‘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.