‘We’re making it up as we go along!’ Co-production in Pluralistic Person-Centred Therapy
Nicola Blunden; BACP Accredited Counsellor, Psychotherapist, Supervisor, and Trainer, Metanoia Institute, London; Co-Convenor Holi: Co-productive Research in Wales
This blog is an overview of co-produced, pluralistic person-centred therapy, as I live it with my clients. I talk about co-production, and what it is generally in health care, where it has been increasing in popularity for three or four decades. Then I include a transcript that illustrates the co-production of a decision around exercise homework. I hope to nudge the person-centred discussion onward from a reductive dichotomy of client-led versus therapist-led practice to a discussion around co–produced practice. Co-production is for me both the realisation of person-centred aspirations, and the basis for a pluralistic ethic of care.
At the time of writing (during the COVID-19 pandemic), we are in the midst of a global, co-produced exercise in public health protection. We can no longer conceive of health-care as a practice that is uni-directional, done to one person by another. Health, like illness, is co-produced in a complex network of systemic relationships and efforts. Health professionals are expected to fulfil their role (to treat the sick), and citizens to fulfil theirs (to stay home), in a mutually interdependent undertaking that may help to protect us all.
Client-led, therapist-led, or co-created?
I am pluralistic therapist with a person-centred specialism. Trained in a person-centred way of working over twenty years ago, and having trained other therapists for several years, I have become more co-productive in my therapeutic approach over my career. In practice, this means that if you were to record and analyse all of my work with clients (although this would be a strange thing to do), about 90% of my verbal therapeutic responses would be recognisable from the tribe of person-centred experiential practitioners. As well as a predominance of reflection responses, congruence, and clarifying questions, you would see metacommunication (exploring what are we engaged in), process reflection (naming the client’s process as well as content), and occasional process direction (guiding a cathartic process in the room). The remaining 10% of my activity would come from a co-produced direction in therapy that falls outside those limits, and might include some psychoeducation, outdoor behavioural experiments, creative activities, guided meditation, or role-playing. Some person-centred practitioners might claim that this percentage of potentially directive activity prohibits me from being person-centred, because in those moments I am not client-led. I agree that my work is at those times not client-led. But neither is it therapist-led. It is co-produced.
Co-production in the wider world
The term ‘co-production’ was coined in the 1970s by Nobel economics prize winner Elinor Ostrom, to describe activity in which an organisation’s beneficiaries, as well as their employees, create their goods or services together. It is very common now in public and private arenas and you have probably co-produced for organisations without even realising it, if you’ve written an online review, used a self-checkout, contributed to a focus group or survey, shared a news article, or volunteered for an organisation. As well as being a way to shift labour onto unsuspecting citizens, co-production can be radical, too. It can turn traditional hierarchies on their heads, leading to ground-up social care initiatives in which service users and professionals meet as equals to design novel community provisions, local foodbanks, urban gardens, youth enterprises, barter schemes, and arts projects. The four original characteristics of co-production that were articulated by Elinor Ostrum still hold true today:
- diverse forms of expertise and resource are brought together in creative ways
- participation must be flexible, and should resist the centralization of homogeneity
- there should be reciprocity of effort
- similarly, all actors should somehow benefit, with reciprocity.
Writers in co-production are keen to point out that, as a method, it is more a process than a state. Sometimes over-simplified as ‘shared decision-making’ it is in fact a messy practice of negotiation, communication, and discussion around sometimes competing aims and interests. If you have ever written a birth-plan, in partnership with a midwife or obstetrician (or pregnant woman), you will appreciate that sometimes what one partner wants (minimal clinical intervention, perhaps), the other partner might not want (preferring constant monitoring of risk). A good, co-produced birth plan does not aim for consensus, because the perspectives of the mother and the health care professional are both held to be valid and valuable, while at times different. Thus, a successful birth plan is neither doctor-led nor patient-led, but co-produced.
Making it up as we go along: A brand new co-creation every time
How might co-production look in therapy? Surely, most modalities of therapy now acknowledge that client autonomy is paramount, and the therapeutic alliance is regarded as an essential characteristic of good therapy by most orientations. One might therefore assume that we are already co-producing our therapy, by engaging with clients as equal partners, and valuing their aims or interests. But co-produced therapy goes further than this. It seeks actively to develop a unique way of working, every time, with each client as therapeutic partner. Co-production starts from the premise that both partners will figure out the ‘how’ of therapy together, from our unique vantage points, experience, and knowledge. So, co-produced therapy is idiographic, resists procedures and techniques, and responds to the here-and-now process of the client.
In the following example (a near-verbatim account, but the client’s identity and issue have been disguised), my client and I develop our approach in regards to her autonomy. Sam had been coming for therapy for several weeks, exploring her long-term neglect of herself, and her grief, which at times felt to her like a dark and stultifying depression. In this session, she proposed that physical exercise would probably help her to raise her mood a little. She knew this, and yet she could not seem to motivate herself to do it. She therefore wondered if a more behavioural approach in the therapy would help her.
Sam: I wish you would set me some homework, you know. ‘Sam, you should go straight home and get your gym gear on, and go to the bloody gym!’
Nicola: Okay, you’d like me to MAKE you go to the gym.
N: [smiling] It feels like, if only someone would tell you to do it, you could do it. But you can’t make yourself do it.
S: That’s right! I’m just going to go home and watch a box set in the dark and eat too many sweets and get more depressed and make myself more ill. I want to go to the gym, but I won’t! [With playful assertiveness] It would be so much easier if you would just tell me to do it, Nicola.
N: …[Pause] I am struggling because I can see the sense in what you’re saying. You know that you’re a co-operative person, so you’re likely to do what I ask. And you’re not sure how to do this by yourself, because you don’t tend to look after yourself under your own steam… if at all…
N: So, I’m very tempted to do what you want, and set you some exercise homework. It probably wouldn’t be the gym, though, it would be something that you enjoy, and something small, like a walk in the sun, or some gardening?
N: But I’m also feeling worried about doing that, in my stomach [places hand over stomach]. Because, although it makes sense, isn’t the whole reason that you’re here, that you’ve said to me, is to learn to put yourself first, because you deserve to be happy?
N: If I tell you what to do, and you do it for that reason, won’t we be undermining you as well? Because again, you’ll be doing something for someone else? And then what happens next week, and the week after?
S: Yes [sighing, deflated].
N: I mean, I will, if you really want me to!
N: But do you really want me to?
S: Not really [smiling]. A bit? I don’t know, I just want it to be easy. I want to be able to be kind to myself, and be supportive and positive, and say, ‘Sam, you should go for a walk today, and it will make you feel better than watching TV and eating bags of sweets.’ But I’m not sure that I’ll listen to myself.
N: Yes, one part of you can say supportive things, but the other part of you might not listen to you?
S: Yes, because she doesn’t WANT to go for a walk and do what she’s told.
N: She doesn’t want to do what she’s told.
S: [Exasperated] No, she’s absolutely fed up of constantly being told what to do.
N: Right, she’s completely fed up of that! …Do you have a sense of what she does want?
S: [Long pause] She just wants comfort.
S: [Sadly] And she wants not to feel so sad.
S: [In frustration] But she wants to avoid all that by watching TV and disappearing!
N: [Attuning to the sadness] She just wants to disappear so that she doesn’t have to feel… feel the sadness.
S: Yes…[pause] I mean, I can understand that.
N: Me too. [I feel a deep, compassionate sadness here, for this part of Sam] I don’t want to tell her what to do. I think she is lonely enough.
S: Yes, she is lonely… I am lonely.
N: You are lonely, and you need comfort.
S: I do. I just need to find better ways of getting comfort. I don’t think you should tell me how to do that. I think I should help her myself. Help myself. You know, just be kind to myself.
Despite my person-centred specialism, I was prepared to set the exercise homework, if the discussion had proceeded that way. I was open to being persuaded. In that case, I would still have preferred the homework task itself to be co-produced, negotiating together what Sam felt able and motivated to do. But what was first essential, in co-productive terms, was that we determined what she genuinely wanted, and that we took our time establishing that. It was also important that I did not either suppress or privilege my own position counter to hers, either resisting her potentially helpful inclination out of a commitment to my person-centred values, or simply going along with it, inauthentically.
To guide my own part in the co-production, I paid slightly more attention to my tacit, physical knowing than to my theoretical knowledge. There are multiple arguments both for and against setting exercise homework to manage mood, and I could mobilise all those arguments, in health terms, and in directivity/non-directivity terms. So, to my mind, there was no objectively ‘right’ answer here to the dilemma of setting exercise schedules. But there was my intention to honour our unique, unfolding co-production. That requires me to be congruent. In sharing my own struggle, which emerged from my tacit knowledge, I resource Sam with more information. In likewise sharing her struggle, which emerged from her inner conflict and pain, Sam reciprocated. In doing so, she and I came to a simultaneous decision about our work. The key phenomenon that led our decision was the emergence of a part of Sam whose voice had not previously been heard. This part emphatically did not want to be told what to do, and the principles of co-production required that we invited this dissonant voice into our team, leading to a much greater richness and meaning in our exploration. It led to greater compassion and permission for Sam just to take her time.
The supposed dichotomy between ‘client needs’ and ‘therapist needs’, or ‘client-direction’ and ‘therapist-direction’ evaporates in examples such as the discussion between Sam and I about exercise and, ultimately, loneliness. As persons, we were both struck by the vulnerability of the sad part of her, as she was revealed, and we were both motivated to support that part. We both began in Sam’s initial predicament (what to do about this exercise dilemma!), and we picked our sensitive way through to a joint resolve. So, client interests and my interests are allied, in those moments of co-production, without necessarily being the same.
Diversity and reciprocity: All voices are welcome
Co-production thrives when a diversity of perspectives is valued, because it is a process that invites dissonance, difference, disagreement, messiness, and confusion. In addition, co-production relies upon a reciprocity of effort. It is not co-production if one person is doing all the heavy lifting. Where clients are courageous, I too must offer courage. I am in the struggle too, alongside the client, as we create a way of working. Similarly, as anyone who works in this way will attest, I am nourished by similar benefits to the client. In figuring it out together, we both enjoy realisations. In sitting together in pain, we both process suffering. This is a restorative process for me, in which paradoxically, although I am working hard, I am sharing the load. As I write, it is beautiful to reflect that I feel supported in the work, as much as I offer support.
And the final arbiter is the client. My commitment to the person-centred way of being grounds me in the knowledge that, when we do differ, it is the client who knows best, who shows me the way to go, and who has the right to decide. So often, clients and therapists both try to figure out what the other person is up to. But in co-production, the rationale for the work is not developed privately by the therapist, or the client, but mutually. Explicit and transparent, this rationale is equally available to both of us, being created by both of us. My job in the co-production is to support the client’s process, to be an equal partner, to welcome the dissonance, to give up my expert position, and to commit to a unique and novel way of working, each and every time. It is a joy when we co-produce something beautiful, and it reminds me that I am much stronger in relationship than I am alone. That is the essence of a pluralistic approach to therapy.
27 thoughts on “‘We’re making it up as we go along!’ Co-production in Pluralistic Person-Centred Therapy”
Loved this! I have struggled to define the way my work has evolved and this blog has just verbalised it perfectly.
Thank you Angie – I’m glad this resonated with you!
As i work exclusively with young people co-production is important practice to understand. It skews the percentage of directive practice for example psycho-education is much larger part of work I do and the I feel you need to go and talk to parts of my work.
I like the bits of work were the client and I produce something greater than we could produce alone. I experience it as a change in the feel of the room. Mind I also feel counselling is a liminal space and as such the rules of that space can be changed by client or counsellor … like the difference when play stops being pretend and becomes real. Its a change that’s hard to explain but sends metaphorical shivers down the spine when it happens. Co-creation and co-production often feels like the moment ‘play got real’ to me as a counsellor. Now i have a reference to refer people too who explains it better than i even could.
I love the idea of the liminal space. It’s so many in-betweens. In-between two people, in-between the past and future, in-between the imagined and the manifest. Your comment really captured that for me. Thank you! It’s a beautiful philosophical addition to the blog 🙂
It was a joyful read and my heart felt warm and touched when reading your conclusion. You mentioned ‘equal partner’ and the enjoyment process of coproduction from both parties, which are my favorite parts and going to keep them in mind.
Thank you so much!
Hi Melbee Wen Chieh!
I love that you felt the blog in your heart. You have a very warm and welcoming presence, so this comment touched my heart too!
Thank you, this has helped to clarify some points, very useful in understanding my own practice. Insightful
I’m glad to hear that, Darren – thank you!
Hello Nicola. I find this very relatable as everything you have mentioned here resonate with me in how I sometimes find private practice “lonely “! You’re absolutely right. We are stronger and supported when we co-produce with our clients.
I enjoyed reading your blog almost as much as I enjoyed being trained by you to become a counsellor/psychotherapist. I’ve now subscribed to your blog and look forward to feel connected with you through your posts.
Ah Mas, it is lovely to hear from you!
You make a good point about the loneliness. I think that when everyone is rowing together (just like in a PD group!) we go from independence to cohesion, and this is a good place for any group to be. I think we often underestimate the reality that a therapeutic dyad is in many ways also a group!
Thank you for prompting these thoughts, and for making contact here 🙂
Hello Nicola. I find this very relatable as everything you have mentioned here resonate with me in how I sometimes find private practice “lonely “! You’re absolutely right. We are stronger and supported when we co-produce with our clients.
I enjoyed reading your blog almost as much as I enjoyed being trained by you to become a counsellor/psychotherapist. I’ve now subscribed to your blog and look forward to feeling connected with you through your posts.
To me, this describes how I work. I’m coming from a pre counselling background in co-production, specialising in tenant participation which provides a real voice for tenants and, as an existential therapist, heavily influenced by Yalom – a new therapy for each client. I regularly discuss the direction of, and options for, the therapy with my clients. Clients often say yes they do want a say in their therapy but they don’t want a passive therapist either. Really enjoyed the article Nicola and hope it prompts a lively debate. Although, to me, it seems obvious that this should be the way forward.
I appreciate the links to tenant advocacy. I come from a youth co-production background, during my training, and I think that had a profound effect on my practice. Empowerment sometimes involves deliberately seeking people’s wishes and perspectives. Society so often doesn’t want to hear it, especially from disenfranchised groups, so I feel that it is in part my job to counter that social condition, by asking, welcoming, and inviting more of the client’s agency and voice.
Thank you for this very helpful comment, Carol.
Useful concept – I like the idea of ‘co-production’. Similar to the idea of ‘co-creation’ which also appeals to me.
Thanks Jay – yes, I think co-creation is even nicer, really, as it points to the aesthetic and existential elements of what we do together.
Thank you Nicola, I enjoyed reading about how you work with your clients. You have given me words to explain what it is that happens in the room with many of my clients.
Hi Alyson! Lovely to hear from you. I’m glad the words resonate for you 🙂
The example of practice given helped to understand how the co production emphasis is used. The subtle interactions were illuminating. Thank you.
I appreciate that, Lesley. The subtle things are hard to capture, so it’s good to get that feedback. 🙂
‘Co-Production’ – a great way to describe it! As a sex therapy trainee who will qualify as a pluralistic practitioner, this has been a helpful article to read, to remind me of what I am practising and remind me of the different ways in which pluralism can be used in the therapy room. Thank you.
I’m glad that this term was meaningful to you. It can feel a bit dry, but it’s anything but, in practice! I’m very interested in how pluralism and sex therapy work together. Looking forward to catching up with you in future!
As a Transactional Analyst I value this thinking. We believe that everyone has the capacity to think and grow, our ethics include the concept of mutuality, and the bilateral nature of the therapeutic Contract and relationship. We also talk about Co-transference… acknowledging the mutual creation and meaning of the past emerging in the present.
Keith Tudor and Graham Summers have written a beautiful book that explores these ideas from a TA perspective. Co-creative Transactional Analysis. You may have read it… but I thought I’d include the link here, in case you’re interested. https://www.amazon.co.uk/Co-Creative-Transactional-Analysis-Responses-Developments/dp/1782201572/ref=nodl_
Thank you for this Rosalind – I hadn’t read this book, but I certainly will.
Yes, I think that co-production is a family simple way of describing the intersubjective relationship, in which we acknowledge the mutuality between us. Co-transference is also in my thinking here, and Stern’s moments of meeting. My TA friends and I tend to agree on all these important points, which adds weight to my philosophical pluralism for sure!
Thank you for this piece Nicola. I also trained in the person-centred approach, nearly 20 years ago at Metanoia. I have always held a strong core belief in the value of a unique co-created alliance in which I strive always to see my client as expert on their own process while also valuing the knowledge, tools, and experience I share within the context of our ongoing dialogue about what will help them and what they need at this time. I have often found myself struggling to articulate what I do and how I ‘be’ in my practice and recognise now how much of that came from my experience of fear of the judgement ‘not person-centred’. I note that with greater distance from my training, the experience of working with and learning from colleagues of all modalities within multi-disciplinary teams and, most importantly, asking clients what they think works for them, I have started to feel much surer-footed in this regard. It is so helpful and affirming, as Alyson says above, to read your articulation of how you work and feel such strong resonance.
I enjoyed reading this piece, and learned a lot from it. It is really great that you were able to include a transcript. The concept of co-production captures something that sits at the heart of pluralistic practice. It has been hard to find the right term for this aspect of the work. Sadly, the concept of collaboration (co-labouring, working together) has been largely appropriated by therapy approaches that use it to refer to the client actively joining in with activities that are initiated by the therapist (rather than initiatives coming from both sides). I believe that the idea of shared decision-making is valuable, because it provides a point of connection with what colleagues in other occupations are trying to achieve, However, I agree with you that the way it is generally used does not reflect important facets of therapy. I also really liked the way that you brought in Elinor Ostrom’s analysis of how the ‘commons’ functions. The transcript of an episode in therapy with a client – Sam – was a really lovely description of how useful it can be to use metacommunication to evoke and take account of different voices within a process of co-construction or shared decision-making. As with most case examples, I wondered what happened next. It seemed to me that there were four (or maybe more) possible therapeutic tasks implied in this therapy episode. The task that came to the surface, by the end of the episode, seemed to be around developing a more self-compassionate sense of self (‘be kind to myself’). Other potential tasks that were perhaps implied in Sam’s opening statement were: (i) activating a valued cultural resource (going to the gym); (ii) asking someone else (i.e., my therapist) to support and encourage me to do something that is hard for me to do on my own; and (iii) generating, and being willing to suggest and follow up on, my own ideas about what might help me to move on in my life. In my own work with clients, I have generally found that it is helpful to identify and pursue several tasks. Healing and recovery seems to require multiple remedies and repair jobs, rather than just one big thing. This made me curious about whether, and how, your therapy with Sam involved other tasks (including tasks not apparent in the transcript episode), or whether the ‘be kind to myself’ line of work turned out to be the main thing that, in the end, made a difference.
Thank you for this comment – which I’ve only just seen!
Yes, I agree that several tasks can work alongside one another, and sometimes mutually enrich and inform each other. In this work, I suppose I wanted to show how a task can change quite dramatically, especially when there is ambivalence, and all parts of the client are encouraged to speak. Sometimes, the most pressing task meets a deep or more hidden need within the client. Pursuing more obvious tasks can potentially cause harm if parts of the client have been silenced or ignored in the process of this negotiation and discussion. In this case, as a postscript, the initial task of providing comfort and nurture to the young part of ‘Sam’ resulted in a more playful period in the client’s life, which opened up another way to view the main goal of therapy. It turned out that Sam loved walking to the park and helping neighbours with gardening, and all sorts of things, that turned into ‘exercise’ in their own way. This led Sam to be able to bring in more activity, and eventually a schedule and structure to physical activity. But I think it happened in a way that was more grounded, more chosen, and more established.
I tend to think that all parts of a client have a tendency to actualise, and an organismic valuing process, or inner compass towards the light. I think in this case, the little part of Sam had the best sense of the fastest way to get there, but it wasn’t the most obvious path. 🙂
A lengthy regurgitation of the key parts of “Breaking Out Again” by Liz Stanley and Sue Wise … but for touchy-feely female therapists.