Asking the right questions: Developing a patient-reported outcome measure (PROM) specific to group analytic psychotherapy

Abstract

The following article describes the background to and rationale for, developing a pilot-patient-reported outcome measure (PROM/questionnaire) designed to capture the therapeutic outcomes of group analysis as existing PROMS do not typically sufficiently capture this or use multiple measures. While group analysis has often demonstrated successful treatment of its members (Lorentzen, 2022), there is insufficient research to make it recognized by NICE guidance (Blackmore et al., 2012). This means it is not uniformly available across NHS Trusts, which is pertinent at an organizational level, because one of the six key trauma informed principles, is client ‘choice’ and those who benefit from group analysis are typically presenting with complex trauma/personality disorder (Lorentzen et al., 2015; SAMHSA, 2014).

This article highlights that, if there was an appropriate bespoke PROM for group analysis to be widely used across NHS psychotherapy departments, a growing body of empirical evidence could, long-term, facilitate a wider availability of group analysis. It will summarise the work of others, who have demonstrated why, in terms of human development, group analysis works and crucially, how it works. This article will also include an exploration as to why group analysis, along with other psychoanalytic psychotherapies, has been reticent in engaging with the provision of objective evidence that it is an effective treatment (Nitsun, 1991, 1996, 2018).

Keywords

research PROM evidence-base NICE measurement

Background

The initial research project, Phase One, entitled ‘Measuring meaningful markers of change’ (Stocks, et al., 2020), aimed to discover if there were specific factors in group analysis which led to desired therapeutic change and if so, what were they and could they be measured using a standardized PROM.

Phase One was achieved by establishing two focus groups, comprised, respectively of four group analytic psychotherapists and four group analytic clients. These groups were asked about elements of recovery that they felt were specific to group analysis. Thematic analysis as explained by (Braun and Clarke, 2006) was utilized to explore their viewpoints.

Overarching themes emerged that could inform the development of a group analytic specific, pilot-PROM which was then critiqued by peers in the original focus groups and in the Institute of Group Analysis (IGA). This was then refined into its final form, which was the pilot ‘ASK PROM’, comprised of 20 questions with each question having a comments box available. From these groups, three overarching themes emerged: (i) Improvement in internal and external relationships; (ii) quality of life improvements and (iii) improvement in functioning and their presenting issues (Stocks, et al., 2020). The pilot-PROM is in the process of requesting further research for validation purposes and is, therefore, not included in the article.

The aim of Phase Two would be to validate the pilot-PROM from Phase One. This research would require the involvement of selected mental health trusts who provide group analysis. Once contacted and if willing to participate, they would be sent specifically designed ‘service opt-in forms’ which explain what involvement entails and asks if they wish to participate (BPS, 2021).

The psychotherapy services involved would send invitations to group analytic clients and former clients to ask if they would like to take part in this pilot-PROM, making it clear that participation/non-participation would not have an impact on their current or future care and that they would be free to withdraw at any time (BPS, 2021). The validation of the ASK pilot-PROM would be achieved by asking a minimum of 100 clients who have experienced/are experiencing group analysis to complete this in alignment with research requirements (Linacre, 2002; Mertler, at al., 2021). Over a designated time, they would complete the ASK pilot-PROM twice for reliability purposes as well as simultaneously completing the existing CORE-OM and WEMWBS PROMs for convergent validity (Evans et al., 2002; Mertler et al., 2021; Tennant et al., 2007). A sample question on a Likert 0-4 scale from the ASK pilot-PROM is ‘I am able to learn from relationships that are personal to me e.g. with colleagues, friends and family and apply this knowledge to other relationships’.

This project continually seeks the views of clients, carers and staff to feed into developing this research with many NHS group analysts across the UK communicating that they would like to partake. Some staff have also been involved in ongoing quarterly practice research networks.

Introduction

If the fundamental question posed in this article is, ‘can we devise a pilot-PROM which is specific to group analysis’, then this question, following Garland (1982, 2018) might be described as the subordinate question, which here means that it is secondary to other, superordinate, questions.

So, our question is subordinate to other questions, which, in order to make sense of our main question, have to be addressed first.

With this principle in mind, we started with five basic, superordinate, questions, which will be addressed over the course of this article:

1. Is group analysis an effective psychological treatment for the client group that it aims to help?

2. Which client group does it try to treat and how does it effectively treat them?

3. Is it possible to accurately measure the efficacy of group analytic psychotherapy?

4. Why has there been no established measuring tool (PROM) with which to accurately capture this?

5. Does the ASK pilot- PROM successfully address this assumed shortfall?

Is group analysis an effective psychological treatment for the client group that aims to help?

Group analysis has been found to be effective in improving psychological functioning for multiple presenting issues such as eating disorders (Ciano et al., 2002; Trombetta et al., 2024), personality disorders/complex trauma (Lorentzen et al., 2015; Lorentzen, 2022), Post-Traumatic Stress Disorder (Tucker and Price, 2007) and complex grief (Kipnes et al., 2002). At present these outcomes have not been captured consistently with an agreed process and this probably contributes to group analysis not being a National Institute of Health and Care Excellence (NICE) approved therapy (Blackmore et al., 2012).

The relatively limited number of efficacy studies conducted so far, suggest that people who have successfully completed group analysis are subsequently less reliant on other mental health and GP Services as well as having sustained improvements in their functioning and presenting issues (Heinzel, et al., 2000; Conway et al., 2003; Lorentzen et al., 2015; Mendelssohn, 2015). In some cases, this was superior to the improvement in those who had received medication only (Knijnik et al., 2009).

Lorentzen et al. (2015) also found that, for those without personality disorder, short-term group analysis was more efficacious for sustained improvements in symptomology and functioning, whereas those with personality disorder continued to improve in long-term therapy. Heinzel, et al. (2000) invited 979 participants to rate their improvements on a Likert scale as well as being asked to comment on their physical health, mental health, work attendance, visits to hospital and social functioning at the beginning, middle and post receiving group analysis or individual therapy. They found that all individuals had significantly improved in all areas and maintained these improvements over two years, particularly from those receiving group analysis.

Lorentzen, (2013) argues that, despite the extensive interest in research, group analysis-focused studies typically used qualitative methods but without following up with quantitative measures or used quantitative measures to capture recovery markers but used unsuitable and/or multiple PROMs.

There is a plethora of measures which have been used to explore group analysis:

- Change in symptoms in specific diagnoses (Shulman and Ben-Artzi, 2003).

- Internal changes such as confidence/autonomy (Barkham et al., 2006).

- Psychosocial functioning (Cooper et al., 1982).

- Process issues (Piper, et al., 2001; Burlingame et al., 2018).

Studies have, typically, used at least two or more PROMs simultaneously, yet still have not captured all the multi-layered, long-term recovery outcomes from group analysis (Blackmore et al., 2012).

Furthermore, simultaneously administering too many PROMs can be fatiguing for both clients and practitioners (Sales and Alves, 2016). Because of this model’s specific focus on underlying change rather than surface change (Hagtvet and Heglend, 2008), it seems that, accurately capturing key markers of change in group analysis and measuring its efficacy through existing PROMs, inevitably poses significant challenges.

Group analysis also has characteristics to consider, such as its group format, integrative nature and heterogeneous clinical application (Lorentzen, 2013; Billow, 2017), which can make it difficult to capture the broad range of areas in which clients may demonstrate improvement (Blackmore et al., 2012; Schlapobersky, 2016).

The lack of a PROM that clearly captures markers of therapeutic change in group analysis, has contributed to a dearth of available efficacy studies (Blackmore et al., 2012; Schlapobersky, 2016; Stocks, et al., 2020; Lorentzen, 2022). Berghout et al., (2012) suggest further examination of interpersonal functioning because this is generally slower to change than symptomology. Additionally, Von Fraunhofer (2008) argues that we need to look at recovery/therapeutic change indicators, such as individuals in the long-term, maturing and becoming more self-sufficient.

Considering the estimated cost-effectiveness of group analysis (Lorentzen, 2006; Horneland et al., 2012; Schlapobersky, 2016; Lorentzen, 2022) and its potential therapeutic benefits, there is a strong case for the development of a stronger evidence-base for group analysis which could support potential inclusion into NICE guidelines. This might be considered as being essential to secure the group analytic model’s long-term and widespread sustainability, again, enhancing client choice. Thus, our first question, ‘Is group analysis an effective psychotherapeutic treatment for the client group that it aims to help?’, the above evidence suggests that this is the case. However, this has not been captured effectively for reasons including methodological research flaws, small samples sizes, qualitative-only research, process-only measures, and conceptual difficulties in capturing recovery outcomes in existing PROMs (Stocks, et al., 2020).

This highlights the necessity of developing a suitable PROM that is acceptable to clients, therapists, and commissioners (Rao, et al., 2010; Blackmore et al., 2012). To facilitate this, a more in-depth understanding of how individuals improve in group analysis is required.

Which client group does it try to treat and how does it effectively treat them?

Which client group does it try to treat?

The clients being assessed have long-term, complex presentations, understood by both therapist and client, to be rooted in early childhood experiences and which involve complex relationships within the self and with others, such as, family, work and the wider social world.

- This will typically involve negative views about oneself, such as ‘I am hopeless, unlikable’, along with low self-esteem and an insecure sense of ‘a self-within-boundaries’. Again, this will involve a repeated pattern of interpersonal relationships, which may include relationships ending prematurely and/or badly, often with the individual being left with feelings of anger plus remorse and this happens repeatedly, in what Roberts and Pines (1992: 475) called a process of, ‘being bogged down by a self-defeating preoccupation with neurotic misery’.

- The individual will be ‘psychologically minded’, meaning that the individual experiences themselves, at least partly, as having their own agency and that they are not as they are, simply because of ‘nature’ or other, outside, forces. They are the centre of their own lives and can sometimes with support, influence these.

- The clients being assessed have had experience of other, often short-term, symptom-based types of therapy, spanning approximately six to 24 weeks usually including Cognitive-Behavioural Therapies (CBT) and report these have not fundamentally helped. This repeated process of assessment and at times unsuccessful treatment, can itself be retraumatizing, which apart from anything else, goes against the principles of trauma informed care (SAMHSA, 2014).

- In respect of demographics, analytic groups are, in their nature, ‘heterogenous’ and encompass all ages, genders, ethnicities etc, with wider demographics giving wider perspectives which, again, is a vital consideration for trauma informed approaches (SAMHSA, 2014).

How does it effectively treat them?

It is beyond the scope of this paper to cover all theories as to how group analysis effects therapeutic change, so, this article concentrates on key pioneering clinicians and theorists who have made significant contributions to this fundamental issue.

These include Leal, Garland, Roberts and Pines, Yalom and Leszcz each of whom have researched and studied this field in different but complementary, ways.

Leal (1983) argues that group analysis ‘works’ because it is grounded in a scientific method which reactivates normal developmental dynamics which are present in all humans in the very first months of life. She then explores and describes how, in human neonates, the attachment process described by Bowlby (1982), occurs at a relatively late stage of emotional development, essentially, the last quarter of the first year of life. However, before that process (attachment) can begin, in the first three to nine months of life, a baby is already hard-wired to seek its affirmation of self and other, through an innate, developmental process, which is called the search for response.

The assertion is, that it is this primary search for response which is reactivated within the now-you-now-me interactions, called in group analysis, free floating discussion (the group equivalent of free-association) which, in turn, takes place within the specifically group analytic, frame. Within this robust and constant frame, the group member has another chance to develop a different self from that which emerged from their original primary group. This represents the healing process which, when exported to the wider world, allows the group-member to live their lives relatively free of the trauma of their original upbringing.

Garland (1982, 2018) explores and explains how being a member of a long-term, group analytic group, induces therapeutic change.

As suggested earlier, the analytic group, being a stranger group, meeting weekly within the (group) analytic frame, establishes a novel and unique, group-setting which members can, uninfluenced directly by other groups, past or current, have the possibility of developing a new relationship with the self and with others.

It describes how, when an individual joins a group analytic group, they are bound to take up a position where they are the nodal point of the pathological system in which the social functions which are essential to his existence, always converge (Garland, 1982, 2018). This is because this is who they are and so, this is how they always present themselves, in every social grouping which they enter and remain for an appreciable period.

In almost all other examples of groups (or systems), for example, social or the workplace this underlying process will be variously masked by the distraction of actions/roles and social conventions, in which absolute honesty is rare and indeed, undesired.

The problem and the non-problem

In a therapy group the opposite of this is true and this is so, because of the constraints of the analytic frame where members, individually and collectively, can gravitate from what Garland describes as the ‘problem’ to the ‘non-problem.’

In order to join a therapy group, all members must, at some point, describe a presenting problem, which they have defined for themselves, with relatives, friends and eventually with the clinicians and services with whom they have interacted earlier, the problem(s) which have led them to this point. This might be recurrent depression, struggling with obsessional traits and/or relationship difficulties and which can be named and described. The new member will expect to describe this problem and often the current group members will also expect this. They may be glad to describe this problem but, if silent, the group will ask ‘why are you here’ and Garland says that this confessional is, in effect, the new members ‘entrée’ to the group (1982, 2018)

Over time, constant repetition of this ‘problem’ becomes tiresome to the member and other group members and this rendition slowly elides into a more passionate discussion and involvement with the shifting roles, relationships and behavioural communications that make up the system of the group. Thus, the group too can elide into what Garland dubs the ‘non-problem’. Overall, whatever goes wrong out there (and back then) in life will go wrong in the therapy group but unlike out there, in an analytic therapy group, this can be explored, understood and in time, worked-through.

Garland elaborates upon the change-producing or transformative properties of the group analysis experience and says that the component parts of this, begin with the creation of an analytic group, which forms a system that is other than the ones from which the individual originated. This new system (or group) is now a powerful simulative system and so a form of play, within which members understand that is both serious and yet not reality.

Within this system, members can move forwards from discussing ‘the problem,’ which belongs out there and back then, to the ‘non-problem’ which exists, instead, in the here and now and where real change is possible.

This is the foundation stone upon which change in the individual is constructed (Garland, 1982).

Yalom and Leszcz (2020) describe what they refer to as, the eleven therapeutic factors in group therapy and we will emphasize factor number five in Chapter One, ‘The Corrective Recapitulation of the Primary Family Group’ (Yalom and Leszcz, 2020: 15). This describes how a group member, before entering the group, has established a pattern of relating to himself and to others, in a stuck, destructive endlessly repeated way, referred to in psychoanalytic psychotherapy, as repetition compulsion. Repetition compulsion being the unconscious tendency of an individual to repeat a traumatic event or its circumstances, placing themselves in a position where they may at last master it. This could take the form of, symbolically or literally, re-enacting the event or putting oneself in situations where the event is likely to recur (Freud, 1920; Akhtar, 2009).

Yalom and Leszcz outline how most clients entering groups have a background of highly unsatisfactory experiences in their first and most important group, the primary family.

They emphasize that the therapy group resembles a family in many aspects, including potential authority/parental figures/peers/sibling figures and says inevitably, the member will interact with group leaders and other members in modes reminiscent of the way they once interacted with parents and siblings. They agree that similar phenomena occur in individual therapy, but the group provides a greater number and variety of recapitulative possibilities.

Importantly, it is not only that early familial conflicts are relived but relived correctively. Re-exposure without repair only worsens the situation. The crucial, transformative experience is to be a member of a new, distinct, long-term, family-sized therapy group, with a conductor and which meets within an analytic-frame and uses the medium of free-floating discussion.

This describes, exactly, the group analytic group, as it enables the process of working through, which involves the group-member repeatedly experiencing the group as they did their family of origin (and all other groups since) but repeatedly discovering overtly (through interpretation) and covertly (through experience and re-experience) that this is not the case in the therapy group. Thus, they can slowly let go of this compulsion to keep repeating the past in the present.

Roberts and Pines (1992), describe the same process in a slightly different but complementary way. They assert that disturbed communication arising from any one person in the group puts the group member into a focal position (as opposed to nodal) and this locates ‘the disturbance’ in the group. In turn, Foulkes (1975) asserted that emotional disturbance arose from incompatibility in the root network of family and that these incompatibilities would be revealed and repeated in the communicative network of the group. Crucially they could then be clarified and worked on with the aim of restoring to the person and to the whole group, a capacity for functional adaptation. Much earlier, Foulkes (1975: 3) had called this therapeutic process, ‘ego training in action’.

Summary

The above authors have found both original yet complementary ways of addressing our question, ‘How does group analysis therapeutically treat the patients/group members?’ A fundamental, group analytic understanding is that peoples’ relationships with themselves (internal) and their relationships with others/the world (external), are laid down in early life and are subsequently determined to be repeatedly and cyclically re-enacted, in all relationships. If this is a benign process there is no problem but if these patterns are damaging, then there clearly is and that is what, at heart, brings people into long-term group analysis.

These patterns, which are, by early adulthood, now part of the ‘warp and weft’ of one’s whole being, cannot typically be addressed by short-term (24 sessions or fewer) essentially conscious models of therapy, which address behaviours and thought process such as CBT.

Instead, these intra and inter-relational difficulties can only be changed via the psychoanalytic concept of working-through and in group analytic groups, this change is affected by the deliberate stimulation at any age of the search for response reaction as seen in early childhood (Leal, 1983) and this will act as an agent for personality growth and emotional development.

An analytic group, operating as it does within the specific group analytic frame, will impel members to slowly stop talking about external problems, the problem and instead, face and work-through the real-life problems of relating within the group analytic setting, described by Garland (1982, 2018), as the ‘non-problem’.

This is also described as being a process of corrective recapitulation of the primary family group and so developing a more secure sense of self within the group analytic frame (Yalom and Leszcz, 2020). In terms of this article, we are bound then to ask: ‘How is this complex matrix of intra and inter-personal relationships to be captured with a PROM which has not been specifically designed for that purpose?’

Is it possible to accurately measure the efficacy of treatment by group analytic therapy?

Garland’s paper, Taking the non-problem seriously begins by likening the then (1982) situation of group analysis, to that of early 19th-century scientists, who, while being certain that evolution was a scientific fact, had not yet been able to establish the certainty granted by verifiable, scientific research and data. They knew that, to be taken seriously, they would have to find a causal mechanism for evolution, and she argued that that is true, too, for group analysis else we, like them, cannot be taken seriously by fellow professionals or the general public.

Garland was addressing the questions of ‘how’ group analysis effects change, while this section of this article is addressing the question, how can we provide scientific evidence that it ‘does’ effect therapeutic change. The principle remains the same; if we cannot evidence that group analysis does effect therapeutic change, then it risks being exactly as Garland says, no more than an act of faith (1982).

However, being mindful of the above, it is one premise of this article, that Phase One of the ASK Research Project (above) has demonstrated that, when the experiences of clients and clinicians are explored, they can be delineated and itemised in such a way that they can, measure the efficacy of group analysis gaining quantitative and qualitative views. In Phase One, this was achieved by identifying particularly relational areas of recovery specific to group analysis, with the aim of facilitating the development of a suitable pilot-PROM for this therapeutic modality (Stocks, et al., 2020).

Why, with so many psychoanalytic psychotherapy services facing potential cuts and even, effective closure, is it not easily accepted that there is a need to bring a clinically demonstrated response, which matches the numerous other researched analyses, such as CBT?

While there can be no definitive answer to this question, it may be that one explanation lies in the very substance (both overt and more covert) of psychoanalytic psychotherapy, which, in its underlying model, can be said to be intrinsically, exploratory and not explanatory. If, this is accepted as being valid, then it follows that that this underlying reality will be reflected in all its aspects, ranging through from theory and into practice.

We raise the idea that, as in all areas of human thought and activity, people are drawn to work with this model because of their own innately high valency for its attributes and qualities and so are naturally predisposed and inclined, to perpetuate and emphasize this dynamic. To be more specific, part of the ‘substance’ of this model may be, for example, not answering, arguably appropriate questions and so purposely allowing, a more ‘curious’ stance and hence more nuanced and indirect, responses.

One might paraphrase this mindset thus: ‘If a client, referral, colleague, student asks me for evidence that this model is effective, then this is not a matter for direct response but rather, it is a communication that needs interpreting’. Overall, the question asked is regarded as a manifestation of underlying processes.

So, there might be a deep-seated and overriding basic assumption in psychoanalytic psychotherapy, that any ‘activity’, such as measuring clients’ responses to therapy, for example via a PROM, gets in the way of the therapeutic relationship and hence the therapy itself (Dalal, 2017).

In theory such PROMs could be delivered by third parties such as admin. However, a significant number of clinicians may still feel that this sullies and distorts the purity of an analytic relationship. To pursue this theory to its logical conclusion, it may be that the sheer historical and intellectual weight of this powerful and sometimes intimidating psychoanalytic model, suffuses into the very fabric of psychoanalytic theory and practice, with a resultant emphasis on interpretation rather than explanation.

Where might group analysis fit into this pattern?

Group analysis was introduced by Foulkes and others in the early 1950s and so this development was, pretty much contemporaneous with the founding of the NHS and the two have been linked ever since, albeit now in a ‘post-code-lottery’ manner with some services closing.

Since that time, a plethora of PROMs have been devised, all aiming to provide evidence of the efficacy of various types of psychotherapeutic treatments. Some of these have come and gone but others have become established to the point of being ubiquitous and are familiar to most clinicians and importantly, to service leads.

Therefore, why, within the field of psychoanalytic psychotherapy, has no group analytic PROM been devised and accepted?

The conscious/practical difficulties of measuring change in a group analytic model

Friedman described that a further challenge is that some concepts are not as easy to conceptualize (Friedman, 2013). Group analytic groups also have heterogenous clinical presentations (Billow, 2017), making it likely that the very complicated and nuanced changes which group analysis aims to effect, have in the past inhibited the creation of a group specific PROM. Nonetheless, there are emerging advances in confirming there is evidence for capturing recovery nuances/outcomes in analytic therapies (Shedler, 2022).

Less conscious mechanisms affecting the creation of a group-specific PROM

Over recent years, one of the most influential concepts in group analysis has been that of the ‘anti-group’, conceptualized, by Nitsun (1991, 2018) who described this as a both conscious and unconscious process which will manifest in groups in different guises but always threatening the integrity of the group and its therapeutic development.

It could be argued that group analysts cannot, by definition, be part of the anti-group, after all, they spend half their time trying to prevent this dynamic from undermining group-therapy. However, Foulkes (1975) memorably described group analysis as ‘the analysis of the group by the group, including the conductor’ and this, surely, suggests, explicitly, that the group analyst, too, cannot be completely aloof from the destructive as well as the creative, ebbs and flows of the therapy group. Overall, group analysts are not always above the fray (and it is good that they are not) but instead, periodically immersed in it and then able to withdraw and observe it. However, there is always the reality that the anti-group, ‘fear of the group,’ will be a human default-position from which group analysts are not always immune.

Still, however one thinks and theorizes about any perceived reluctance of psychoanalytic psychotherapies, of which group analysis is one of the most long-established and consistent in its model and application, it remains a fact, that it is not recommended by NICE guidelines, while other models of psychotherapeutic interventions, are. It seems inescapable that, if group analysis is to be more widely and evenly available across the NHS, its recommendation by NICE will be an essential part of that process and that developing an established and validated PROM which is group-specific, will be an equally essential part of that development.

Does then the ASK PROM successfully address this assumed shortfall?

To date and being mindful that the intention will be to validate this in Phase Two, the evidence suggests that the ASK pilot-PROM does measure the outcomes arising from Phase One. Given that the ASK pilot-PROM would be the only group-specific outcome measure, it is essential that it is fully validated and then accepted by the psychotherapeutic community. If this is the outcome of Phase Two, then group analysis as a treatment could be supported in becoming more widely available in the NHS and beyond supporting its long-term future.

Conclusion

This article set out to establish as to whether it was desirable and possible, to devise a pilot-PROM which accurately measures the efficacy of group analysis. This was examined by establishing which clients and with which difficulties, it is trying to treat and how it is agreed that this treatment effects therapeutic change. It also explores why a specific PROM for group analysis has not been developed.

In terms of the desirability of developing and establishing as the accepted standard, a group analytic specific PROM, it seems that the argument for this is persuasive. If group analysis is ever to be recommended by NICE guidelines, then research evidence that it is efficacious is essential and an agreed PROM would be a huge step in that direction. At a practical level, this has always posed greater problems than that faced by more symptom-targeted therapies, but it may be, too, that there is a more unconscious, perhaps at times pre-conscious, reluctance to ‘sully’ our work with statistics and questionnaires.

If over past years, for whichever reasons, group analysis has been reluctant to grapple with this dynamic, then it may just be that then ‘was not the right time’ but perhaps now ‘is the right time’ and it has been the intention of this article to propose this.

Footnotes

ORCID iD

Helen Chadwick

Anthony Ashton qualified as a group analyst in 2003 and has worked in that capacity in the NHS since then, partly in West Yorkshire and partly in a mental health trust in the North East of England where he continues to work as a practising group analyst. Address: Psychoanalytic Psychotherapies Service, Wessex, House, Stockton, TS18 3TS, UK. Email: tonyashton@nhs.net

Dr Helen Chadwick has worked in the NHS since 2009 in various primary and secondary mental health settings. She currently works as the Principal and Lead Counselling Psychologist on the Trauma Informed Pathway (TIPD) for those presenting with difficulties aligned with personality disorder in South West Yorkshire Partnership Foundation Trust. Helen has an interest in patient-reported outcome measures (PROMs), particularly for therapies with a psychoanalytic component. Address: Trauma Informed Personality Disorder (TIPD) Pathway, Kirklees and Calderdale, Ravensleigh Resource Unit, 28 Oxford Road, Dewsbury, WF13 4LL, UK. Email: helen.chadwick@swyt.nhs.uk

Eleftheria Panteliou is a psychodynamic psychotherapist. She is interested in contributing to the existing paradigm of understanding outcomes in psychodynamic and psychoanalytically based psychotherapies. Address: Upper East Wilmslow Road, Manchester, M20 5WD, UK. Email: Ellie.Panteliou@gmmh.nhs.uk

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