The understanding of the connection between personality, social context and multiple psychological problems is that these are forms of intentionality connected together in more complex social ways to produce semi-fixed habits and abilities. Human beings are biopsychosocial entities who live in a meaningful world. The devil is in the detail though, concerning precisely how individuals can be understood.

Intentionality

The term “intentionality” is taken in the German sense rather than the English one of just meaning purposeful. Intentionality concerns the many ways in which people have meanings and conscious experiences of all kinds. Types of intentionality include the five senses of perception, the conceptual intentionality of internal dialogue and speech in language and the empathising of what others’ experiences might be. There are combinations of intentionality such as imagining what another person might be thinking or feeling, through looking at their body, for instance. Being in a meeting, group or crowd concerns how types of intentionality get pooled together. The diagram gives an impression of the whole. The word “intentional” means that processes and relationships are conscious and about some object of attention.

What I want to provide first is an overview, a map, of the whole. The territory is the relationship between suffering and well being. These two areas are not completely different but co-exist, simultaneously or one after the other. The bad news is that there will always be suffering and the potential to suffer. (But suffering will not last forever). The good news is that well being can be attained but it needs effort, practice and sufficient time to gain proficient skills. (But well being will not last forever either). The commonality between the psychotherapies, Buddhism and the philosophy of Friedrich Nietzsche is that effort is required to attain well being. A life without striving and struggle is not living fully. If all that human beings seek is avoiding suffering, then mediocrity follows. The soil of suffering is the ground from which well being can grow. However, the conditions for growth need to be ripe in order to create the crop of well being from the plant called life. Without soil, water, light, shelter and the efforts of gardening there will be no crop.

Less metaphorically, the relationship between suffering and well being is a two-way transition. The infant, if well cared-for, can fall from the state of grace of well being into suffering. This is a direction of travel that can happen temporarily or for longer periods of time.

Travel in the other direction is also possible. Suffering can be turned back to well being through effort, skill and a clear understanding of what genuinely satisfies. The direction of cure or recovery demands self-care and the individual creating conditions that satisfy rather than perpetuating the suffering.

Psychotherapy is the helping profession that understands the full breadth of human being as biopsychosocial. For some, the tendency towards suffering might be biological in origin due to genetic and other biological and material influences. For others, the causative influences are psycho-social conditions, past and present, of the meeting between the personal and the social in terms of trauma and other social conditions that produce a personal response. Therapy is helpful in that it can define problems, explain them and enlist clients to self-care. Essentially, what counts are the lived experiences of suffering actually lessening and being replaced by well being and on-going self-care.

Similarly, the influences that are creative of well being are also biopsychosocial. If biological-material conditions are right and the psycho-social context in the present is managed well, then it is possible to create an amount of well being relative to the type of problems being faced. This is even so when the problems being addressed are biologically-inherited forms of mental illness and the personality disorders. Even in these cases, with understanding, practice and effort, it is possible to achieve a degree of well being parallel to those who are born with a physical handicap.

To summarise: There is a potential for on-going movement between suffering and well being throughout the lifespan. The totality of influences is biopsychosocial. What therapy does is know how to help people create more well-being than suffering. The direction of initial on-set or relapse is a qualitative set of experiences of narrow living, inaccurate and defensive understanding and belief, and purposes that are dysfunctional in that they do not provide proper satisfactions. The direction of recovery is towards psychological well being, the good life, where clients can look after themselves well after therapy has finished. This is also a set of experiences that are functional in that they provide proper satisfactions through wider, more accurate understanding and beliefs. The state of well being is one of coping, resilience and robustness, of happiness and satisfaction despite all the bad things that may have happened. Therapy works by helping clients select the understanding and beliefs for adequate role performance and the attainment of genuine satisfactions. Good choices are those guided by the relevant regions of experience that have been properly interpreted.

The other key terms that need to be understood include the difference between an object of attention and the many senses that are possible about it. For instance, an object of attention could be another person, a thing, an abstract quantity, a general concept or a socially-maintained tradition of some sort. All such senses will be different according to the type of intentionality involved. It is possible to see another person in the flesh, to think about them in their absence, to draw them, or write a poem about them. All these are different experiences of the same object of attention. The sense conveyed could be the same. Or the senses being portrayed could be different according to how they are experienced. If the person is currently apprehended in anger, then there may be more complex feelings of disappointment, anger and hate. And the sense of loving them is currently lost or not accessible, perhaps. Objects of attention are also called cultural objects. This is a very general term and a reminder that social meanings get added to objects of meaning. There was a first occurrence of sense that gets updated everytime it is experienced. Sometimes the first sense is strong enough to still be present many years later. Or perhaps the first-ever sense is only occasionally present.

The other key term to understand is that of context or horizon. All objects of attention and the types of intentionality that behold them, occur in various contexts of sense, person and time. The diagram below brings these concepts together in order to show how they relate as a whole.

A figure to show how intentionality, sense, object and context occur together.

So to explain the diagram above, let me recap the very general terminology being used. Intentionalities are mental processes of all kinds, simple and compound sorts. These mental processes only appear through what they produce: conscious experience. All believed and dis-believed objects of attention are cultural objects. In this way, the entire contents of the human world are referred to. It is important to note that selves and others can attend to one and the same cultural object, although there is no guarantee that any two persons will have the same description of their perspective on it. Indeed if they were to have the same experience, it would mean that they had become the same person, rather than remaining two different people. So what is being discussed are the ways in which meaning is social and socially-accessible rather than some entirely personal experience. The idea of context means that there are progressively larger contexts in which public cultural objects make sense. For children, there is the great importance of what parents and the immediate family of known persons think and feel. As children grow and venture outside of the home there are then the increasing contexts of social meanings of culture, society and history and ultimately the sum total of experiences of the entire world.

What the above means for therapy is that psychological problems are attempts at solutions that are due to intentional processes that contribute a series of interconnected experiences: Specifically, emotions, behaviours, temporal experiences, social and personal experiences form a whole and are distributed across the lifespan. Specific problems like worry or avoidance are created through temporal and social connections.

What this means is that psychological change occurs through taking a new perspective on oneself and one’s problems. Psychological change is part of a greater whole including behavioural, social, emotional and linguistic changes. Altering a form of intentionality will change the sense of a problematic object, from a felt-sense to an intellectual sense, for instance. Cultural objects cannot be removed and the past cannot be changed in reality. But the senses of these objects of attention can be different according to changing the context of understanding - and the perspective taken towards ‘the same’ object or event. For instance, a traumatic memory can have a number of meanings associated with it. The memory means something about the cause of the trauma, about the self who was traumatised, it means something in terms of the emotional sense that co-occurs when the memory comes to mind. It means something else all together when it is described to another person. The factual existence of the memory can be in doubt if third parties dispute that the event remembered ever happened. If there are other parties who can explain the event in the traumatic memory, then the circumstances of its occurrence might become clear and it could be more reliably understood. All of these experiences are intentional and about the same event but are experientially different and the mental processes involved are different.

Uniting talk and action

Where the psychodynamic and cognitive behavioural traditions converge is that they both are concordant as long as conscious events are attended to. Research shows that the quickest way to achieve change for many problems is through changing current behaviour in order to change meaning. However, the way to engage clients is through speech and providing an explanation of their problems in ways that are fully understandable to them. Thus speech and understanding changes the meaning of their problems even prior to them altering their behaviour.

If discussion is the main medium of therapy, then there can be spontaneous changes in sense that occur first of all through conceptual intentionality in combination with the whole of the senses of the client. The meaning of memories, events, thoughts, actions and feelings are altered through creating new contexts for understanding the behaviour of self and others. The four key concepts above are intentionality, sense, object and context.

Psychological problems have complex causes. Changes in sense are attainable through changing the type of intentionality involved: changing the sense of the same object, changing the context of meaning and changing the duration of time spent on attending to the object. Clearly, changing one object of attention for another will also change the subsequent senses gained. The worth of the intentionality model is having a simple system of concepts that are flexible yet provide a structure for thinking through the experiences of clients in order to think creatively about what can be helpful in creating change.

The argument for a qualitative psychology of conscious experience to guide interventions is against an excessive reliance on natural psychological science as a guide for practice. The formulation of intentionality is that it should help client and therapist agree the nature of the problem and the nature of the answer. When intentionality features as a central concept, it is in the service of promoting accountability and the explanation of techniques to the public and colleagues. Hermeneutics is a form of explanation for the approaches of each client and therapist.

The line of argument taken below notes the limits of quantitative psychology and answers the problem of the naturalistic attitude first. This understanding of intentionality forms the basis of the rapprochement between the talking and action therapies. The ability to choose, and choosing between intentionalities and objects of attention, occurs through free will. The naturalistic attitude ignores individual choice and the intentionality of consciousness in the social world. The view is that there is pseudoscience in therapy research. For the biopsychosocial perspective, what is required is basic understanding to interpret the qualitative experience of psychological problems. A biopsychosocial perspective has not yet been attained in the developmental psychology of psychopathology and so currently there is no consensus and that cannot guide practice.

Against the naturalistic attitude

The most all-embracing problem of therapy is an excessive reliance on justifications concerning the material, biological, neurological and physical substrate of human being. This is a problem because an over-emphasis on one aspect of the whole decreases, mistreats or ignores the other two aspects of human being. The naturalistic emphasis in therapy is a problem because the biopsychosocial whole is irreducible to any one of its parts. The problem is a hasty focus on one third of the causal factors involved. In philosophy, clear thinking prior to action, this is called the problem of the naturalistic attitude. In psychology, the same problem is known by a series of equivalent terms. It has been referred to as Scientism, physical reductivism, materialism, material reductionism and psychologism. Briefly, the problem of the naturalistic attitude is due to a philosophical position that believes that empirical psychology is a sufficient procedure for all justifications including ideal knowledge (like theory, mathematics and logic). Edmund Husserl countered this in the Logical Investigations (Husserl, 1970a), by pointing out that there are real and ideal types of knowledge. He furthered an appreciation of an ideal theory of meaning: This means that speech and writing work because people know in an ideal way, what the referents of speech are. The referents of speech are the same in metaphor and sarcasm, in Mandarin or French. Similarly for Husserl, ideals need to be found and understood in philosophy and psychology to create a preliminary theoretical overview to co-ordinate action. Husserl’s phenomenology exists to find the ideals of consciousness in relation to other consciousness, the world of meaning and the objects of attention in it. Phenomenology does not replace empiricism but is preparatory for it.

But the naturalistic attitude of natural psychological science acts as though understanding can only be gained through empirical means. If this were true, it would follow that people who have psychological problems are not good scientists and need to apply science to themselves. The problem of the natural attitude is that psychological science acts as though intellectual work is absent from the creation of its results. The consequence of the problem concerns how to create a justified position for understanding psychological life, specifically as psychological, and not the by-product of natural-material processes. Psychological here means emotional, relational and concerning intentionalities about conscious lived experiences such as behaviours, thoughts, feelings and beliefs. This is a restatement of the purpose of theory and empiricism because an exclusive focus on natural being means that only natural-material cause is worthy of attention. Hence, the naturalistic attitude rules out the complex inter-connections between the three aspects of the biopsychosocial whole. It contradicts the as-yet-unknown overall inter-action between each aspect.

The limitations of empiricism and statistics

Furthermore, the manner of argument in psychological science is suspect. The problem is that the quantitative model is built on the following confusion between two forms of argument, modus tollens and modus ponens. Modus ponens is the argument that when a theory is true, observations from its perspective are held to be true. Modus tollens is the argument that if an observed finding is false with respect to a theoretical prediction, then the theoretical prediction is also false. Thus, quantitative psychology puts the cart before the horse. In quantitative psychology that uses statistics, the premises are always unsound because they are averages and not actual reflections of the highly complex inter-related factors under consideration.

On the contrary, the proper relation between theory and practice is that theory comes first, but it is not the sole measure of what is real. Rather, theory serves its purpose determining what should be considered. One alternative to modus ponens is putting the pure before the applied. What this means is that theory serves a role in identifying what counts and this can inform practice. Accordingly, the use of statistics in large areas of the experimental approach to therapy is completely unjustified because the situation of measuring quality of life, supplied by a specific input from the therapy, is statistically indeterminate. When changes of meaning and lifestyle itself are the matters at hand, these subjects are not capable of supporting scientific evaluation in the proper sense of science. Furthermore, the experimental designs used and the size of the groups used are frequently far too small for the statistical packages used. Theory is refined by consideration of the applied to create a new pure: in an on-going inter-play between the pure and the applied.

It is a stark fact that the ontological dualism of biological traits and chemical aspect of meaningful psychological problem is never going to be met by material treatments or science - but only by a psychosocial treatment that helps clients understand and change their own behaviour. What counts in therapy practice is the experience of practising. When practice is understood from the inside of what it feels like to provide and receive care, then the experiential basis can be understood and theorised. Intentionalities form part of helping clients re-assess how they make the end-products of their own conscious experience. How people have experience and the intentionalities involved is the concern of qualitative theories that attend to the lived experiences of meaning. The intentionality model exists to balance opposing forces between theory and practice, empirical research and ethics. In the qualitative view, nothing about therapy is factual or measurable in the scientific sense. The intentionality model supplies a simple structure and is flexible and designed for the delivery of individual care. The values that it upholds are the preferences for flexibility, immediate responsiveness in sessions and how to structure individual meetings and series of meetings towards specific agreed goals.

Briefly, natural science is a perfectly acceptable approach for understanding material being, inanimate matter and acting towards it. Natural science appears in psychology as psychophysics that, for instance, could never possibly grasp what it means to see. Natural science appears in therapy as ideas of natural cause and invariable, measurable effects. It uses statistics to measure psychological distress. Its purpose is not to understand distress. Nor can it understand those who do not sufficiently understand themselves or others.

Generally, in the natural view of attachment theory, a brief introduction on inter-responsiveness between child and carer, or between two adults, then leads into a discussion of neurological processes as the genuine representation of what empathy is, how child development occurs and how memory processes work. Typically in this type of research, psychological justification is begun but suddenly broken off to discuss the material substrate only, with none, or only the slightest regard for personal choices and intersubjective influence. Thus, intersubjective influence is not treated as intersubjective but as neurological or physiological and anything but psychosocial. On the contrary, the task of a pure or theoretical psychology of secure attaching and its vicissitudes, discerns what is significant as opposed to what is peripheral.

One way of stating the task for therapists is that they need to be able to understand and digest the distress and negativity that they might feel, as a result of listening to painful and distressing material. It is a limitation of therapists that they should only work with the level of distress with which they can cope. A person who specialises in particularly distressing material like rape, neglect, sexual abuse, suicide and self-harm may need to limit their exposure and monitor the way in which they deal with their feelings. Some negative and traumatic objects when brought to attention and communicated have the consequence of strong negative emotion that is passed on to the listener.

There are a number of consequences to understand how an excessive focus on the natural misconstrues the meaning-oriented changes that are the proper substrate of helping people change their psychological lives by helping them change it themselves. The meaning of attachment relationships currently falls outside of the domain of what can be studied by natural psychological science. Attachment as a lived experience is psychologically meaningful.

Through thought alone it is clear that the material being of humans is not the same as meaning, values, intentions, beliefs and practices in the sociocultural world. This is not to state that the biopsychosocial perspective is currently impossible or over-ambitious. The concern is that natural psychological science lives or dies by its own precision. A day may come when it can be specified that the personalities and problems of a specific client can be explained because of the specific impact of their inherited traits, in relation to triggering social environments, in relation to their intentionality and choices. At some point in the future, it may well be possible to specify precisely how inherited material developments inter-act with culture and personal choice for an individual. Until then, there is uncertainty about the amount of natural cause in relation to the amount of psychosocial.

As therapists have no means of diagnosing or providing material changes in the brain, for instance, they lack the means of providing physical remedies to psychological matters. Even if natural causes do predominate in any specific case, certainty about that would not help the practitioners of the psychological therapies. This is because practice concerns how to create actual outcomes with real people (given their limitations, those of therapists and the situation as a whole). Practice employs social skills and encourages specific things happen for clients, the general public. Practice is not technical know-how by itself.

An excessive focus on material being and the problem of psychologism need to be tackled in proposing the intentionality model as a qualitative psychology of conscious meaningful experience.

The skills of formulation

The remainder of this entry are notes of a lecture for a skills workshop on integration and formulation by Ian Rory Owen PhD, for the Society for the Exploration of Psychotherapy Integration in the UK, given on 2 May 2009, at Regents College, London.

1 Aim

To provide a brief overview of the intentionality model leading to the skill of the practice of formulation. There will be time for practising formulation with simple and then complex cases and closing with a discussion.

2 Sequence and overview

First a brief overview of the intentionality model will be provided. Next formulation will be presented as a major unifying task that models co-operation and security in the therapeutic relationship. The idea of formulating on paper will be practised at first with simple cases and then with much more complex ones.

3a Reasoning for integration: Learning from the whole of psychotherapy

What clients want

Clients want help and change. They do not know about the differences between the various types that are available (generally). Clients are embarrassed about asking for help and feel shame about the problems they have. Self-disclosing about the problems is difficult for them. Clients do not want to have brand names types of therapy. Clients want to lead problem-free, or problem-minimal, lives and have choice and understanding about their experiences.

What therapists want

Therapists want to help but their investment of time and effort in purist non-integrative brand-name approaches blocks their ability to be objective about their own effectiveness. In this way, inaccurate high self-esteem of therapists can block the ability to be properly effective in delivering change. To be effective can only be achieved by building in feedback from clients. Being effective means being able to understand outcome results that say that CBT is most useful for single disorders and be able to understand why this is the case. Actually applying CBT with people with complex multiple problems is the usual case of practice. In order to be properly effective, therapists need to understand, work with and manage the relationship in a transparent and equitable way because it is the medium for the delivery of the care being provided. The rejection of clients, because they have worries and difficulties about entering therapy and self-disclosing (etc etc), is a failure to deliver care.

Against single trainings in non-integrative practice

Here are some drawbacks of common positions within the field overall:

Behaviourism is wrong to suggest that hermeneutics is not relevant. This attempts to disconnect meaning from its version of pragmatism. On the contrary, meaning is the base experience of being alive and aware.

Psychoanalysis and psychodynamics are wrong to hypothesise in terms of unconscious emotion, unconscious intent and unconscious communication. There is nothing wrong with the descriptive use of the word unconscious. If some object or aspect of observable communication is not currently conscious, then it is acceptable to say that it is currently outside of awareness. The problem is that emotions are always conscious when they are felt as are intentions when they are acted on and communications.

Lifestyle choices and developmental windows of opportunity were set down consciously in the past. They were consciously chosen at the time of making them. That is not to state that all the emotional and moods influences on a person are always understandable at the time of being so influenced.

Cognitive behavioural therapy (CBT) is wrong to place so much store on the empirical evidence for randomised control trial (RCT) research on single axis I problems and axis II personality types. The core of practice is improvisational art, hermeneutics and good communication skills in order to share a formulation and get informed consent for practice. Formulation is one place where hermeneutics is in action.

Security of attachment in the professionally-provided time-limited relationship is promoted through clarity of roles and boundaries in terms of knowing how to provide care. Specifically, security is increased through an attention to detail of how to provide talk and relating and meaning-altering interventions for complex short- and long-term psychological problems. It is the attention to the detail of how to practice that enables therapists to remain calm and for clients to value sessions and receive help. It is insufficient to provide clear boundaries and no care. The reality of the performance of sessions is most important.

Integration

The premise of practising only according to a single non-integrative brand name of therapy is wrong. There are great lacks of certainty and consensus within all aspects of the subject areas that could be capable of justifying practice. Therapy exists in the middle of competing claims for justifying any aspect of practice.

On the contrary, there are only small distinguishable differences between the brand name types of talk and action therapies.

The main aspect of practice is to tailor interventions to meet individual client needs and abilities. Only offering a small number of interventions will inevitably be unable to meet the full range of the needs and abilities of clients. For instance, what is also ineffective is beginning CBT with someone whose ability to trust is very low. Starting a talking therapy that never gets close to supporting actual change is also unacceptable.

There is great difficulty in writing a therapy manual for practice because there is a substantial inability to standardise practice.

Four commonalities in all conscious experience

Changes in psychological health involve complex changes in all aspects of intentionality and sense (the duration of a sense). Changes in practical intentionality are most likely to change mood and that has knock-on effects on self-esteem. The most general strategies for change are:

Change intentionality.

Change the sense gained of any object of attention and the length of time spent on it.

Change the objects attended to.

Change the contexts of understanding involved.

Definition: Intentionality, sense, object and context are four ubiquitous aspects to the definition of any problem and the provision of an answer.

Defining the intentionality of consciousness

Intentionality: The many ways in which the mind is conscious of people, self, things, ideas and the views of others. For instance, here are some simple types:

Perceiving events in the here and now: vision, hearing, body sensation. The bodily sensation of ones own body is a type of perception.

Imagining that something might happen at an unspecified time.

Behaviour is (often) a purposeful practical intentionality towards some desired outcome.

Affect is often about values or represents how self is relating towards others and is felt in the body but also mediated by thoughts and beliefs.

Empathy is the learned appreciation of the perspective of others and can be immediate or absent, strong or weak, intellectual, affective, remembered, anticipated or imaginative.

Conceptual intentionality occurs in internal dialogue, all written and verbal communication, and in intellectual forms of notation (music, maths).

Signitive forms e.g. road signs, the weather.

Believing that something is (or is not) the case.

There are also complex nested types of intentionality:

Remembering what a visual scene looked like.

Remembering what another person said and what they meant.

Anticipating what would be seen.

Anticipating what would be said.

Imagining what someone might think or feel.

The use of phenomenology

The concept of intentionality works to explain and map experiences of different sorts. It is an easily understandable medium that needs no explanation of the basics such as what imagination is, or what memory is. These experiences are common although they may not be fully understood. Thus, the worth of phenomenology is to make a common language to enable co-operative working, collaborative empiricism.

For instance in health anxiety, the full experience is that a person worries in internal dialogue about what it means that their heart is palpitating. What they experience is the consequence of the belief that they are having a heart attack. This belief brings on a panic episode where they feel that their throat is closing up and that they cannot breathe. This produces the further idea that they are going to die and at this point they can imagine their family gathering around their death bed and see them crying. The next thought is that their life has been wasted and that they have done nothing with the opportunities that they had.

Clearly, every step in the above concerns a different type of object experienced in a different intentional way.

Worry in internal dialogue produces physical sensations of anxiety.

The bodily sense of anxiety is interpreted as evidence to support the belief that a heart attack is current.

The belief that there is a current heart attack increases the anxiety level to produce a panic attack.

The panic experience includes difficulty in breathing and produces the belief that their throat is closing.

The visual imagination of their own death is the next experience.

Finally, that promotes the conceptually-expressed thought that their life has been misspent.

Consciousness is self-reflexive and how to reflect on it

Not only do we have experiences but we automatically know that we have them. Many therapies work by increasing awareness of the problem through discussion or other means. Encouraging clients to be aware of their problems brings them into a sharper focus. The general process is: Stop.

Reflect and stand back.

Think and understand.

Re-engage in a new way and act differently.

Hermeneutics

Definition: The formal study of the ways of making sense, of how things are understood as something and not something else. For instance, in understanding how the same perceptual object is interpreted differently by different persons or interpreted differently by the same person at different times. For instance, one action is interpreted as the outcome of a purposeful intention to achieve it. Another action is interpreted as the outcome of a mistaken intention to achieve it.

Accurate understanding is fore-knowledge that shows the phenomena that it is about and is proven in accurate striving towards functional satisfactions: such as the promotion of ones own quality of life. Good understanding explains clients situations to them. Pragmatic outcomes prove good understanding. From the perspective of clients, the new understanding supplied is less harsh and more all inclusive than the old.

Other remarks

Action and intentionality-oriented interventions are highly effective because they target specific aspects and communicate explicit principles for self-care. Empirical research shows that changing behaviour is the most effective aspect for promoting change (Longmore and Worrell, 2007). In comparison, talking and relating is the medium for all care but is best suited to more complex problems of understanding and bearing witness to what clients experience. Through talking and relating alone it is possible to alter meaning.

Practising therapy means being ethical and effective, working with the relationship and targeting specific areas for self-managed self-care.

Psychological problems and the so-called personality problems are multi-faceted and multi-factorials caused. At base what clients complain about are their conscious experiences and therapy is only successful when it enables change and its maintenance.

Emotions

Some emotions cannot be trusted and do not necessarily have to be expressed. For instance, fear, if trusted and expressed, may lead to dysfunctional avoidance. Other emotions might be negative but might be functional even if they are painful. Some negative emotions should be trusted and accepted as negative motivation towards some positive functional outcome. For instance, loneliness should drive a person towards becoming attached with friends. If it promotes alcohol abuse, then that is a dysfunctional outcome. Only with care can the distinction be made between which actions can be permitted with respect to any emotion.

3b The manner of reasoning

The phenomenological argument

Applied physics: Pure mathematics

Practice and skills: Pure psychology of consciousness in its social and meaningful context

Application of physics: Pure maths about real natural being

Practice and skills: Theoretical ideals about the conscious psychosocial experiential whole

Walking from A to B: Use of a map about an actual territory that has A and B on it

Practising in a session: Use of a map about actual practice and ideas about how to facilitate changes from distress to health and its maintenance

The basic skills set for practice

The general skills of understanding are supported by theory and research findings

Skills exist towards specified outcomes, some of which are precise and some are woollier:

Assessment (including risk, safety, the decision not to treat and re-referral)

Formulation: Provision of insight for self-managed self-care

Treatment planning and use of supervision

Treatment via talk (and relating) and action-oriented (intentionality) interventions

Review, two-way feedback and pre-emption of problems in the relationship

Relapse prevention, a round up of what worked

Ending

What the therapist embodies is the knowledge of clear ideas that help and is then flexible in applying the ideas of good practice in order to create a working relationship with each client. Flexibility in the manner of caring and the potential to agree a focus for sessions is understood as taking the idea of boundaries and roles for client and therapist and taking it further into the detail of how to make the therapeutic relationship secure even with the most complex and reluctant self-disclosers. However, some aspects of practice and the transparent structure of the help being provided are not negotiable: These are matters such as providing informed consent, choice to clients in whether they follow treatment recommendations or not and that therapy should be legally defensible. There are large bodies of evidence to synthesise in determining what justifies practice. Accordingly, dealing with risk, suicidal intent, poor functioning close to breakdown in the ability to cope with everyday activities due to mood and emotional exhaustion are priorities. The basic theory of formulation presented is to be open and honest about what therapists think is the best type of help they can provide without being tactless. On the other hand, bad practice is being unresponsive to risk, not getting informed consent, and not attending to actual or potential danger (to self and others and emotional exhaustion).

Talking and relating-oriented interventions

The therapeutic relationship is the basic medium for all aspects of the work.

Use empirical findings from attachment research to understand the conscious emotions on both sides of the relationship: The psychodynamics of providing and receiving care.

Action and intentionality-oriented interventions

Cognitive behavioural interventions are re-cast as means of using intentional it to explore and change meaning. These are generally called action interventions as they all require clients to choose actions of new sorts. That means making changes in intentionality, sense (including the length of time spent on any object), object and context.

The use of empirical research

There are many relevant evidence bases for practice.

Behavioural genetics research on the heritability of problems and personality types.

Process and outcome research.

Qualitative research into attachment processes in the provision and receipt of care.

NICE guidelines generally and those on how to deal with risk (Department of Health, 2007) and the RCT evidence base.

Developmental psychopathology.

Epidemiology of personality types and psychological disorders, specifically complex presentations.

4 Content

Accurate understanding shows itself in gaining good outcomes on a regular basis with clients from a wide range of backgrounds. (And the corollary is that poor understanding is shown in poor outcomes). Good social skills and accurate understanding prove their worth in being able to capture the experiences of clients and translate them into problem definitions that aid self-managed care.

The receipt and provision of care in therapy is broader than the RCT model and hypothesis-testing can understand. Problems, personalities and practice are intersubjective in that they exist in open systems of social contexts.

Work Training & theoretical beliefs

Family & friends↔ Client ↔Therapist ↔Supervisor & colleagues

Culture & society Own life, therapy & recovery

The RCT model and hypothesis testing are inappropriate for understanding the whole of everyday living and practice. This is for a number of reasons. The foremost being that bad science abounds in the place of the proper use of statistics in psychology: The use of statistics is only appropriate when the groups are large scale. Even then the full range of influences on clients cannot be modelled and are not screened out by there being large numbers in the therapy-receiving group nor in the control group.

How to formulate

This way of formulating is both pragmatic and meaning-oriented. It is assumed that people do things because of the meanings they interpret, plus the beliefs and understanding they bring to publicly-observable situations and the moods and emotions they feel. The pragmatic aspect of formulating is boiling down the great detail of clients’ experiences to pinpoint the problem with respect to the most accessible and changeable elements of it. If such elements were changed that would promote the most immediate access to new, more adaptive experience. Often this is through open discussion of self-care principles and asking clients to look after themselves.

The role of formulation in therapy

Formulation serves the purpose of defining problems in order to separate clients from their immersion in them. It pairs up clients and therapists as being on the same side - against the problems. Formulation also turns clients towards more precise views of their aims. It leads to clear, specific targets for action such as “I will ___ twice a week for 20 minutes each timeâ€ÂÂÂÂÂ�. Or “I will ____ whenever necessary from now onâ€ÂÂÂÂÂ�.

Formulation is an ethical and practical necessity. It creates informed consent about the focus of the work to be done. It helps to explain the type of treatment being offered. Basically, there are only two main types of treatment: talk or action – plus complex mixtures of both. “Talkâ€ÂÂÂÂÂ� really means relating in sessions. (After which it is often left to clients to apply the changes in their understanding, and change their behaviour by themselves). “Actionâ€ÂÂÂÂÂ� means the use of talk leading to clients changing their own behaviour, under their own steam, outside of sessions. Clients then report back on what they have experienced and learned.

How to formulate and interpret simple cases

The process on which therapy rests is argued to be a formal process of making sense of psychological situations of all kinds (e.g. of the current functioning and maintenance of individuals, of the development of their problems across the lifespan, of the more general patterns of understanding what brings on psychological distress biopsychosocially). This is done with clients in sessions, either in writing or verbally, and is based on judgement and clinical reasoning concerning cause and effect and makes sense of the overall pattern of experiences of clients as they report them. In this light, formulation is really interpretation and a shared verbal discussion with clients over the course of several meetings with them. The processes of reasoning and concluding need to be shared and transparent and open to question from clients and supervisors (and others if necessary, if there is a formal complaint made). Formulation makes explicit what is implicit in the habits, moods, assumptions and associations that clients live. The process of formulation is implicit for therapists also and this needs to be open for discussion concerning how these important conclusions are made. The following remarks are an attempt at explaining the philosophical underpinnings at the heart of how to understand understanding itself.

Basic statement of the hermeneutic circle in action

Understanding & belief ↔ Action & experience

Inaccurate understanding ↔ Unhelpful unnecessary defensive

& belief actions that narrow choice and experience

Accurate understanding ↔ Satisfying assertive actions that increase

& belief quality of life, self esteem and achieve

attachment satisfactions – proving the pragmatic

accuracy of the understanding & beliefs

What need to be interpreted are those experiences that include risk and danger.

1. Only select those items that pose the most risk, or refer to mood and basic functioning, before identifying other problems.

2. Assess and treat risk. Suicide and self-harm are pragmatic and ethical priorities for treatment. Gain informed consent for interventions with clients.

3. If there is a personality problem present, of very longstanding or lifelong problems, that can be treated by breaking down the problematic lifestyle into smaller more manageable pieces, then that can be tackled next.

4. Assess for contra-indications. Some contra-indications for therapy include excessive impulsiveness, lack of self care and asking for help when suicidal or self-harming, alexithymia, high resistance in expressing the truth of the extent of the problems, pending crises and a chaotic lifestyle.

1 General biopsychosocial formulation

The following diagram spans the lifespan, from childhood and earlier experiences on the left hand side, to the present in the middle, and towards, the anticipated future on the right. The mnemonic is that “personality = character + traitsâ€ÂÂÂÂÂ�. Character is psychosocially-acquired nurture interacting with traits, biologically-acquired nature.

Psychosocially-acquired learning, Felt-sense of self: Defensive decision.

influence from others, eg trauma. Natural bio traits Bio

Biological traits exist that could → can be over-ridden → potential not

be made manifest, potential by acquired learning. manifested.

could be expressed.

Psychological ↔ Social

↕ ↕

Biological

The most general formulation of the biopsychosocial causes of current problems of personality and psychological disorders, across the lifespan, is to note that the biological and genetic inheritance of any individual is shaped by the cumulative effect of psychosocial contexts since infancy.

2 Basic intentional formulation

Use the diagram below as a template for cases of psychosocial learning.

Intentionalities linked to an object of attention

Classical conditioning, learning, association

Associated or resulting negative affect

Practical or mental avoidance of negative affect Stand-alone problem or problem of personality functioning

Temporary relief provided by avoidance of negative affect Operant conditioning or negative reinforcement

General re-statement of the relation between classical conditioning and negative reinforcement (Wolpe, 1958).

3 Speech acts to render into language implicit beliefs

The background knowledge against which questions are asked, and answers are made sense of, is the sum total of DSM IV definitions. The background is understanding DSM IV in connection with how it feels to live these problems. Clients can be asked to work back from key intense negative emotions, problematic thoughts and worries and omissions of functional behaviour – in order to sum up the feeling, the style of self-talk and behavioural omission – in order to make explicit statements of the beliefs expressed in them. Clients can do this for themselves or with the help of therapists. The outcome would be a statement of the following sort, spoken in the first person on their behalf: “I act as though I believe that____â€ÂÂÂÂÂ�. “I talk to myself as though I believe that____â€ÂÂÂÂÂ�. “I feel as though I believe that____â€ÂÂÂÂÂ�. Clients are openly invited to agree or disagree.

When putting a formulation back to clients, the following type of wording can be used in speaking on behalf of them and stating their experiences so they can check and understand cause, effect and the meanings they experience. “When I am in ____, I feel ___ and think ___ and avoid doing___. This maintains the problem of ___ because ___ is a type of reward that I get when I avoid what I need to doâ€ÂÂÂÂÂ�. This type of wording helps clients to understand themselves and invites them to respond and reflect on their experiences.

How to formulate complex cases

General principles: work with client to prevent death and self-harm through increasing their motivation to self-care. Several psychopathologists agree that there is no strict demarcation between axis I and II problems (Kupfer et al, 2002, Newman et al, 1998, Petrocelli et al, 2001). Consequently, aspects of the so-called personality disorders of lifelong or very longstanding problems of general functioning, particularly with respect to social life, can be made the target of specific strategies. Clients can be consulted about how they want to proceed on important decisions concerning whether to accept the current state of dissatisfaction or whether to make plans about making changes.

1. Assess risk and focus on it as an ethical and pragmatic necessity: Make a written plan with clients about how they will deal with their risk, triggering situations and strong negative emotions and moods.

2. Focus on the primary mental health problem to improve mood, everyday functioning, self-esteem and self-acceptance.

3. Ask open questions to formulate the primary mental health problem on paper. Show it to clients and ask what they think. Ask them to disagree if they wish.

4. Therapists state what they think is the focus (the next main problem to be worked on). Ask clients what they think is the next main problem. Agree what the focus will be.

Primary mental health problem, formulation 1

For use when sketching out a focus on beliefs and biological cause.

Protective beliefs and biological inheritance ↔ Personality and problems of

impaired mood, inaccurate

self-esteem and basic role

performance

Primary mental health problem, formulation 2

For use when targeting mood that impairs basic functioning in everyday life.

Fixed negative beliefs ↔ Impaired mood

↕ ↕

Inaccurate self-esteem

Primary mental health problem, formulation 3

For use when there is a self-reward through avoidance, eg self-harm, drink and drugs, vomiting.

Mood and self-esteem ↔ Inability to function and cope

↕ ↕

Avoidance of necessary self-care, pleasure-bringing

activities and social support

↕

Temporary relief from anticipated sense of burden and difficulty

Example: Depression and low self-esteem

The problem:

Three key facets of experience are mutually supportive.

Beliefs ↔ Lack of action

& understanding

↑ ↓

Low inaccurate self esteem

Behavioural activation:

Increasing activity levels acts as a distraction, improves mood and self-esteem.

Take necessary action ↔ Begin to solve problems

↑ ↓

Improved mood and self-esteem

Example: Negative reinforcement

All kinds avoidance of negatives that need tackling: Help clients to reduce avoidance, e.g.

Drink and drug abuse with the emotional function of temporary respite

Self harm to relieve psychological pain

Other means of altering mood to avoid problems that need a more adaptive type of solution

Bingeing and vomiting as a ‘necessary punishment’ to temporarily improve mood

Negative emotion & mood.

Problems remain intact.

Mental or physical action to distract, avoid or reduce mood.

↓

Temporary relief only

Good mental health formulation

Initial accurate understanding and belief guides actions that satisfy needs (for self and others).

Accurate adaptive beliefs ↔ Assertive actions towards clear

outcomes

↕ ↕

Accurate self-esteem & good mood

In short, the process of formulation is led by therapists but involves clients in it. It has the purpose of promoting co-working to gain further co-operation on the treatment strategy plus the pace and means of achieving the targets that clients desire.

From the perspective of therapists, the practice of formulation means adopting a role that is secure and facilitates a secure and calming response from clients. Formulation provides explicit help through the detail of being transparent in one’s own clinical reasoning. It involves clients in being able to explain and motivate them to achieve what they want. Therapists should also state clearly what they think will help people best. They should invite clients to speak particularly on the issue of the next focus for work in sessions. All matters about the treatment are open for discussion and questions, worries, fears and disagreement should be invited: i.e. “please disagree with me if you think this won’t work for youâ€ÂÂÂÂÂ�. “I cannot make you do anything you do not want to doâ€ÂÂÂÂÂ�. “I might make suggestions but you are free to follow them or not as you think fitâ€ÂÂÂÂÂ�.

Clients can also be asked to think creatively about what they think will help them. Clients set their own targets, general aims and are in control of the pace of work from week to week. Therapists encourage clients to challenge themselves and help them maintain their motivation to pursue new aims, even after the therapy is over.

There is no biopsychosocial consensus on the causes of personalities and problems. This is the clinical reality faced by practitioners.

5 The problems that this model of integration overcomes

There are a number of shortcomings to single brand name trainings. All therapies need to have a broad base of justification in order for them to make sufficient contact with mainstream positions in psychology, psychiatry and other relevant mainstream topics such as RCT research, quantitative and qualitative psychology, behavioural genetics and biological determinism.

10 Keys

Key 1 is the belief that personality theory describes aspects of a multi-factorial biopsychosocial whole. Human nature is biopsychosocial, containing complex inter-actions between three types of multi-factorial cause. Specific problems arise as the result of inherited personality characteristics, early and later adult life experience, personal choice and the influence of others and culture.

However, the intentionality model believes that the development, perpetuation and solution of problems concern the social learning of self-care. What is argued for is key 2 that social learning is a significant ‘causal’ and maintaining factor in the development of psychological problems. What this means is that social triggers or stressors are frequently a psychosocial partial ‘cause’ of a first occurrence of a psychological problem.

Key 3 considers meaningful and chosen psychological factors in the on-going perpetuation of these problems. There is the on-going phenomenon of the maintenance and persistence of a personality style and set of psychological problems that accrue through the inter-relationship of personal choice with the current social situation and biological traits. Formulation of the parameters of maintenance on paper happens through drawing a simple diagram for discussion. Or formulation can be achieved entirely in discussion. The aim is to promote informed consent and collaboration for achieving the goals of clients in a transparent and accountable manner.

Key 4 is the belief that the process of therapeutic change includes a permanent means of choosing a lifestyle for positive mental health. What is necessary is understanding the qualitative basics. Directives exist that encourage consideration of evidence-based practice, clinical reasoning, quality assurance and clinical governance in professional networks, professional bodies and employers. Psychological change occurs via changes in belief and experienced-meaning that promotes and enforces new understanding in relation to the conceptual intentionality of new beliefs, new speech and other realisations expressed in language.

Key 5 is that permissible interventions are any that are relevant and can be explained to clients before they are used. The use of talk, action or both, must take into account the wishes, abilities and lifestyle of clients. This indicates the ranges of interventions that are appropriate according to a critical appraisal of relevant factors. Therapists need to maintain informed consent throughout treatment and be flexible about their recommendations.

Key 6 is understanding that there are different amounts of client ability and willingness to participate in what is being offered and that is what constitutes stages in the progression of therapy. It is crucial to relate therapeutic stages to choices of interventions. Stated in the order of four steps through the first stage of not having begun therapy and insight, through gaining an assessment and formulation, through working towards identified targets and finally attaining them.

(1) The attempts of clients at solutions are the starting point for therapy. The usual starting point is one of confusion and not knowing the cause and effect, or the personality and the influence of social contexts past and present. This lack of insight and psychological understanding can include avoidance of consequences, negative changes in mood, not being aware of how to tackle the causes and so create better solutions. When it comes to long-standing problems these may create false identity and attachment relationships. The overall problem of the first stage is that the sense of self accepts the false beliefs and the problem as an inevitable part of self.

(2) What assessment and formulation achieve is the understanding of cause and effect in an easily accessible way. Part of the stage concerns the acceptance of the present and the past because there are matters that cannot be changed. The formulation and assessment stage also requires the identification of attainable targets for therapy. Hermeneutics is necessary to identify defensive purposes that dictate motivations and the choice of lifestyle. Explanation occurs through a comparative process with clients entirely on-board. The outcome of formulation is that clients are able to distinguish the problem and the set of beliefs that drive it. Only when this realisation happens can clients become self-caring and consciously work to attain their goals. This is why the diagnosis of personality disorder is unhelpful. It places the locus of responsibility entirely on clients in an unhelpful way. The more helpful way of stating targets for working on personality problems is to dis-identify the person, from “I am the problemâ€ÂÂÂÂÂ�. And to re-identify them with some means towards making changes even on very long-standing problems to produce “I can see the problem and I know how to work on itâ€ÂÂÂÂÂ�. It is part of the role of hermeneutics to make this change.

(3) The working through stage is the main process of having therapy itself. It requires therapists to support and motivate clients towards the realistic and attainable targets that are the focus for the meetings. The process of working towards targets that are not yet achieved requires courage, determination and the expenditure of energy without the reward of attaining the target itself. One of the drawbacks of this stage is frustration as clients clearly want the endpoint that they have not yet achieved and have not yet received that reward. The process includes using the understanding to plan actions in the real world. It demands using effort and the honing of skills in order to attain the pay off.

(4) The pay off, the ultimate target and reward of self-managed psychological understanding, is that clients can solve their own problems and know how they do that. This includes managing mood and other aspects. Positive outcomes need to be maintained. They are the result of accurate understanding. The proof of accurate understanding is a higher quality of life. Key 7 is the awareness that theory and clinical reasoning justify the psychosocial skills of practice in relation to the lived experiences of providing and receiving care. Psychological help requires the assessment of hope, motivation and its encouragement in the face of difficulty. Therapists should be psychologically present in the room with clients and responsive in making a therapeutic relationship with them. This is their professional responsibility. It is an ethical requirement for therapists to set people at ease and enable them to participate in what is offered, to the best of their ability.

Key 8 is considering therapeutic aims as needing to be gender-, age- and culture-appropriate because of the embedded nature of human being. Work should be tailored to individuals’ mental states and the specifics of how they are living, as part of their family, religion and culture.

Key 9 is the necessity of reviewing meetings for assessment, formulation and therapy, at the end of each meeting, and particularly during the first few meetings, to monitor clients’ mental states and adjust the approach taken. Finding out the perspectives of clients on what is happening in the meeting is a major part of the ability to tailor the care provided according to abilities, level of readiness and general needs. Therapy ends when either the agreed focus has been achieved or most of the aims of clients are met. In the light of feedback from clients, therapists should change their approach according to discussions and gain informed consent for every intervention, particularly if distress is entailed and there is avoidance to be over-come. Therapists may also suggest that certain issues may need to be looked at, so clients may approach those issues that are difficult for them. Yet tackling them would be helpful. Key 10 is the belief of the importance of harnessing and motivating free will to provide self-care and care for others. Belief is seen as the tenth key to over-coming persistently negative estimations of self and other and a sense of threat. Despite the clarity of the hypotheses of classical conditioning and negative reinforcement within behaviourism, the identification of belief is a way of working on parts of the whole of much more complex problems.

6 The answer that this model of integration provides

The totality of skills for practising concern attachment-related ones for working with the relationship and intentional ones for working towards specific targets that clients want. The other skills are theoretical ones for use in interpreting clients’ developmental histories and current predicaments.

Personal effectiveness with a wide range of complex presentations is one of the major responsibilities of practice. Personal effectiveness can be monitored via CORE forms (CORE System Group, 1998). Reviews at the beginning and end of each session, plus other discussion at regular intervals, will help clients voice any concerns that might impede their progress.

7 Consequences

The variability inherent in meaning enables it to change. The lived experience of meaning is not scientific but an a-factual experiential phenomenon. The changeability of meaning that therapy can provide is entirely due to the unscientific hermeneutic base of everyday living and conscious experience.

What is the good life? Self-directed work towards achievable satisfaction in attachment relationships, having a wide and rich social life including having a number of sources of satisfaction: meaningful work, home and family, hobbies and interests, the self-directed management of mood and behaviour. The role of therapists in boundary setting extends to make the process of having therapy itself understandable: When this is the case clients can continue to look after their needs by applying the principles they have understood long after the meetings have to an end.

8 Recap and conclusion

The intentionality of consciousness is an easy concept to grasp that renders experiences understandable and discussible with people from all walks of life. Further, once it is understood that talking therapy works by changing meaning and the manners of being aware, then it is possible to spot how clients are oriented in time, place and person when they speak. CBT is re-written in this way to become a much more direct way of understanding the problems of personality functioning and groups of psychological problems that co-exist. When intentionality is understood as a key concept, it enables the analysis of the manners of awareness that are the psychological problem and that enables clients to understand how to help themselves.

References

CORE System Group (1998) CORE system user manual. Leeds: CORE System Group.

Department of Health (2007) Best practice in managing risk: Principles and evidence for best practice in the assessment and management of risk to self and others in mental health services.

Longmore, R.J. & Worrell, M. (2007) Do we need to challenge thoughts in cognitive behavioural therapy? Clinical Psychology Review, 27, 173-187.

Kupfer, D.J., First, M.B., Reigers, D.A. (Eds)(2002) A research agenda for DSM V. Washington: American Psychiatric Association.

Newman, D.L., Moffitt, T.E., Caspi, A. (1998) Comorbid mental disorders: Implications for treatment and sample selection. Journal of Abnormal Psychology, 107, 305-311.

Petrocelli, J.V., Glaser, B.A., Calhoun, G.B. (2001) Personality and affect characteristics of outpatients with depression. Journal of Personality Assessment, 77, 162-175.

Wolpe, J. (1958) Psychotherapy by reciprocal inhibition. Stanford: Stanford University Press.

Secondary sources

Assessment

American Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders (4th ed). Washington: American Psychiatric Association.

Cooper, J. & Alfillé, H. (Eds)(1998) Assessment in psychotherapy. London: Karnac.

Jaspers, K. (1963) General psychopathology. (Trans J. Hoenig M.W. Hamilton). Manchester: Manchester University Press.

Livesley, W.J. (2003) Practical management of personality disorder. New York: Guilford.

Mace, C. (Ed) (1995) The art and science of assessment in psychotherapy. London: Routledge.

Plomin, R., DeFries, J.C., McClearn, G.E. & McGuffin, P. (2000) Behavioral genetics (4th ed.). New York: Freeman.

Richters, J.E. (1997) The Hubble hypothesis and the developmentalist’s dilemma. Development and Psychopathology, 9, 193-229.

Zubin, J. (1977) From Joseph Zubin. In H.H. Strupp, S.W. Hadley & B. Gomes-Schwartz (Eds) Psychotherapy for better worse: The problem of negative effects. (pp. 340-343). New York: Jason Aronson.

Empirical findings

The British Psychological Society and The Royal College of Psychiatrists (2004a) Eating disorders: Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders, full guideline 9. Leicester: British Psychological Society.

The British Psychological Society and The Royal College of Psychiatrists (2004b) Self-harm: The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care, full guideline 16. Leicester: British Psychological Society.

Department of Health (2001a) 12 Key points on consent: The law in England. London: Department of Health.

____________________ (2001b) Treatment choice in the psychological therapies and counselling: Evidence based clinical practice guideline. London: Department of Health.

McIntosh, A., Cohen, A., Turnbull, N., Esmonde, L., Dennis, P., Eatock, J., Feetam, C., Hague, J., Hughes, I., Kelly, J., Kosky, N., Lear, G., Owens, L., Ratcliffe, J. & Salkovskis, P. (2004a) Anxiety: Management of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and community care, full reference guideline 22. London: National Institute for Health and Clinical Excellence.

National Institute for Health and Clinical Excellence (2004b) Depression: Management of depression in primary and secondary care, full reference guideline 23. London: National Institute for Health and Clinical Excellence.

_________________ (2005) Post-traumatic stress disorder (PTSD): The management of PTSD in adults and children in primary and secondary care, quick reference guideline 26. London: National Institute for Health and Clinical Excellence.

_________________ (2006) Bipolar disorder: The management of bipolar disorder in adults, children and adolescents, in primary and secondary care, quick reference guideline 38. London: National Institute for Health and Clinical Excellence.

_________________ (2009) Borderline personality disorder: Treatment and management, quick reference guideline 78. London: National Institute for Health and Clinical Excellence.

Formulation

Butler, G. (1999) Clinical formulation. In A.S. Bellack & M. Hersen (Eds) Clinical formulation in comprehensive clinical psychology, vol. 6. Burlington: Elsevier.

Clark, D.M. & Fairburn, C.G. (Eds)(1997) Science and practice of cognitive behaviour therapy. Oxford: OUP.

Denman, C. (1995) What is the point of a formulation? In C. Mace (Ed.) The art and science of assessment in psychotherapy. (pp. 167-181). London: Routledge.

Ingram, B. (2006) Clinical case formulations: Matching the integrative treatment plan to the client.

Kuyken, W., Padesky, C.A. & Dudley, R. (2008) The science and practice of case conceptualization. Behavioural and Cognitive Psychotherapy, 36, 757-768.

Persons, J.B. (1989) Cognitive therapy in practice: A case formulation approach. New York: Norton.

Sturmey, P. (1996) Functional analysis in clinical psychology. Chichester: Wiley.

________ (Ed.) (2007) Functional analysis in clinical treatment. Burlington: Elsevier.

________ (2008) Behavioural case formulation and intervention: A functional approach. Padstow: Wiley-Blackwell.

Tarrier, N. (Ed.)(2006) Case formulation in cognitive behavioural therapy: The treatment of challenging and complex cases. London: Routledge.

Tarrier, N., Wells, A. & Haddock, G. (Eds) (1998) Treating complex cases: The cognitive behavioural therapy approach. Chichester: Wiley.

Wells, A. (1997) Cognitive therapy of anxiety disorders. Chichester: Wiley.

Theory and treatment

Kern, I. (1986) Trinity: Theological reflections of a phenomenologist. In S.W. Laycock & J.G. Hart (Eds) Essays in phenomenological theology. (pp. 23-37). Albany: SUNY Press.

______ (1993) Our experience of the other. In R. Bernet, I. Kern & E. Marbach An introduction to Husserlian phenomenology. (pp. 154-165). Evanston: Northwestern University Press.

______ (1997) Intersubjectivity. In L. Embree, E.A. Behnke, D. Carr, C. Evans, J. Huertas-Jourdas, J.J. Kocklemans, W.R. McKenna, J.N. Mohanty, T.M. Seebohm & R.M. Zaner (Eds) Encyclopaedia of phenomenology. (Trans W.R. McKenna). (pp. 355-359). Dordrecht: Kluwer.

Kern, I. & Marbach, E. (2001) Understanding the representational mind: A pre-requisite for intersubjectivity proper. Journal of Consciousness Studies, 8, 69-82.

Marbach, E. (1982) Two directions in epistemology: Husserl and Piaget. Revue Internationale de Philosophie, 36, 435-469.

___________ (1984) On using intentionality in empirical phenomenology: The problem of ‘mental images’. Dialectica, 38, 209-229.

___________ (1988) How to study consciousness phenomenologically or quite a lot comes to mind. Journal of the British Society for Phenomenology, 19, 252-268.

___________ (1992) What does noematic intentionality tell us about the ontological status of the noema? In J.J. Drummond & L. Embree (Eds) The phenomenology of the noema. (pp. 137-155). Dordrecht: Kluwer Academic.

___________ (1993) Mental representation and consciousness: Towards a phenomenological theory of representation and reference. Norwell: Kluwer Academic.

___________ (1996) Understanding the representational mind: A phenomenological perspective. Human Studies, 19, 137-152.

___________ (2000) The place for an ego in current research. In D. Zahavi (Ed) Exploring the self: Philosophical and psychopathological perspectives on self-experience. (pp. 75-94). Amsterdam: John Benjamins.

McCluskey, U. (2005) To be met as a person: The dynamics of attachment in professional encounters. London: Karnac.

Owen, I.R. (2006) Psychotherapy and phenomenology: On Freud, Husserl and Heidegger. Lincoln: iUniverse.

_________ (2007) On justifying psychotherapy: Essays on phenomenology, integration and psychology. Lincoln: iUniverse.

_________ (2007) Understanding the ubiquity of the intentionality of consciousness in commonsense and psychotherapy. Indo-Pacific Journal of Phenomenology, 7.1. www.ipjp.org/May2007/Ian_Owen_7e1.doc

_________ (2009) Talk, action and belief: How the intentionality combines attachment-oriented psychodynamic therapy and cognitive behavioural therapy. Bloomington: iUniverse.

Perner, J. (1991) Understanding the representational mind. Massachusetts: MIT Press.

Premack, D. & Woodruff, G. (1978) Does the chimpanzee have a theory of mind? Behavioral and Brain Sciences, 1, 515-526.

Pylyshyn, Z.W. (1978) When is attribution of beliefs justified? Behavioral and Brain Sciences, 1, 592-593.