collaborative reflective activities: for instance, ‘I followed the client’s lead rather than staying on the topic we were speaking about.’ In 32 instances, this was because they were general descriptions of client activity: for instance, ‘client came with more focused goals.’ In 24 instances, this was because they were general descriptions of therapist activity, for instance: ‘I offered him some psychoeducation about his daughter’s presentation of OCD’. In addition, in 20 instances, therapists gave only non-specific descriptions of MTC: for instance ‘continuous feedback.’ Responses that described therapists’ metacommunications (rather than collaborative conversations), but which made explicit reference to inviting clients into a dialogue (e.g., ‘I checked with the client whether the way that we were working was ok for him’) were coded as valid. Two key dimensions of MTC emerged from the valid meaning units in our analysis: 1. The subject matter of the MTC; 2. The temporal focus of the MTC (Table 1). There was also a third dimension that emerged from our analysis, the time at which the MTC took place. However, this latter dimension was less a descriptor of a characteristic of MTC, and more an ‘external’ feature of this communication. In total, there were 528 instances of MTC that could be coded by each of these three dimensions. Subject matter: What the MTC was aboutThis first dimension referred to the subject of the MTC: what the therapist and client discussed about the therapeutic process during these instances. Most predominantly (n = 234) this was the particular Methods, including tasks, to be utilised. For instance, a therapist noted that ‘At end of session I introduced the idea of doing a formulation session [next week, and the] client said he would prefer to work in the way we did today as he found it helpful’.Therapists also invited their clients to reflect on the particular Topic (n = 135) that the latter wanted to discuss. For instance, ‘I asked the client what he’d like to talk on now, and the client chose how we used the last 20 mins of the session’. Therapists also frequently (n = 105) stimulated MTC when inviting clients to consider the specific Goals of therapeutic work as a whole. For instance, ‘[We] Discussed which goals she wished to prioritize’. A fourth subject for MTC was the client’s Experience of therapy (n = 27). This primarily involved what they had experienced as helpful or unhelpful up to that particular point, including their experiences of the therapist and/or the therapeutic relationship. For instance, ‘We compared our scores on the WAI [Working Alliance Inventory] forms and discussed how we understand the discrepancy between our scores, and what the implications might be for our relationship and our work together’.Metatherapeutic communication could also be about the Progress made (n = 14). This was primarily in reference to the previous sessions and the therapeutic work as a whole. For instance, ‘[We] Discussed whether we are “on track”’. Again, the use of particular measures was cited by some therapists. Finally, therapists reported that MTC sometimes focused on Understandings of clients’ difficulties: a process of ‘co-formulation’ (n = 13). Understandings-focused MTC was primarily in relation to the current session and also the following one. For example, a therapist reported: ‘For next session I suggested we attempt a formulation which might help us get more sense of his life events and his current needs, prioritise and plan better which he agreed to and stated he could find it helpful’.Temporal focus: When the MTC referred toThis, second dimension of MTC was the time period on which the dialogue of MTC was focused. Most predominantly the focus for the MTC was on the Current session (n = 225). This took place usually at the start or within sessions and it regarded mainly the topic of discussion. For instance, ‘[I] asked the client what [they] wanted to talk about and [they] said they wanted to focus on [their] career’.Very frequently, MTC also focused on the Therapeutic work as a whole (n = 208). This tended to take place at the start or within sessions, with the focus being predominantly on the goals set and the methods to achieve them. Various measures were reported to have been used. For instance, ‘whilst completing the Goal Assessment Form we negotiated what her goals could be and I tried to offer some guidance as to how she could choose goals’.Metatherapeutic dialogue could also focus on Extratherapeutic activities (n = 46). This related to clients’ activities that could be undertaken outside of the immediate therapeutic encounter. This took place both within sessions and towards the end of sessions, for instance by exploring and negotiating the ‘homework’ that clients could do before the following session. In some cases, and mostly during the end of the session, MTC could also regard the therapeutic focus--primarily for the next session (n = 23). For instance, ‘We discussed things that might work for the client and agreed to look at techniques to help with anxiety next session’.The Previous sessions could also be a temporal focus (n = 21). This was typically either at the start of a session or during a review point. For instance, ‘[we] reviewed goals and the progress or difficulties with these’. Finally, the temporal focus of the MTC could be on the upcoming Ending of therapy (n = 5). This was primarily discussed at the end of a session. For instance, ‘she (the client) expressed her concerns about our ending, and we discussed how she might deal with not having the weekly support of our sessions in the future’.Time: When MTC took placeThis last dimension referred to the particular time period during which MTC took place. Such timing referred to either a particular time period within a session or, a particular session within therapy.Most frequently (n = 200), therapists reported that MTC took place at the Start of sessions. Here, therapist and client discussed the goals for therapy (e.g. ‘Negotiation about goals for [the] session today- [the] client asked for my ideas and I asked for his’); the methods to be employed to achieve these goals (e.g. ‘The client complained about his disrupted sleep patterns and I offered different techniques on how to deal with this’); or the topic to be addressed (e.g. ‘[I] raised with [the] client that she might want to focus on reviewing tasks, but [the] client brought in that [they] wanted to talk about something else’). All these were mainly in reference to the current session or the therapeutic work as a whole. Very frequently, MTC took place Within sessions (n = 191). As with the start of sessions, the focus here tended to be on the goals for the therapeutic work as a whole, the tasks and methods to be utilised during that session or during therapy in general, or the topic to be discussed during that current session (e.g. ‘I gave the client choices about what he would like to talk about- Client expressed wish to do relaxation exercise at the end’). MTC was also reported to have taken place at the End of sessions (n = 98). Here, therapists and clients discussed the client’s experience, usually regarding the specific session that had taken place (e.g. ‘Checking with [the] client how talking was. [The] Client said ‘better’: perhaps less upsetting than had been fearing’). MTC at this time point also focused on the topic of the session. Another focus at this point was the methods and tasks to be undertaken outside sessions in the form of extra therapeutic activity or homework. For example, ‘Towards the end of the session we talked about looking online for relevant support groups between now and next week’).Therapists also reported MTC at Review points (n = 21), which could either be specific review sessions or occur spontaneously during a session. Here, the goals as well as the methods tended to be the primary focus, with respect to either previous sessions or the therapeutic work as a whole. As part of this, therapists reported the use of different measures. For instance, ‘We revisited the [Goals Form] and reviewed some of her goals and the progress she feels she has made, as well as how effective our chosen tasks and methods have been’.Finally, therapists invited clients to engage in MTC during Final sessions of therapy (n = 18). This was most frequently reviewing the progress of therapy as a whole in terms of what was achieved, for instance by ‘Discussing [the] presenting issues and [the] “learning occurred”’. Additionally, the methods and tasks that had proved helpful for the client for the duration of therapy were discussed. For instance a therapist initiated MTC by asking the client ‘what particular things we did during therapy will you want to keep practicing?’. MTC around ‘exploring and discussing future goals and steps to be taken to reach those’ was also reported at this point. Inferential analysisChi-squared tests indicated that there were significant differences in the temporal focus at different time points (p < .001). There was more likely to be a focus on the previous session and the current session at the start of sessions, while the focus was more likely to be on the therapeutic work as a whole and extratherapeutic activity within sessions. At the end of a session, the focus was more likely to be on the next session. Chi-squared tests indicated that there were significant differences in what discussed at different time points (p < .001). Goals and topic were more likely to be the focus at the start of sessions, understandings and methods were more likely to be the focus within sessions; and progress was more likely to be discussed at the end of sessions. Chi-squared tests indicated that there were significant differences in the temporal foci of different subject matter (p < .001). Goals, methods and progress were more likely to be discussed in relation to the therapeutic work as a whole, while topic and experience were more likely to be discussed in relation to the current session. Understandings were more likely to be discussed in relation to extra-therapeutic activity. DiscussionThe principal finding of this study was that two main components of MTC could be meaningfully identified: the subject matter of the MTC and the temporal focus of the MTC. There was also a third component: the time at which the MTC took place. This was less of a descriptor of MTC, per se, and more of an external aspect that related to it. In terms of subject matter, MTC most frequently focused on the therapeutic methods, followed by the goals for therapy and the topic of sessions. However, it could also be focused on understandings of the client’s difficulties, the client’s progress, or their experiences. In terms of temporal focus, MTC was most frequently reported to be focused on the current session or the therapeutic work as a whole, but could also focus on extratherapeutic activities, the next session, the previous session, and the ending. MTC was most frequently reported to take place at the start of sessions or within sessions, but was also reported to take place at the end of sessions, at review points, and in the final session. Combining across all three dimensions, two forms of MTC were by far the most frequently reported. The first was discussing the topic of the current session at the start of that session. The second was discussing the methods to be used within the therapeutic work as a whole during sessions. The three other most common forms of MTC that we found were discussing the methods for that session during the session, discussing the topic for that session during the session, and discussing the goals for the therapeutic work as a whole at the start of a session.The present findings provide some challenges to the pluralistic literature ADDIN EN.CITE <EndNote><Cite><Author>Cooper</Author><Year>2011</Year><RecNum>2748</RecNum><Prefix>e.g.`, </Prefix><DisplayText>(e.g., Cooper &amp; McLeod, 2011)</DisplayText><record><rec-number>2748</rec-number><foreign-keys><key app="EN" db-id="0swazwvvzv2zzfe0fs75dwsza2wreftvrrpv" timestamp="0">2748</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Cooper, Mick</author><author>McLeod, John</author></authors></contributors><titles><title>Pluralistic Counselling and Psychotherapy</title></titles><keywords><keyword>pluralistic framework: 0 general</keyword></keywords><dates><year>2011</year></dates><pub-location>London</pub-location><publisher>Sage</publisher><urls></urls></record></Cite></EndNote>(e.g., Cooper & McLeod, 2011). To date, MTC has primarily been conceptualised in terms of discussing the goals, tasks and methods of therapy, as well as understandings of the clients’ problems. However, in the present research, we did not find it meaningful to distinguish between discussion of methods and tasks. In addition, we found that the topic of the therapy work was a principal subject matter for metatherapeutic negotiation. Previous pluralistic literature has also neglected to mention that MTC may be focused on the clients’ progress, or their experiences in therapy. LimitationsA principal limitation of this research is that it is wholly restricted to therapists’ self-report. This means that the actual forms of MTC conducted may have been inaccurately represented in several important ways. Therapists may not have remembered, or been aware of, the main forms of MTC that took place in their sessions. They may also have had particular biases in their recall due to demand characteristics: for instance, over-emphasising the extent to which they discussed particular aspects of therapy. We also acknowledge that the request to ‘briefly describe any moments of negotiation or collaboration around the goals, tasks and methods of therapy (and indicate when in the session they occurred)’ presents with some vagueness; therapists’ reporting of the MTC may therefore have been influenced by idiosyncratic interpretations of the Therapist Note Form instructions. This was evidenced by the large number of excluded responses, where therapists often understood MTC to include all collaborative activities, such as psychoeducation. In addition, in many instances we inferred the existence of MTC through therapists’ descriptions of their activities and invitations to the clients, rather than an explicit description of a shared, collaborative activity. A second important limitation of this study is that therapists were asked to practice a specific form of therapy, and one that emphasised MTC. They were also given guidance at the start of their practice on a range of different forms of MTC that might be appropriate for their work (e.g., collaborative case formulation). Importantly, too, the Therapist Note Form specifically asked therapists to record moments of negotiation around the ‘goals, tasks and methods’ of therapy. Hence, it is not surprising that methods and goals were two of the three most frequent categories in the subject matter dimension. A third important limitation is that we only had data from the ‘working phase’ of therapy. Critically, this means that no evidence was available on MTC during assessment sessions, which is likely to be one of the main places in which it takes place ADDIN EN.CITE <EndNote><Cite><Author>Cooper</Author><Year>2011</Year><RecNum>2748</RecNum><DisplayText>(Cooper &amp; McLeod, 2011)</DisplayText><record><rec-number>2748</rec-number><foreign-keys><key app="EN" db-id="0swazwvvzv2zzfe0fs75dwsza2wreftvrrpv" timestamp="0">2748</key></foreign-keys><ref-type name="Book">6</ref-type><contributors><authors><author>Cooper, Mick</author><author>McLeod, John</author></authors></contributors><titles><title>Pluralistic Counselling and Psychotherapy</title></titles><keywords><keyword>pluralistic framework: 0 general</keyword></keywords><dates><year>2011</year></dates><pub-location>London</pub-location><publisher>Sage</publisher><urls></urls></record></Cite></EndNote>(Cooper & McLeod, 2011). We were also unable to capture MTC that took place prior to an assessment session (for instance, initial email contact), or after therapy had ended. In addition, as indicated above, the study was carried out within a positivist frame. Further research might therefore explore moments of MTC as subjective, personally experienced events with no ‘objective reality’. This would provide a useful alternative perspective on what it means to share decisions in therapy, as well as an opportunity to compare therapists’ and clients’ experiences. Through viewing MTC in this non-positivist way, we might also be able to explore in more depth what it means for therapists to talk about their practice and the reflexivity of this act. A final limitation is that data were only collected from work with clients who met criteria for depression. It is possible, then, that other forms of MTC would emerge with other client groups. It could also be argued that drawing data from a sample defined by diagnosis is inconsistent with the dialogical and relational principles underlying an emphasis on MTC. These limitations mean that there may be many forms of MTC that we did not record. The relative frequency counts should also be read as very exploratory, and unlikely to be representative of practice within different therapeutic orientations. StrengthsNevertheless, the aim of this study was not to establish a definitive list of forms of MTC. Rather, we aimed to develop an initial and non-exhaustive understanding of the forms that MTC might take. In this respect, despite being limited to the self-reports of pluralistic practitioners, our results provide an important first step towards understanding the different forms that MTC might take. Further researchFurther research needs to widen this understanding of MTC, using more precise definitions of MTC to reduce the number of ineligible responses. It will also be important to record MTC as it is conducted throughout the period of contact: from initial to final engagement. There is also a need to explore MTC from different perspectives and with different client populations, and particularly from the standpoint of both observers and clients. In particular, focused observational studies of audio or video recordings of therapy sessions would be very helpful in providing a more objective assessment of the kinds of MTC taking place. Once this wider framework has been established, studies can then go on to develop a more precise understanding of the relative frequencies of different forms of MTC: for instance, through using the taxonomy developed in this paper as a coding framework for therapy recordings. Ultimately, research needs to go on to look at the relationship between MTC and therapeutic outcomes. This would both be in terms of the overall amount of MTC, and also in terms of the amount, or relative frequency, of different MTC types. In addition and due to space limitations there was a missed opportunity to link the types of metatherapeutic communication derived to other interesting process variables collected about each session (for example, clients’ helpfulness ratings of the sessions). This is something that is worthy of future research. Furthermore, it would be interesting to replicate the study requesting therapists to also complete relevant scales (e.g., Helpful Aspects of Therapy Scale; Session Effectiveness Scale) in order to compare their results with clients’ ones.Implications for practiceIn terms of clinical practice, the findings provide a framework in which psychological therapists can begin to conceptualise how and when they talk to clients about the therapeutic process itself. Perhaps, more importantly, it can help therapists to consider further opportunities for dialogue, collaboration and negotiation with their clients. This may be something they reflect on within the therapeutic sessions, at supervision, or during the process of training and continuing development. For instance, the findings here can help trainees to recognise that MTC can be conducted at the end of therapy, as well as its commencement; or that the therapeutic method can be a subject of MTC as well as the client’s goals. Given the current evidence base supporting the development of a collaborative therapeutic relationship, there are emerging indications that such work may be of value to the therapeutic process. ReferencesAhmad, N., Ellins, J., Krelle, H., & Lawrie, M. (2014). Person-centred care: From ideas to action. London: The Health Foundation. Retrieved from [Accessed 30 May 2016]Berne, E. (1961). Transactional Analysis in psychotherapy. New York: Grove Press.Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance.?Psychotherapy: Theory, research & practice,?16(3), 252.Brooks, J., McCluskey, S., Turley, E., & King, N. (2015). The utility of template analysis in qualitative psychology research.?Qualitative Research in Psychology,?12(2), 202-222.Cooper, M. (2014). Strathclyde pluralistic protocol. Unpublished manuscript, Faculty of Humanities and Social Sciences, University of Strathclyde, Glasgow.Cooper, M., & McLeod, J. (2007). A pluralistic framework for counselling and psychotherapy: Implications for research. Counselling and Psychotherapy Research, 7(3), 135-143.Cooper, M., & McLeod, J. (2011). Pluralistic counselling and psychotherapy. London: Sage. Cooper, M., & McLeod, J. (2012). From either/or to both/and: Developing a pluralistic approach to counselling and psychotherapy. European Journal of Psychotherapy and Counselling, 14(1), 5-18. Cooper, M., Wild, C., Rijn, B. v., Ward, T., McLeod, J., Cassar, S., . . . Sreenath, S. (2015).?Pluralistic therapy for depression: Acceptability, outcomes and helpful aspects in a multisite study.?Counselling Psychology Review, 30(1), 6-20.Cooper, M., Dryden W., Martin, K., & Papayianni, F. (2016). Metatherapeutic dialogue and shared decision making. In M. Cooper & W. Dryden, Handbook of pluralistic counselling and psychotherapy. London: Sage.?Coulter, A., & Collins, A. (2011). Making Shared Decision-Making a Reality:?No decision about me, without me.?London: The Kings Fund.Da Silva, D. (2012). Helping people share decision making: A review of evidence considering whether shared decision making is worthwhile. London, UK. Research commissioned and funded by the Health Foundation.?The Health Foundation. Retrieved from [Accessed 30 May 2016]Duncan, B.L., Miller, S.D., Sparks, J.A. & Claud, D.A. (2003). The Session Rating Scale: Preliminary psychometric properties of a ‘working’ alliance measure. Journal of Brief Therapy, 3(1), 3–12.Elliott, R. (2000). The Session Effectiveness Scale. Unpublished questionnaire. Toledo, OH: University of Toledo.Gyani, A., Shafran, R., Layard, R., & Clark, D. M. (2013). Enhancing recovery rates: Lessons from year one of IAPT. Behaviour Research and Therapy, 51(9), 597-606. doi:10.1016/j.brat.2013.06.004Hill, C. E., & Knox, S. (2009). Processing the therapeutic relationship. Psychotherapy Research,?19(1), 13-29.Horvarth, A. O., Del?Re, A. C., Fluckinger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Evidence based responsiveness (2nd ed., pp. 25-69). New York: Oxford University.King, N. (2012). Doing template analysis. In: Symon, G., Cassell, C. (Eds), Qualitative organizational research: Core methods and current challenges (pp. 426– 45). London: Sage. Kroenke, K., Spitzer, R.l. & Williams, J.B. (2001). The PHQ-9. Journal of General Internal Medicine, 16(9), 606–613.Lindhiem, O., Bennett, C. B., Trentacosta, C. J., & McLear, C. (2014). Client preferences affect treatment satisfaction, completion, and clinical outcome: A meta-analysis.?Clinical psychology review,?34(6), 506-517.Llewelyn, S. (1988). Psychological therapy as viewed by clients and therapists. British Journal of Clinical Psychology, 27, 223–238.Makoul, G., & Clayman, M. (2006). An integrative model of shared decision making in medical encounters. Patient Education and Counselling, 60, 301-312. McLeod, J., & Cooper, M. (2012). A pluralistic approach to counselling and psychotherapy for depression: Treatment manual (V.1 ed.). Dundee: University of Abertay.Rennie, D. L. (1994). Clients’ deference in psychotherapy. Journal of Counseling Psychology, 41(4), 427-437. Spitzer, R.l., Kroenke, K., Williams, J.B. & Lowe, B. (2006). A brief measure for assessing generalised anxiety disorder: The GAD-7. Archives of Internal Medicine, 166(10), 1092–1097.Swift, J. K., Callahan, J. L., & Vollmer, B. M. (2011). Preferences. In J. C. Norcross (Ed.), Psychotherapy relationships that work (2nd ed., pp. 301-315). New York: Oxford University Press. ADDIN EN.REFLIST Tryon, G. S., & Winograd, G. (2011). Goal consensus and collaboration. In J. C. Norcross (Ed.), Psychotherapy Relationships that Work: Evidence-based responsiveness (2nd ed., pp. 153-167). New York: Oxford University Press.Tables Table 1. Frequency of metatherapeutic communication by dimensions of Subject Matter, Temporal focus, and TimeTemporal focusTimeSubject matterPrev-ious sessionCurrent sessionNext sessionTherapeutic work as a wholeExtrath-erapeutic activitiesEndingTotalStart of Sessions11121626200Goals2213053Methods52519655Topic75580UnderstandingsProgress33Experience189Within Sessions 7419719191Goals32831Methods3416711113Topic3434Understandings21811Progress112ExperienceEnd of Sessions 228222714598Goals1719Methods2971413449Topic113519Understandings112Progress11Experience1818Review points811221Goals358Methods45211TopicUnderstandingsProgress112ExperienceFinal Sessions 211518Goals44Methods516Topic22?UnderstandingsProgress66ExperienceTOTAL2122523208465528Note. Total Goals = 105, Total Methods = 234, Total Topic = 135, Total Understandings = 13, Total Progress = 14, Total Experience = 27. Acknowledgements Thanks to all therapists and clients for their valuable contributions, Professor John McLeod for his feedback on the findings, and the co-investigators on the pluralistic therapy for depression project: Biljana van Rijn, Tony Ward, Ciara Wild and Simon Cassar.Notes on contributorsFani Papayianni is a HCPC Registered and BPS Chartered Counselling Psychologist. She works as a Lecturer at the Doctorate in Counselling Psychology programme at Glasgow Caledonian University and, as a self-employed practitioner.Mick Cooper is a Professor of Counselling Psychology at the University of Roehampton and a chartered counselling psychologist. Mick is author and editor of a range of texts on person-centred, existential, and relational approaches to therapy. Mick has also led a range of research studies exploring the process and outcomes of humanistic counselling with young people. ................
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