The case against ‘reviews’ in therapy
There are the obviously contentious and highly debated practices in therapy and there are those that are less questioned – perhaps because they are presumed to be benign or assumed to always be good practice. These practices get less scrutiny and one that has been on my mind lately is the topic of ‘reviews’ in therapy.
In brief, a review is the practice in therapy where the therapist ‘reviews’ with the client how the therapy is going, often in a structured way by having a review session. These are often at set intervals (6 sessions is often mentioned, or 6 months in long-term therapy) and involve specific questions about the client’s goals, progress, whether they are being achieved, etc. There are many valid reasons for doing this - to make sure the therapy is working, that the client is progressing, to get feedback from the client about this and so on. However, we don’t often hear about the potential negative impacts or why some people may not use reviews at all.
I work from the person-centred model and some of the criticisms I have are specific to that modality, but others are relational and trauma-based reasons that are not necessarily about modality so will be more broadly useful. I also work long term and have a lot of long-term experience as a client which also informs my perspective.
Reviews are often referred to in training and in the wider therapy discourse as something that everyone should be doing, without considering whether this, like many other interventions is something that could be navigated on an individual bases. They are suggested as a way to check on “progress”, at times of ‘stuckness’ or as a standard part of long-term therapy. There is a belief that not doing reviews could mean a client is stays in therapy that is not working and that this is unethical. However, approaching a review as one would an ethical issue can bring in more thoughtfulness e.g. by exploring the pros and cons, and really engaging with the underlying ethics of why one chooses the practices one does.
Reviews were included in my person-centred training and expected of me during placement and once qualified, as I moved out into the world of private practice and started making my own decisions, I dutifully tried to bring these into my work. However they often felt clunky, or sometimes worse in a way that I couldn’t’t quite put a finger on. They didn’t fit smoothly into the work. I could feel the potential for confusion and rejection in them. When I came into sessions with the intention of doing a review I was showing up with an agenda in a way that did not fit with how I worked at other times. I find it hard and also incongruent to my way of working to do something I don’t understand the value of just because somebody else says I should, so I gradually just dropped them altogether. (Interesting side note, there is research that links client outcomes to the therapists relationship with their own rationale of working, so offering an unconvincing review probably wasn’t doing my clients much good anyway).
Now with a lot more experience and reflection I can express cognitively what was formerly a felt sense of discomfort and these broadly break into two categories. Firstly, having structured review sessions that are initiated and led by the therapist is a distinct step away from the core person centred stance of non-directivity so of course they can feel clunky and incongruent from the rest of the therapy process. This may not be an issue for other modalities or integrative or pluralistic person-centred therapists but for a very non-directive practitioner - and the client who is used to it - of course this could feel incongruent. In addition, a review is often explicitly or implicitly asking about things like goals and ‘progress’ which in person-centred work may not be easily identified and this can place more focus on the therapist’s frame of reference rather than the individual clients needs.
I did in some of my attempts at reviews get into some kind of compromise - for example asking how clients felt about the work, what they were getting out of it etc. then immediately caveating that with ‘but it is ok if you are not sure, or don’t have any goals’. In hindsight I think this probably just came across as confusing for clients. I know that therapists cannot know what is ultimately going on for clients and we should not assume that things are going well just because we have not been told it is not, but I ended up letting go of the review as a specific intervention and instead trying to incorporate the things a review is supposed to inform into the relationship. I developed trust in my own ability to attune to the relational dynamics and got more comfortable and fluent at reflecting back in real time if I saw progress, or stuckness or naming if I felt there was a change in the dynamic that might mean the work was changing course or coming to an end. This felt much more aligned with my way of working.
The second and I feel more important reason I have ended up not using reviews is about the relational vulnerability that many people bring to therapy, and the power the therapist has because of this. These are valid whatever your modality, but especially in long-term and relational work. People who do not necessarily present as particularly vulnerable can still have this insecurity. How often have you heard clients say that they worry their problems are not ‘bad enough’, or question if they deserve the space in therapy (even as they are paying for it). I wonder this too about my own therapy sometimes, even as I know on another level how much I do need it. How might the perception that the therapist wants to end due to a lack of “progress” land on such feelings, which may be too vulnerable to have been directly expressed in therapy so far?
We often may never know the full extent of a client’s vulnerabilities around being able to even access the therapy space, even if we have worked with them long term. People who are sensitive, with interpersonal trauma, cPTSD and/or innate neurodivergence or otherwise ‘fragile’ areas of process (which one could argue is potentially a large population of clients, since these are the very things that often bring people to therapy in the first place) can experience even a subtle hint that they may not be making progress or doing therapy ‘right’ as very painful. They may also be used to masking or fawning as a way to stay safe in relationships so they may well not show noticeable signs of distress. Carolyn Spring has shared very well from a client’s perspective around this and other seemingly innocuous (at least to the therapist) ways that clients can feel excluded or rejected in therapy. For those with interpersonal trauma and deep attachment wounds, the suggestion however well meant that their access to the therapeutic relationship is conditional upon them displaying progress in a way that is meaningful the therapist can feel deeply destabilising and potentially re-traumatising, and understandably so. I have similar criticisms of the concept of ‘always working towards an ending’ because it introduces a relational insecurity from the get-go that can prevent a person from feeling feel safe enough to do deep relational work. How is it possible to lean into a relationship in the ways that people often need to in long-term therapy if the other person has one foot out the door the whole time?
I do think being a long-term client myself does significantly inform this kind of work. It could be hard to imagine the client’s side of this if you do not experience it yourself. I think that therapists without experience of long-term work as a client need to be aware that they may lack the client’s perspective on this and be mindful not to overlook that the client can experience this quite differently.
For those who do work long- term, the generally accepted review periods (6 sessions, 6 monthly, annually) will roll round quicker than you think and to be repetitively putting a client through a review process every six months when they're in long term therapy to me again feels like it layers up that potential for making a client feel like the work they're doing, whatever they're using the space for is not being experienced as valid or useful. It makes me wonder who the review is actually for, ultimately, and if we offered clients the choice, how many would decline them. I personally do not want reviews in my long-term therapy and I'm happy to say that my therapist and indeed my supervisor (the latter at my request) don't ask me to participate in structured reviews because for me they would be unhelpful.
As is usually the case when I have launched some criticism of some of the accepted norms of therapy, I like to explore then what do I do instead because it's not that in the absence of doing reviews I'm doing nothing to evaluate or check in with my clients or even with myself about how the therapy is going.
One could develop an approach to reviews that was sensitive to those issues. I think this would look more collaborative, with consent and the option to change or adapt it. I am wary about frontloading the initial therapy sessions with too much paperwork or questions but finding a place to ask about these things and get consent would be useful (and fits with a pluralistic and personalising approach to therapy – Mick Cooper).
I have ended making the things that a review seeks to achieve part of the ongoing relationship - by noticing and reflecting back progress where I see it, stuckness, when that comes up, and explicitly seeking clients consent and feedback as ongoing qualities in the work. This is very congruent with a person-centred approach and can feel a more organic and gentle way to get the clients input around those issues.
One example of this is - which I am sure many therapists will recognise - is a shift in the feel of the therapy, this is often described as it ‘feeling more like a chat’ in a relationship that has previously felt more therapeutic. This change can be named very naturally and doing so often opens up the knowledge that the client may be moving towards an ending.
Finally, I want to address the hypothetical concern that without reviews, clients would stay long-term in therapy that is not working. I question this (although I am interested if anyone has evidence of this happening). Certainly, in the UK, long-term therapy on the NHS is as rare as hens’ teeth, third sector/free provision is very time limited, the only place where open ended and years long therapy happens regularly is in private practice. Those with the capacity to arrange and pay for their own private therapy I would argue will mostly have capacity and a have a strong financial incentive not to keep paying for a premium service if they are not getting something from it. It would be unethical and against most membership bodies codes of practice to coerce clients in any way to stay in therapy or act in other ways to diminish their autonomy around this (e.g. by telling them they must be in therapy for a certain amount of time, or that they should continue even if the therapy doesn’t feel right) but reviews are by no means the only way to handle this potential risk.
As always, I am not saying everyone should work how I do but I hope that by having thoughtful discussions that consider more perspectives, particularly the lesser heard ones that individually we can all work more intentionally and collectively that can have the effect of making therapy more accessible to a wider range of people.
Intuitive eating and person-centred therapy
I have been reflecting on the various different places I draw from in my work as a therapist in addition to person-centred theory and practice and I have recently realised how much the intuitive eating movement aligns with person-centred theory.
A bit of personal history - like many people I was a yo-yo dieter for much of my adult life. In my case from my early 20’s until my late 30’s. Throughout my formative years in the 80’s and 90’s and my young adulthood in the early 2000s, diet culture and the pursuit of thinness was such a central part of the culture there were simply no other options visible. I would lose then regain (and then some) the same few pounds or couple of stone. There came a point in my late 30’s when I remember looking the mirror and thinking ‘what is the point of all this effort, I have been doing this for 15 years now and I am fatter than when I started’. In that moment a penny dropped for me. I wondered what would happen if I just…stopped - stopped trying to lose weight, stopped the endless treadmill of diets. I googled “how to be happy and fat” and as this was 2015 I quickly discovered the health at every size movement, body positivity and intuitive eating. It was a pivotal moment for me - I stopped trying to change my body into a shape it was not ever going to be stable at and spent the following years embracing intuitive eating and learning body acceptance instead (written like that it sounds like an easy and quick process, but in reality it is a longer and more complex process that I am still working on).
Finding alternatives to the diet-culture world was revelatory and I hoovered up everything I could find at the time. I learned about earlier iterations of this movement (for more background here is a brief history of the fat acceptance movement which had not reached the mainstream until the body positivety movement become well known. I will list some of the useful resources at the end of this article.
I grieve for the years of wasted time and energy that 15 years of dieting took from me - time and energy that I could have spent on much more valuable things than pursuing an impossible dream of a thin body. Most people who lose weight regain what they have lost and and more - a fact I wish I had known a lot sooner. I grieve for the impact it has no doubt had on my body, pushing up my set-point. But it is the lost time and energy I grieve the most. There are a million more valuable things to spend this precious life on than trying to be smaller.
I didn’t at the time connect just how person-centred the intuitive eating movement was but I resonated with it instantly in the same way I did the person-centred approach to therapy. Person-centred therapy is based on a fundamental belief that people have the ability to sense what is right for them (this is called the ‘organismic valueing tendency’) and move towards growth, even if the conditions are not ideal (the ‘actualising tendency’). Rogers used the analogy of potatoes, persistently trying to grow towards any light. I often picture a tree growing in a sheltered valley vs a tree growing on exposed moorland - both grow in the best way they can for their conditions and the results can look quite different.
In therapy the ‘organismic valueing tendency’ is often experienced as feelings, sensations or other instinctive ways of knowing what we need that we can tune in to to inform our choices in life. However, there is nothing so fundamentally innate as our bodies ability to express hunger and gain satisfaction through eating (a caveat that there are things that make this harder, such as interoceptive differences experienced by neurodivergent people). Intuitive eating is about learning to reconnect with and trust the bodies cues both of hunger and satiety in order to allow the bodies innate wisdom to be a guide on what, when and how much to eat. It is a biological as well as psychological process. Therefore we can absolutely equate the ‘organismic valuing tendency’ of person-centred therapy with a non-disrupted hunger and satiety system, which is what intuitive eating aims to develop. People who are naturally slim and/or have never dieted may eat this way. For many others it can seem inconceivable.
I say non-disrupted as the impact of how western culture approaches food and diet massively disrupts people’s relationship with food and bodies in a way that means that many people don’t believe that trusting ones hunger is in any way a safe or reasonable way to eat. Control is prioritised. Dieting, disordered eating or even the seemingly less harmful general beliefs about what constitutes ‘healthy’ eating, all are based on the belief that left to our own devices, we would not eat in a way that is good for us and we need to micromanage or control that based on external rules (diets) rather than using our bodies inbuilt signals. Eating disorder behaviours are normalised, bodies are policed and assumed to be unhealthy based on size. Yo yo dieting is normalised. We are so used to this that so many of it goes unquestioned but when you actually step back and take a critical view of it is all deeply harmful and unnatural.
It is heartbreaking to hear of people being put on diets from age 4, or even younger. Being bullied by family members for their bodies/eating patterns, growing up with the constant stress that their bodies and appetites are wrong or dysfunctional. This permanently impacts their relationship with their very self - destroying self-esteem, deeply disrupting the developing relationship between appetite, hunger and fullness and is a huge predictor of eating disorders and lifelong yoyo dieting.
People pursue weightloss because they are constantly told that they are not worthy of love or anything good in life if they are not thin, which places this battle squarely in the realms of therapy and ‘mental health’ and as a profession we have been far too slow to make this connection and address fatphobia, weight stigma and the very real impact it has on people’s entire lives. When I first started talking about this in counselling spaces online I felt like a bit of a lone voice in the wilderness, now 10 years later I am happy to see lots more therapists are getting on board with this approach.
Even eating disorder treatment and recovery spaces are often still based around fatphobic assumptions, including that fat people can’t be anorexic or that recovery means maintaining a specific weight. One of the reasons I don’t offer eating disorder support as yet is because I have yet to find a training that is neurodivergent affirming and centres weight neutral/fat positive values. (if you know of one please let me know).
This is of course, a deeply complex area. I am not expert in nutrition or the science of weight but there are many good resources here if you want to learn more. The Health at Every Size framework is very science based. The intersections of fatphobia with racism, gender/sexuality etc. are also very complex. The social determinants of health are not addressed enough. Many in the anti-diet and fat acceptance field argue that weight stigma, as much as the physical impact of weight is potentially responsible for much of the the health impacts of being at a higher weight and anyone who works with marginalised folk should well aware of the very real impact of stigma and minority stress on mental and physical health. Amidtst this complexity though what does seem simple to me though is that no-one should be traumatised and oppressed for their body size (or indeed any other ways bodies vary). Fatphobia is oppression and systemic violence - Sonya Renee Taylor has called this ‘body terrorism’ and we need to address this in the field of therapy and move to health and mental health that supports and values individuals wherever they are at. At the moment that means sitting with individuals who are currently being deeply harmed by a very fatphobic culture, learning how to not perpetrate that in our work and finding liberatory and congruent ways to engage with this from an anti-oppressive stance.
So back to intuitive eating. It is essentially ‘person-centred’ eating, in that it promotes a return to the individuals own bodily sensing of what is right and offers a way to unlearn all the mental and physical imbalances that arise from years of dieting or otherwise disordered eating patterns. There are principles and steps one can follow on the journey to intuitive eating (set out in the original Intuitive Eating book) or you can embrace the overall approach in a less structured way like I did. Some people have promoted a less structured approach, probably because many people were so attached to diets that they were co-opting the steps of intuitive eating and making them into just another set of diet rules (for example the “hunger and fullness diet”).
When I work therapeutically with people around their eating, using the intuitive eating framework offers a shared paradigm that we can both work within. Then it is about exploring what comes up when people choose to step away from dieting: fear of weight gain, self-esteem, trauma from bullying/rejection based on their body size, relationship/intimacy issues, how to deal with the people around them who may be still working from a diet culture frame of reference, navigating fatphobia in the wider culture, dealing with the stress of being stigmatised due to body size, and trying to develop positive or at least accepting self identity around the body they do have. This is where the work becomes deeply personal and follows the individual process, very much as general person-centred therapy does, especially person-centred work with people who are marginalised.
It is a real privilege to support people on this journey - one I have walked myself and continue to walk - so if you are interested in therapy or supervision around intuitive eating then please get in touch.
Here are some really great resources if you would like to learn more:
The Body is not an Apology by Sonya Renee Taylor
You Have the Right to Remain Fat by Virgie Tovar
Aubrey Gordon What We Don't Talk About When We Talk About Fat and “You Just Need to Lose Weight”: And 19 Other Myths About Fat People and the podcast Maintenance Phase
Body Bositive Power by Megan Jayne Crabbe
Health at Every Size: The Surprising Truth About Your Weight by Linda Bacon
Anti Diet by Kristy Harrison and the podcast Food Psych
Fearing the Black Body: The Racial Origins of Fat Phobia by Sabrina Strings
Jes Baker Things No One Will Tell Fat Girls and Landwhale
Eat the Rules Podcast with Summer Innanen
Centre for Body Trust (various resources)
Photo by Charis Gegelman on Unsplash
Why person-centred therapy was the original anti-oppressive therapy
Person-centred therapy is one of the most popular forms of therapy in the UK, but it is also widely misunderstood and misrepresented. When it was initially developed in the 1940’s by Carl Rogers, it was a really radical change from the other therapies around at the time such as Freudian psychoanalysis and behaviourism. I think that one reason it has become somewhat misunderstood is actually because a lot of the ‘core conditions’ (empathy, genuineness and positive regard) are now considered essential qualities for most therapists these days, so the fact that it was Rogers who originally spent his whole life advocating for these very basic human qualities to be a central part of therapy has been somewhat lost to time.
I am really glad that these relational qualities have been so broadly embraced. This only improves the therapy world overall, but I do wish the person-centred approach was given the credit it deserves for being the original promoter (at least in western schools of psychotherapy) of this type of therapeutic relationship.
I am not an expert in the other modalities. I have a decent enough broad understanding of the overall profession, but I have focused my career more on getting a really deep understanding, skill and appreciation of one modality. I know that there are many people practicing a variety of types of therapy who are doing great work to make them less oppressive to marginalised people, however I think I can make the case that person-centred therapy actually lends itself better than most approaches to being an anti-oppressive approach at its core, and therefore very relevant to current and future generations of therapists.
Sadly a brief glance at the history of the medical model, (e.g. the DSM), psychology, and various therapy modalities will show that they have openly categorised marginalised people (queer, trans, disabled, neurodivergent, people of colour) as ill, deviant or otherwise not ‘normal’ and as such actively contributed (and in some cases are still contributing) to the oppression and harm of members of these groups in therapy. Whilst there is no doubt that individuals practicing person-centred therapy could hold oppressive views, this is not ‘baked in’ to the approach itself and instead runs contrary to its fundamental principles.
These core principles include a respect and appreciation of the diversity of individuals, and a willingness to believe people’s accounts of their own experience. It is much easier to be anti-oppressive when you believe that difference is a good thing, and that people should be believed and centred as the experts on their own experiencing. These values are shared across other ‘humanistic’ schools of therapy. However, the person-centred approach places the most emphasis on individual autonomy and doesn’t seek to fit people into models or predetermined structures. This makes therapists less likely to impose their own theories and expectations onto clients and means that they are open to listening to clients when they express that something is harmful to them, in a way that say a medical model based approach is not (these often blame the client when the therapy doesn't’ work, e.g. by describing someone as ‘resistant’ to the treatment).
This sets up person-centred therapists to believe marginalised people’s accounts of themselves and continually adapt therapy to meet a wider array of access needs. It is open to the way therapy can inadvertently harm (because we believe people when we hear about harm, and don’t dismiss them) and works to reduce the amount this happens especially as a result of failing to meet individuals’ needs around accessibility or cultural sensitivity.
Person-centred therapy tends to be more flexible in how it offers itself. If something doesn’t work for somebody, we are more likely to listen and flex what we offer to meet the needs of the individual. This often includes a willingness to change the length, frequency or location of appointments. Some modalities and the therapists practicing them require people to have weekly sessions or maintain that ‘real therapy’ can’t take place in shorter or less frequent appointments, or do not accept any kind of between session contact or won’t work with camera’s off. This kind of flexibility means that person-centred working is readily set up to meet a wider range of access needs making it overall more inclusive as an approach.
It has also been used to great effect to make therapeutic contact with people with various degrees of difficulty engaging due to cognitive differences and psychosis (a form of person-centred therapy referred to as ‘pre-therapy), which means it is more accessible to people who may not be deemed ‘suitable’ for other kinds of therapy.
Unfortunately in a world where freedom, autonomy and diversity are not centred (despite superficial lip-service to these values) and hierarchy, power and the medical model still prevail, person-centred therapy is both too radical because it sets itself up in opposition to those things and also gets misunderstood and portrayed as weak because western culture unfortunately is built on the assumption that strength equates to aggression, dominance and control of self and others. This can show up in say the NHS’s and other official bodies lack of valuing of the approach because it rests on an entirely different paradigm which is deeply incompatible with the one they are based on. (I deeply value the NHS but it is incredibly hierarchical and is not a natural home for or appreciator of the person-centred approach).
Given the great social changes that have happened and are continuing to happen since the origins of person-centred therapy and psychotherapy more generally, there is a need for all approaches to listen to, learn from and incorporate the best from a range of social movements and anti-oppressive practices outside of the field. I find person-centred therapy very compatible with other anti-oppressive practices because they share some fundamental values that I mentioned earlier - intersectional feminism, LGBTQ+ rights, the neurodiversity paradigm and movement, the social model of disability, disability justice, the intuitive eating and health at every size movements, anti-racist, anti-colonial and liberation movements, to name a few.
In practice, many therapists are integrative or pluralistic and blend or adapt approaches to suit the individual client. This is often offered on a ‘base’ of person-centred practice that prioritises client autonomy and choice and many do offer wonderfully accepting and accessible therapy, but I think it is the person-centred principles that mostly enable this, as well as the therapists’ personal values and a desire to better serve the people they work with.
Ultimately, person-centred relationships are ones where there is genuine participation, care, non-hierarchical, non-coercive power dynamics, a respect and welcoming of difference and genuine curiosity and willingness to really learn about each other without any agenda. Although rare to find expressed fully, these are fundamental human qualities, the person-centred approach doesn’t ‘own’ them. However, given how the therapy field is mapped out currently, the person-centred approach is often appropriated, misunderstood and undervalued, and I think in doing so we miss both its power and its relevance within and beyond the world of therapy.
(Photo credit Duncan Shaffer 2020 and shows protestors in Seattle)