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A case study exploration into the lived experience of a client receiving a positive missing experience… Westwood, Dianne 2007

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A CASE STUDY EXPLORATION INTO THE LIVED EXPERIENCE OF A CLIENT RECEIVING A POSITIVE MISSING EXPERIENCE IN A THERAPEUTIC SESSION by DIANNE WESTWOOD B.N. , McGil l University, 1974 M.Ed., McGil l University, 1979 A THESIS SUBMITTED IN PARTIAL F U L F I L M E N T OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE F A C U L T Y OF G R A D U A T E STUDIES (Counselling Psychology) THE UNIVERSITY OF BRITISH C O L U M B I A May 2007 © Dianne Westwood, 2007 ABSTRACT This study explored the meaning of receiving a positive missing experience during therapy, from the perspective of a client. It was undertaken to expand the theoretical understanding and practice of the intervention. A single case study, with a hermeneutic approach to data analysis was used. A semi-structured interview was conducted with one participant who had received a positive missing experience during a Therapeutic Enactment, (Westwood & Wilensky, 2005), and who had a videotape of the session. The phenomenon of the positive missing experience itself is only one part of the participant's complex, experiential therapeutic session; a session which was enacted within a group. The interview was analyzed using van Manen's (1990) "Methodological Structure of Human Science," creating seven themes that represent the client's experience. A schematic, containing the themes and their relationship to each other, was developed. The themes within the schematic are: longing/receiving, things start moving, alchemy of repair, embodied sense of an intact core, vantage point, things start falling into place, and insight comes. The schematic suggests a flow of experience as well as progression and a sequence over time. While each theme is presented as an important or essential feature of the experience, they could not be easily separated from one another. Each theme arose as distinct from the others. ii T A B L E O F C O N T E N T S Abstract ii Table of Contents i i i List of Figures v Acknowledgements vi CHAPTER 1 Coming to the Question Introduction 1 Coming to the Question 2 Purpose of the Study 3 The Research Problem 4 Study Rationale 5 Research Question 7 CHAPTER 2 Review of the L i terature Introduction 8 Defining Missing Emotional Experience 8 Causes of Missing Emotional Experience 9 Providing a Positive Missing Experience 12 Hakomi Assisted Self-Discovery Psychotherapy 14 Therapeutic Enactment 17 The Role of Emotion in Psychotherapy 21 The Role of Positive Emotion in Psychotherapy 28 Attachment Theory 32 Client Perspectives 35 Summary 43 CHAPTER 3 Researching L i ved Experience Introduction 45 Research Paradigm and Method 45 Researcher Subjectivity 48 Procedures 50 Ethical Considerations 51 Selection of the Participant 51 Data Collection and Interview Protocol 53 Recording and Transcription 54 Data Analysis 55 Member Checks 56 Representation of Findings 56 Criteria for Worth of the Study 57 Summary 59 ii i CHAPTER 4 Metaphors of the Positive M iss ing Exper ience Introduction 60 Brian 61 Themes of the Positive Missing Experience 69 Theme One: Longing/Receiving 71 Theme Two: Things Start Moving 76 Theme Three: Alchemy of Repair 80 Theme Four: Embodied Sense of an Intact Core 84 Theme Five: Vantage Point 87 Theme Six: Things Start Falling into Place 89 Theme Seven: Insight Comes 92 Some Additional Thoughts 94 Summary 95 CHAPTER 5 Discussion Introduction 96 Implications for Theory 96 Implications for Practice 100 Implications for Research and Future Steps 102 Limitations of the Study 103 Conclusion 105 REFERENCES 106 APPENDIX A: Recruitment Letter 115 APPENDIX B: Telephone Selection Interview Script 116 APPENDIX C: Questions for Reflection Prior to First Interview 117 APPENDIX D: Consent Form 118 APPENDIX E: Interview Guide 121 APPENDIX F: Certificate of Approval, BREB, U B C 122 i v L I S T O F F I G U R E S Figure 2.1 17 Figure 4.1 70 v A C K N O W L E D G E M E N T S I would like to thank the people who contributed to this study. To Brian Thank you for your generosity, candor, wonderful presence, evocative metaphors, and for sharing your session with me. To family and friends Thank you for patiently and lovingly ushering me through. To Maria Buchanan, Norm Amundson, and Bi l l Borgen Thank you for your unwavering encouragement, support and trust. vi C H A P T E R 1 Give your weakness To one who helps ... God created the child, that is your wanting, So that it might cry out, so that milk might come. ... Cry out! Don't be stolid and silent with your pain. Lament! And let the milk of loving flow into you. (Rumi, in Barks, 1997, p. 157) Introduction A major goal of emotion-focused therapy is for clients, within a safe and supportive relationship, to be able "to return to past distressing, traumatic and/or unresolved events and to repair negative, traumatic influence resulting from the event through a corrective emotional experience. This allows the client to re-experience past problems in new and more benign ways. Franz Alexander (1946/1980) recognized that unresolved or unsettled conflict was often tied to strong (negative) emotion. Rather than be overwhelmed, the client would be able to process the strong negative emotion and remain in relationship with a subsequent return to spontaneity and a sense of agency (Fosha, 2006; Greenberg, 2002). As infants and young children, when we are faced with painful or overwhelming circumstances we are naturally anticipating a nurturing and supportive social network to comfort us in order to cope, understand and learn from experience (Lewis, Amini, & Lannon, 2001). When this support is not provided the child adapts by automatically responding in one of several ways: initiating or remaining in social engagement; initiating attachment behaviours such as crying or clinging; fleeing; fighting; collapsing or submitting (Levenson, 1999; Ogden, Minton, & Pain, 2006; Porges, 2004). Lack of comfort and support at these 1 times has the potential to produce containment (defense) rather than expression and it is this lack of support and comfort that is a basic missing experience (Kurtz, 2006). The habits of containment which develop as a result of missing experiences keep the original painful or traumatic material from being integrated and in and of themselves can create distress and negative symptomatology. Being able to receive what has been missing can have a powerful impact on a client for the better (Fosha, 2000a, 2000b; Schore, 2003). Coming to the Question My initial interest in this research arose from two impact/full personal events. The first occurred in a conversation with a friend who is a therapist with many years experience. I immediately resonated with his sense of "honor and gratitude for being a therapist" - "work", he said, that "calls forth the best in me" (personal communication, February, 2005). This is what I had felt was happening to me as I began to see clients. I was more and more aware of the privilege the work conferred, seeing and being self at best with relative strangers. He was in fact speaking about what van Manen (1990) calls a certain loving responsibility that emerges in the intimate encounters with our clients when they share their vulnerabilities with us. It is within this called forth goodness (van Manen, 1992) that we experience the uniqueness of the other and our own willingness to reach out, touch and be touched. The second event occurred two years ago while doing training in Hakomi Assisted Self-Discovery Psychotherapy (ASD). I was deeply touched when watching Ron Kurtz, the founder of ASD, work with a man in his forties. Following the processing of intense negative emotion by the client, and while the client was in a calm, receptive state of mind, Ron expressed compassion and great kindness in the form of a small teaching from older man to younger man. This act of kindness appeared to allow the client to savor his new realization 2 (from the emotional processing). From my observer's stance, the client seemed pleased. I wondered about what was happening, what was going on for the client. Was the client receiving something meaningful? Was he anchoring his new understanding? Was he being held longer in his integration of the new learning? Was he in some sense practicing letting in something previously unavailable to him - perhaps taking in nurturing that he could not previously do? Why was I so touched by such a simple act of kindness? Researchers in both psychotherapy and qualitative methodology suggest that scholarly rigor can and needs to dare to incorporate the tender, the subtle, the soul/full, and the sensitive into its attempts to understand human experience (Fosha, 2004; van Manen, 1990). Purpose of the Study In this study I explored the meaning of receiving a positive missing experience during therapy, from the perspective of a client. It was undertaken to expand the theoretical understanding and practice of the intervention. A single case study, with a hermeneutic approach to data analysis was used. Because of the intimate and dyadic nature of psychotherapy processes, hermeneutic phenomenology, as a methodology, was a good fit. Phenomenology and hermeneutics are terms associated with human science or the study of persons and how human beings exist in the world. Max van Manen (1990) writes about phenomenology as an act of knowing about human existence through caring, and being deeply interested and appreciative of the mystery of human experience. He says that phenomenology begins and ends with lived experience and introduces the idea of borrowing the experience of others and their reflections on it to better understand an aspect of the life world. So it is with this study: beginning with my experience in Hakomi A S D and ending with the participant's experience of receiving a positive missing experience. 3 The Research Problem When I decided to look at experience as it is lived, I was immediately caught in the middle of two issues: the richness of the study and practicality, and how to balance them. This was particularly true because I was planning to explore a phenomenon, a positive missing experience, that is conceptually and experientially complex, and it had not been directly studied. In order to contain the scope of the study this meant attempting to clarify specific aspects of the phenomenon as I understood them, by reviewing the literature and selecting a site or context for study. In this study I attempted to fill gaps in the literature in three areas by providing a rich, thick description of one client's experience of a significant event in therapy, revisited five years after its occurrence. First, there is a large body of research devoted to studying therapeutic change processes and client perspectives, indicating the importance placed by the profession in client feedback and satisfaction. In fact many therapists seek client feedback regularly, as part of therapy itself and do so both informally and through brief post session questionnaires (Bohart & Tallman, 1999). Up to the last decade much of this research was quantitative. There is a wide range of research approaches to client experience in the literature including quantitative and qualitative approaches examining specific helpful or significant events within sessions, particular therapeutic sessions themselves, and whole courses of therapy. Whole treatment approaches have given us broad categories about helpful and hindering aspects of client experience (Bachelor & Salame, 2000; Elliott & James, 1989; Gershefski, Arnkoff, & Glass, 1996; Levy, Glass, Arnkoff & Gershefski, 1996; Lietaer & Neirinck, 1996) and suggest which factors are common across modalities, such as strong therapeutic alliance. More recently the interest in moment-to-moment processes has emerged, 4 as has examination of helpful episodes or events (Warwar & Greenberg, 2000). However, there is much less research containing qualitative in-depth client accounts about their experiences in therapy, especially at the event level. Second, Hakomi Assisted Self-Discovery Psychotherapy (ASD) (Kurtz, 1990, 2005, 2006), from which the construct of missing experience comes, has not been researched with respect to its processes and outcomes. They have to date relied on research from neuroscience, emotion theory, gestalt, body therapy traditions, and common factors (Hubble, Duncan, & Miller, 1999; Wampold, 2001) to inform their practice. Third, Therapeutic Enactment (TE) (Westwood, Keats, Wilensky, 2003; Westwood & Wilensky, 2005), also uses positive missing experience. However, they call it resourcing. There are a number of studies on TE (Baum, 1994; Buell, 1995, Brooks, 1998; Black, 2003) but none have examined the phenomenon of positive missing experience/resourcing within the method. Study Rationale There are several reasons for exploring the phenomenon of positive missing experience from the perspective of a client. First, according to Strong (2003) "hermeneutics sees human understanding and action as negotiated and coordinated between people in ways that cannot be pre-mapped" (p.270). He says that as the therapist and client proceed in counselling they inevitably stumble into an experience with ambiguous meaning. Knight (2005), reminds us of a "cardinal axiom of objects relations therapy is that experience in therapy is found by the patient rather than being provided by the therapist" (p.30). How many times has a therapist registered wonder when a client returned to a session quoting something she/he said that had an important impact and the therapist, in recollecting, had attached little importance to it? Understanding client perspectives about their therapy is important because clients and 5 therapists have different vantage points from which they view therapy, including different values and goals (Strupp & Hadley, 1977; Strupp, 1996). Having received training in A S D and participated in several TE groups, I have experienced first hand the processes and effectiveness of ASD, and I have witnessed the impact of ASD and TE on others. I have also heard testimony from many individuals who have participated in an enactment about its long-lasting, positive effects. ASD does not own positive missing experience. As previously mentioned, a very similar type of intervention, resourcing, is used in TE. The construct is not completely unique. It is a form of emotional support, and as such can be recognized in many therapy approaches and many other disciplines, such as nursing and teaching (Fosha, 2000a; Jones & Wirtz, 2006). Although a qualitative study of this type cannot be generalized, it may inform the understanding and practice of emotionally supportive processes both in psychotherapy and other contexts. This research study contains one client's perspectives of receiving a positive missing experience during a therapeutic session. It is an account of his reflections of this experience to date. I have tried to be true to his words in the hopes of capturing his interpretations and meanings. In this way I took up the challenge of the hermeneut and entered into the shared world of one person trying to understand the words of another. At best, of course, I have interpreted what he said through the lens of my own experiences and the theoretical lenses of Hakomi assisted self-discovery psychotherapy, therapeutic enactment and experiential processing, as I now understand them. 6 Research Question Based on the assumption that exploring the lived experience of receiving a positive missing experience would further the understanding of this phenomenon, the following research question was formulated: "What is the lived experience of a client receiving a positive missing experience during a therapeutic session?" In order to answer this question one man was interviewed and asked to describe his experience in detail. 7 C H A P T E R 2 Review of the L i terature Introduction Van Manen (1990) suggests that the literature review, as part of the research plan, is one way the researcher begins the discussion of themes that have emerged in the first stages of reflecting on the research question. The following summary of scholarly sources presents how selected theory and research relate to the lived experience of a client receiving essential affirmation (positive missing experience) in a therapeutic session. The areas of theory and research which will be discussed in this review of the literature are: the nature and cause of missing experience, Hakomi Assisted Self-Discovery Psychotherapy (ASD), Therapeutic Enactment (TE), attachment theory, the role of emotion in psychotherapy, the role of positive emotion in psychotherapy, and client perspectives. Defining Missing Emotional Experience According to Kurtz (1990), missing experience is that "experience which in the normal course of growth, should have happened, but didn't" (p.47). These missing experiences, he says, are often related to how we organize our experience of safety, intimacy/contact, comfort, belonging and control within relationship (Kurtz, 2006). Some common examples of missing experience and their antecedents are: believing it is necessary to put in effort for love and attention, having learned it was based on good behaviour or some other condition; being free to rely on others having been expected to do things independently at too young an age; being appreciated and validated not having had accomplishments valued or acknowledged; feeling safe and welcome having not been supported or comforted when hurt, or not being seen and understood. Patterns of these types of experiences within early family 8 relationships, as well as later critical incidents, may contribute to an individual's sense that deep down in the self something is missing or wrong. The significance of these missing experiences is that they tend to arise in our early relationships and are repeated. We respond to them as if they were true, and a whole cascade of patterned emotional, behavioral and relational responses arise to any instance in our environment that mimics aspects of the original experience(s) (Bowlby, 1988; Gerhardt, 2004; Kurtz, 1990). In short, we tend to organize our behavior around them and this is largely out of awareness. Causes of Missing Emotional Experience How is it that these experiences are missing? As human mammals we come into a social world highly dependent on our care-givers for support, nurturance, sustenance, encouragement and protection. The very fact of this great dependence implies a nurturing environment. When these confirming experiences do not happen they are registered as missing (Keller, 2004). The unique genetic make-up of each individual sets the stage for future development; however, this is by no means an automatic process. Individual development is influenced by multiple complex factors. Infants need to constantly adapt and adjust to their own internal chemical and social systems, and to those of the environment. Healthy growth and development is dependent on the infant learning to regulate her systems, and this is done largely through the social matrix of relationship with the primary caregiver(s) (Gerhardt, 2004; Karen, 1994; Schore, 2003; Siegel, 1999). Accurately attuned, available and responsive caregivers help the newborn maintain appropriate arousal levels of both physiological and emotional responses such that the infant begins to learn and anticipate that within her primary relationship(s) she will be nurtured, comforted, fed, supported and 9 protected. She learns to anticipate certain response patterns. In turn, the child responds in certain patterns, for example, lowered arousal in response to love and nourishment or increased arousal to unmet needs for protection and comfort. Siegel (1999) defines memory as "the way past events affect future function" (p. 24). In other words, our early learning experiences shape how we behave and this includes our emotions and relationships. In addition, repeated patterns of firing neural networks have the tendency to determine how the brain develops, increasing the likelihood that patterns of response will be repeated, and this will occur automatically and out of awareness (Siegel, 1999; Levenson, 1999; Lewis, Amini, & Lannon, 2000). So, when a child falls, feels pain, is frightened and sees a parent approaching she remembers to expect comfort and relief or she may become more distressed and anxious or perhaps even withdraw. Because the brain initiates the cascade of hormonal, sensorimotor and emotional responses to events and stimuli in the environment, a series of associated and learned behaviours begin to be patterned over time and the stimulus for them is stored in implicit memory (Siegel, 1999). When an infant or very young child is overwhelmed by strong emotion, especially terror, there is evidence that the immature brain cannot process such events and they are not stored in explicit memory. Rather, they are encoded implicitly (Siegel, 1999), which makes voluntary retrieval difficult. However, the influence of such events is not lost. A child who expects her mother to comfort her will initiate attachment behaviours such as moving towards her parent, crying, or perhaps holding out her arms. For a child who has learned that the parent is non responsive, avoidant or even dangerous other behaviours will be mobilized. These may be moving away or withdrawal (flight), struggle (fight) or in some cases becoming very still (submit/collapse) (Ogden, Minton, & Pain, 2006; Porges, 2004). Lack of 10 comfort and support at these times produces containment (defense) rather than expression and it is this lack of support and comfort that is a basic missing experience (Kurtz, 2006). There is considerable theoretical support and research evidence for the idea that patterns of relating and emotional arousal and regulation are set up early in life within relationship (Bowlby, 1998; Fonagy, 1996; Fonagy & Target, 1997; Schore, 2003; Siegel, 1999). Although these tendencies are amenable to influence it is also true that the more time we spend on a pathway or in a habitual and patterned way of responding, the more difficult it is to change (Bowlby, 1998; Levenson, 1999; Gerhardt, 2004). The unique ways in which individuals respond to missing experience is highly adaptive and protective (Kurtz, 2006; Porges, 2004). Mahoney (1991) states that "human self organizing processes of valence, identity, power and meaning are functionally structured so that the center of the living system., its core ordering processes, are given special protection against changing; that protection (defense) is most apparent when demands for change are extensive or urgent " (p. 268). As a consequence, patterns of containment set up early in life have a tendency to become ingrained into behaviour and character style, and to leave the individual "in a state of longing for parental approval, for social reinforcement, love and belonging, whilst having little confidence in being able to obtain these things" (Gerhardt, 2004, p. 115). For example, an adult who has had experiences of being disappointed or humiliated when reaching out for support may have developed a reluctance or fear of asking for help. When an event arises that mimics just enough of the situation in which the pattern or emotionally laden situation of original disappointment or humiliation occurred, his/her core organizing model is set in motion (often out of awareness) and she will resist asking for help that is available, pull away or defend against support when it is offered. He/she cannot catch up in time because this 11 working model operates automatically and largely out of awareness (Bargh & Chartrand, 1999) and "the individual has no awareness that he/she is doing anything to keep the experience from happening" (Kurtz, 2006, p. 62). Patterns of containment and defense developed early in the lifespan, although once adaptive, may prove limiting at different life stages when circumstances improve and when the very thing an individual desires is available or even offered. In fact the over reliance on strategies of protection may contribute to problems such as depression, relationship difficulties, chronic over self reliance or functioning, caretaking and hypervigilance, to name a few. Individuals develop variously and unevenly, as Ken Wilber says "I'm good at some things, not-so-good at others . . . " (Wilber, 2006). This uneven development will sometimes activate or create vulnerability and distress at different points in the lifespan when we are challenged, stressed, injured or shocked. Providing a Positive Missing Experience What is a positive missing experience? It is a deliberate and strategic offering of comfort or nurturance which was previously missing because it was not available or the person could not take it in and integrate it (Kurtz, 2006). In psychotherapy it is a specific interaction/intervention provided near the end of processing in a session and is a more concentrated form of affirmation and validation than would be normally be part of the therapist stance and attunement. There are many variations of what positive missing experience an individual seeking therapy might need and even wider possibilities of what the specific interaction would look, feel and sound like. These will depend on the type, intensity and circumstances of past events, and the beliefs (meaning making structures) about self, other and life that have emerged from them. Some examples of patterns of defense and their 12 associated positive missing experience might be: withdrawal and isolation met with welcome and pleasurable contact; dependence and clinging met with freely given attention and affection; over self-reliance met with support and freedom from challenge; over-functioning and over-focusing met with appreciation and freedom to relax and play; attention seeking or entertaining met with freely given love and attention; "bearing up" under pressure for others and being overly responsible met with encouragement for self expression and doing for the self (Kurtz, 1990). In ASD the positive missing experience is typically provided by the therapist in a dyadic single session, although in training groups other members may be selected to offer specific support, as happens in TE. The following example is from an A S D training group but illustrates how a missing experience can be provided by either a therapist or by a group member, i f available. The client, in this scenario, was in a regressed child-state re-experiencing how lost she felt as an eight-year-old girl at her father's funeral. The therapist asked her if anyone had talked to her about her Dad's death. When she said "no" he asked her if he could speak to her about the death. In a quiet voice and at an age appropriate level he explained that sometimes people die and we do not know why it happens (her father had been killed in a plane crash). This evoked deep grief and sobbing and she readily leaned into the therapist to be held. He continued to talk quietly to her, contacting her feelings, letting her know her reactions and feelings made sense and helping her put words to what she was experiencing. When her deep grief and confusion was expressed fully, and she was in a quiet and alert state, he looked out to the other group members, back to her and said: "I think some of these people might also want to say something to you," as they had been watching what was going on for her. Again, with her permission, the group members came to her one by one 13 speaking as one would speak to an eight-year-old girl at her father's funeral. After a few greetings she spontaneously stood up beside the therapist and signaled to the group she would like to hear from all of them. It was like a receiving line. Some hugged her when she gave signs she wanted it and some touched her shoulder or took her hand. In this example the positive missing experience was deliberate and strategic in terms of need, readiness, and timing and was carefully directed by the therapist. Hakomi Assisted Self-Discovery Psychotherapy Hakomi Assisted Self-Discovery Psychotherapy (ASD), first presented by Ron Kurtz in 1990 as the Hakomi Method, was one of the earliest body-centered approaches, recognizing embodied expression (non-verbal movements, gestures, voice expressions, physical structure) as a source of information and as a vehicle to unconscious core beliefs that shape the way we organize our experiences. The method is built on spiritual principles derived from eastern philosophy and incorporates an experimental mindset and process to engage the client in self-discovery. It has its origins in: Buddhism, psychotherapeutic technique, (living) systems theory, and more recently is informed by affective neuroscience. In Hakomi, we help our clients study how they create meaning and feeling out of events, that is, how they organize their experience (Kurtz, p. 11). ... That is, [we] assist our clients to study and discover the operations of their adaptive unconscious minds and [we help them] develop the specific daily practices that will change those operations and stabilize new ones (Kurtz, 2005, p.3). The procedure of the method as described by Kurtz (2005, 2006) in his most recent writing is based on the client being in a state of mindfulness and the therapist's use of interventions as experiments. "Mindfulness means paying attention in a particular way: on 14 purpose, in the present moment, and non-judgmentally" (Kabat-Zinn cited in Segal, Williams, & Teasdale, 2002, p. 40). Interventions are specifically chosen and designed to evoke reactions that will both help to bring unconscious material such as.encapsulated memories, unexpressed primary emotions and implicit beliefs about self and others, into awareness and be productive to work with. Interventions are used to help move the process forward faster than would following the client's story. There are six activities or tasks that are being performed by the therapist in each session and throughout therapy. According to Kurtz, these tasks are: 1) creating a positive emotional context and building a strong therapeutic relationship; 2) observing (client non-verbal behaviors, emotional state, while listening to the client's story), hypothesizing about core beliefs based on bodily expressions and what the client is saying, and identifying a related non-verbal indicator of the hypothesized unconscious model(s) that could be the basis for study by the therapist and client; 3) selecting and/or designing an intervention that will evoke the underlying belief structure as meaningful emotional experience; 4) shifting the client's attention to that indicator by explaining and inviting the client into the experiment. If the client is willing, assisting her/him into a state of mindfulness and doing the experiment; 5) working with the outcome of the experiment (the client's response, which may be emotions, memories or both) by either deepening the experience or eliciting the meaning of the experience (this may include reality testing), and finally, 6) offering the missing experience, nourishment blocked by the unhelpful implicit belief, and helping the client savor the nourishment. Although described as linear the steps do overlap and fold back on one another experientially. From a process point of view each session and the whole course of therapy can be seen as an inverted " U " comprised of five phases, illustrated by the schematic in Figure 2.1 (p. 15 17). Contacting marks the beginning of a session where the relationship and therapeutic bond are being formed and where the therapist and client are reconnecting to each other in subsequent sessions. It involves creating and maintaining contact as well as keeping track of the flow of experience in the session. Accessing refers to processes that "unlock the path to information not otherwise available" (Kurtz, 1990, p. 115), moving down to deeper levels of experience where unconscious beliefs, memories and unexpressed emotion reside. In ASD the client is in a state of mindfulness and is actively engaged with their present internal experience. This is not unlike Gendlin's felt sense (1996). The therapist uses specific interventions as experiments to evoke deeper experience. As experience deepens and the client reacts to the intervention processing begins and there is often a rapid transition from attending to self in the moment to the remembering and re-experiencing of past memories and to the expression of strong emotion previously defended against. It is not uncommon for the client during processing to regress into what appears to be a child state while she/he is re-connecting to painful past experiences and expressing strong emotion. Supporting and assisting the client to fully explore these memories and give full expression to emotions will result in the client being able to make sense or meaning from the experience. Support at this phase may involve listening, moving in closer to the client, talking to the client in an age appropriate way, encouraging the client to give words to the experience, complete actions or speak to someone from the past to say things that were left unsaid. It is towards the end of this phase and the beginning of the next when a missing experience is provided. This process will naturally finish and may be marked by a relaxation or a slowing or quieting of activity. Integrating involves savoring the nourishment, coming fully into the present, making connections, appreciating the previously encapsulated parts of the self or self experience and 16 beginning to think about where the new realizations and understandings fit in the larger frame of the person's life. Completing is bringing the session to a close. If the session has been intense and processing has been completed, then the session will end naturally. Otherwise, the therapist will need to discuss closure and assist the client to move from focused interaction to a more relaxed and natural conversational end, so that the client is prepared to go into the everyday world. F i g u r e 2.1 contacting accessing positive missing experience Model of a Therapeutic Process or Session (Adapted from Kurtz, 1990) Therapeutic Enactment Therapeutic Enactment (TE) as developed by Westwood and Wilensky (2005) is a therapeutic intervention which involves a therapist guiding a client through the re-enactment of a difficult or traumatic event within a structured group context. The process is very agentic and action based. The therapist and client carefully plan the re-enactment prior to the session to maximize the achievement of the client's goals and to ensure safety and a sense of personal control for the client. There are many reasons for re-enacting a difficult or traumatic experience and these are client specific. Sometimes the event chosen will be a single defining 17 completing integrating processing occurrence that impacted the client in a very specific way such as an assault or the death of a significant attachment figure, while other clients will choose one or two scenes which represent a pattern or dynamic in a relationship which was harmful. Common client goals for re-enactment are: restoring relationship, releasing unexpressed grief, repairing trauma, expressing hidden and unexpressed emotion(s) such as rage or shame, having the experience of receiving longed for validation or affirmation which was unavailable or withheld, in order to restore a stronger sense of self. TE is a complex, multimodal approach which has its origins in psychodrama, self-psychology and object relations, script and schema theory, and gestalt and group theory. It is unusual in its efficacy in producing rapid and long lasting change (Black, 2003; Brooks, 1998). However, because the intervention itself occurs in a matter of hours it is essential to note that clients who seek the method out for therapeutic change do so after considerable reflection, preparation, and if not direct experience in enactment groups, then at the suggestion and referral of another therapist. Like Hakomi ASD, TE requires the client to be motivated, aware, able to articulate clear personal goals for the work, capable of attending to and staying with present experience and prepared to actively self study. There are five stages to the intervention articulated by Westwood and Wilensky (2005). The first stage, is assessment and preparation which involves establishing a relationship with the therapist(s), client preparation mentioned previously as well as meeting with the therapist(s) to discuss goals, needs and to plan the enactment. The second stage is group building which refers to the coming together of the group and building a safe environment for both the client and the members who will serve as witnesses and take roles for the client in the enactment. Particular attention is paid to this phase in order to build a sense of safety, cohesion and care among the 18 members. In a sense a firm, warm container or holder is established for the work and interactions. Enactment is the third stage where clients re-visit the traumatic event or scenes from the past and group members take on roles in the action. It is here that the major therapeutic work occurs through the exploration, processing and re-experiencing of old memories, full expression of emotions and completing actions interrupted or not enacted. Toward the end of this phase positive missing experience is provided. The fourth stage is sharing, reconnection, and closure. The client is reintegrated into the group and all members share their responses to the enactment without evaluating it. This helps clients and other members consolidate new learning and it deepens group solidarity. Lastly, integration and transfer move the client into reflection about the experience and the feedback given by other group members. The client is then encouraged to commit to a plan of applying the new learning in her/his life. The five phases readily fall into the process steps described earlier and found in Figure 2.1 (p. 17). Both assessment and preparation, and group building are part of accessing. Enactment begins in accessing and moves back and forth between accessing and processing with the client contacting memories and emotions in different scenes and events being re-enacted. Sharing, reconnection, and closure are part of integrating and integration and transfer are part of completing. In relation to psychotherapy and change theory, both TE and ASD are highly experiential and share several similar ideas about what promotes change (Kurtz, 1990, 2005; Westwood, Keats, & Wilensky, 2003). Some of these are: strong therapeutic alliance is related to positive outcome, identifying and facilitating missing, nourishing (and longed for) experience challenges (self-harming or dysfunctional core) beliefs and schema, providing a 19 safe container /environment for the client facilitates exploration and self discovery, interventions that facilitate client experiencing promote change, increased depth of experiencing and emotional expression is related to change, new meaning can be created by attending to the periphery of awareness or by accessing unconscious material at the core and bringing it into awareness, understanding early establishment of core beliefs or schema and challenging their current utility (reality testing) opens the door to personal choice/freedom and new self organization, empathic attunement/ limbic resonance (the compassionate "other") contributes to the regulation of biological states required for healing and growth. Despite TE being a group based intervention and ASD being primarily a dyadic model, both approaches rest heavily on accessing emotion, supporting its full expression and processing for meaning, and both emphasize resourcing clients through what ASD calls positive missing experience. There are several important procedural differences between these two approaches, aside from their theoretical differences. Both approaches focus heavily on creating a safe, warm and affectionate environment, TE is able to amplify this with the group. This amplification occurs as a result of members witnessing the work and providing a mirror for the client when the client sees their reactions and this provides validation and increased awareness to the client. ASD teaching and training groups have similar advantages but when practiced one on one, ASD relies on the secure base the therapist creates, in particular by expressing affirmation and loving presence towards the client. The group confers another advantage in that participants have more opportunities for interpersonal engagement, as does the client in focus. Additionally, as group members are recruited to take roles and move into action projections and intrapsychic dynamics are operationalized and externalized. This is not 20 pursued in ASD. One last significant difference is how each method evokes experience. TE evokes reliving past events and emotion primarily through action and enactment, whereas ASD evokes experience through therapist interventions such as offering nourishing probes that challenge client beliefs and taking over certain of the client's containing behaviours leaving the client freer to experience what lies under the defensive behaviours. The Role of Emotion in Psychotherapy Emotion was early recognized as a central integrating process in human communication and social functioning. In the late nineteenth century Darwin (1872/1965) documented emotional expression in both humans and animals thereby establishing its roots in the body and its evolutionary importance for survival. Much later Paul Ekman (2003) validated Darwin's belief that humans and animals expressed basic emotion in universal ways, particularly on the face. William James (1884) articulated a definition of emotion and Freud wrote about affect, its repression and its relation to psychological problems, although he never articulated a theory of emotion (Ford & Urban, 1998; Neborsky, 2006). In the past decade there has been an explosion of interest and research about emotion as a result of affective neuroscience advances (Schore, 2003), the need for psychotherapy approaches to produce evidence about outcome, and in response to the dominance in the field of research on cognitive processes. In addition, there has a been a recent shift by cognitive and cognitive behaviourist (CBT) researchers acknowledging that emotion is not simply a post cognitive phenomenon (Carek, 1990; Greenberg & Safran, 1984, 1988; Whelton, 2004), but rather a complex type of information processing that functions at an automatic, core level (Levenson, 1999; Lazarus, 1984, 1991; Porges, 2004) in response to charged events and circumstances. Emotion and cognition are now understood to reciprocally affect one another and as Greenberg (2004) stated, "the important question for the field now is: When is it important 21 that emotion is mediated by cognition and when is it important that cognition is mediated by emotion and what are the best forms of intervention for the different instances?" (p. 1). There is no consensus on what emotion or affect is. For the purposes of this discussion emotion or affect is defined as "subjective responses or felt states of readiness to events that are important to the individual" (Frijda, 1988, p. 351), "characterized by physiological, experiential and overt behavioural change" (Sroufe cited in Siegel, 1999, p. 123). Since every event or thought in our lives do not trigger an emotional reaction, Ekman (2003) proposes nine common ways of turning on affect: automatic, hard-wired appraisal of environmental concerns such as security and need, thinking about what is going on in the environment which then turns on the automatic appraisers, remembering past emotional experience, imagination, talking about past charged events, empathy, learned emotional responses, and violations of social rules such as personal boundary intrusions or distancing. Emotion helps us organize how we are in relation to our environment and this includes our relationships with people in our environment. Diana Fosha (2000a) writes about emotional processes from a clinical phenomenological stance: "Subjectively, the experience of affect is what makes us feel alive, real and authentic, what allows us to be spontaneous, and what gives meaning to our lives" (p. 14). She goes on to say that individuals who have neurological damage (right prefrontal cortex) do not have access to their emotions and this creates many problems including memory, decision making and relationship impairment. In short, she says their "very sense of self ... and other is disrupted." When clients seek therapy their emotions are always involved (as are cognitions and behaviours) and not infrequently the emotions expressed are not our primary or core 22 emotions. Greenberg (2002) distinguishes between primary emotions, maladaptive primary emotion and secondary emotion. If we look at these distinctions using the four elements of emotion found in the earlier definition of emotion - arousal (physiologic), experience (subjective felt sense), expression (observable behaviours), and processing (integration of emotion and cognition) they are readily understood. According to Greenberg, primary emotions are those internal gut reactions (appraised states of readiness) to events and situations which have been structured into us by evolution such as "anger at violation, sadness at loss and fear at threat" (Greenberg, 2002, p. 44). They are observable by others, especially in the face and musculature of the upper body, and felt by the individual physiologically, through changes in heart rate, breathing and perspiration, to name a few. They are spontaneous, and arise rapidly, often out of awareness, although they can be evoked consciously. Greenberg says maladaptive primary emotions emerge out of malfunction such as trauma or other past learning. A common example is overwhelming fear that arises as a result of a trauma. The emotion lasts for an extended time after the event and the person gets caught in it. The emotion is real and primary but no longer signals current circumstances, and so becomes problematic as the individual reacts to situations that are objectively safe with fear. Secondary emotions are affects about affects and often serve the function of defending the individual against a feeling which is overwhelming or intolerable for some other reason. A common example is resentment or anger which covers the underlying emotion of hurt or disappointment, thus masking its original meaning. Core affect is a term Fosha (2000a) uses to describe (primary) affect which emerges spontaneously, when the individual is making no effort to contain the arousal or expression of the emotion. As discussed earlier, blocking or suppressing our emotions cuts us off from 23 adaptive responses because we miss the vital message in the essential action tendency the affect was designed to convey. This has tremendous effect on our well-being and optimal functioning. Similarly, Fosha says (2000a) that releasing the full expression of core affect and understanding its meaning has a powerful impact on the self and as such is a vehicle for change. Central to the formulations of both Fosha (2000a, 2006) and Greenberg (2002) are the three principles of emotional awareness, emotional regulation and changing emotion with emotion. Working with these principles involves assisting clients to overcome their fears of experiencing emotions and memories which they have previously contained or defended against. What has been encapsulated needs to be experienced in awareness so that the individual can have access to the embedded meaning and action tendency in the emotion. Such exposure is well substantiated in the literature, including in TE research (Baum, 1994; Black, 2003; Brooks, 1998; Foa & Kozak, 1986; Littrell, 1998). This is accomplished by careful attention to alliance building and by helping the client learn to relax her/his defenses using the next principle of emotional regulation. Regulation can be in either direction as some clients are over regulated and need to be encouraged to allow their emotions to emerge, while others are under regulated and need assistance with calming overwhelming, flooding emotion. Working with emotions necessitates working within a window of tolerance (Siegel, 1999). In order for change to occur, the client must be aroused enough to experience previously warded off experience, but regulated enough to be able to be aware and reflect on what is happening. This means working at the edges of the window of tolerance is most productive (Ogden, Minton, & Pain, 2006). In both cases learning to identify emotions correctly, self soothing, breathing, increasing positive emotion, learning compassion for the 24 self and internalizing the support and acceptance of the therapist (and eventually others) are a few of the essential tasks of emotional self regulation. The third principle of changing emotion with emotion is referring to how maladaptive emotion is replaced with core affect or emotion. This happens when primary core affect, underneath maladaptive emotion is evoked, experienced, expressed and then reflected on, releasing its meaning for the related memory or situation and releasing important readiness or information about what to do. This results in the spontaneous emergence of positive emotions such as a sense of personal truth or Tightness, gratitude, or a sense of being moved, Fosha (2000a, 2000b) asserts. She believes this is something that naturally happens and is a marker of important integration and change. Bridges (2006), Greenberg (2002), and Greenberg & Pascual-Leone (2006) describe positive emotion as being recruited or as appearing when difficult or painful emotions are processed, thereby enhancing emotional processing, and changing the maladaptive emotion. For most practitioners this is the goal of emotional processing (Greenberg, 2002, Neborsky, 2006). Fosha's (2000a) Accelerated Dynamic Experiential Psychotherapy (AEDP) articulates a further step, called meta-therapeutic processing. In this phase client and therapist track the experience of change itself, both experientially and reflectively. Fosha (2006) identifies four discrete processes, each characterized by certain affective markers: "acknowledging mastery ... expressed as joy, pride and exuberance; mourning the self or acknowledging what one did not have ... expressed as emotional pain; affirming recognition of the self... expressed as being moved or touched within oneself and feeling gratitude , tenderness toward the affirming other (the healing affects); and finally, traversing the crisis of healing change characterized by fear, excitement, startle, curiosity, vibration sensations and positive 25 vulnerability" (p. 572). Fosha (2006) believes this process creates more change by strengthening the individual's sense of self. Recent research reviews (Greenberg & Pascual-Leone, 2006; Whelton, 2004) highlight that working directly with emotion is now considered an essential component of therapeutic change across all major therapeutic modalities. Despite the theoretical and methodological variance across therapeutic approaches and researchers, both reviewers validated that the four distinct emotion processes described above are supported by research as being useful for most clients - emotional awareness and arousal, emotional regulation, reflection on emotion for the purpose of meaning making, and restructuring or transformation of emotion (Coughlin Delia Selva, 2006; Foa & Kozak, 1986; Missirlian, Toukmanian, Warwar, & Greenberg, 2005; Pennebaker, 1990;.Watson & Bedard, 2006). In addition, several common threads emerged across modalities which have important implications for practice. Emotional arousal and experiencing can be helpful provided they are mediated by support which allows for exploration, understanding and articulation of the experience. When clients are engaged experientially in processing emotion and information therapeutic outcome improves. Exposure to traumatic material in a structured, safe context reduces anxiety and changes expectations. Although therapeutic alliance was not specifically reviewed, it emerged over and over as the precondition for emotional expression and therapeutic change. Acknowledging that all major psychotherapeutic approaches recognize the close relationship between client emotional expression and therapeutic change, Iwakabe, Rogan, and Stalikas (2000) attempted to build a process model of effective therapist interventions in response to clients' emotion expressions. To do so they posed two sets of questions: the first set focused on clients and their emotional expression and the second set focused on 26 "therapists' responses to and clients behaviours around emotional expression" (p. 380) in order to identify i f a pattern would emerge around interactions between clients and therapists in high and low alliance conditions. From a sampling of 25 audio taped expert demonstrations of the major approaches to psychotherapy eight sessions were chosen - four that were rated high on the Working Alliance Inventory (WAI; Horvath & Greenberg, 1989) measuring alliance and four that were rated low by the McGi l l Psychotherapy Process Research Team for inclusion in the study. Two other measures were used. The Strength of Feeling Scale (SFS; Iwakabe, Stalikas, & Rogan, 1995) was used to assess the intensity and type of emotion expressed on audio taped sessions. The Questionnaire for Emotional Expression Events (QEEE) was developed specifically for the study by the authors to capture the assessments of expert clinical judges categorizing client's emotional expression as well as therapists' responses and interventions to client expression of emotion. Specific findings were: regardless of level of working alliance clients express emotions of similar intensity; in low alliance relationships emotions were often directed at the therapist whereas in high alliance relationships the emotion was expressed towards the object of the clients concerns; therapists with high alliance ratings were seen to use empathy more and their clients were more engaged in exploring and elaborating their feelings; in low alliance relationships where effectiveness was rated as good it was noted that therapists responded to clients' feelings about them and this allowed clients to express their feelings more directly to the therapist; on the other hand, in those relationships rated low on alliance and low on effectiveness it was noted that when clients expressed feelings towards the therapist the therapist ignored or was inaccurate in responding and this led to frustration and the 27 disengagement of clients from the therapeutic process. This study provides evidence that alliance is important for emotional expression and it supports research on common factors (Bohart & Tallman, 1999; Hubble, Duncan, & Miller, 1999; Wamplod, 2001) for what makes therapy effective that reach beyond theoretical orientation - emotion and alliance. It also provides preliminary evidence that "therapists' immediate and accurate responses to clients' emotional expressions are crucial, andean be seen to complete an arc of potential" (Iwakabe, Rogan, & Stalikas, 2000, p. 398). The implications of these findings for practice relate to Alexander's (1946/1980) assertion that spontaneously random or neutral response on the part of the therapist during and after a corrective emotional experience is not desirable since it has the potential to mimic the lack of comfort and responsiveness inherent in the original painful event. Rather, a deliberate offering of comfort, which Kurtz (2006) calls a positive missing experience, at this point in a therapeutic session may be an integral part of deepening emotional processing, integration and completion (Bridges, 2006; Fosha, 2000a). The Role of Positive Emotion in Psychotherapy The function of positive emotion as it is emerging in the literature may play a role in enhancing emotional processing and anchoring and deepening client integration (Bridges, 2006; Fosha, 2000b; 2004; Greenberg, 2002; Greenberg & Pascual-Leone, 2006). Several findings support this idea. First, many negative emotions limit thoughts and actions because they automatically call forth specific action tendencies such as flight and attack (Fredrickson, & Branigan, 2005; Levenson, 1999). Second, positive emotion has the effect of undoing arousal associated with negative emotion (Fredrickson & Branigan, 2005). Third, positive emotion tends to encourage broadminded thinking and the urge to explore. The relationship 28 between positive affect and broader thought-action repertoires is reciprocal, with one pulling for the other in an upward spiral (Fredrickson & Joiner, 2002). Fourth, positive appraisal is associated with positive emotion, and this can be recruited by resilient individuals even under very stressful situations (Moskowitz, Folkman, Collette, & Vittinghoff, 1996). Fredrickson and Joiner (2002) assessed the Broaden-and-Build Theory (Fredrickson, 1998, 2001) of positive emotions which asserts that positive emotion broadens thinking and incidentally resources, which in turn evoke positive emotion (and so on). This reciprocal relationship was tested to see if one predicts the other. One hundred thirty-eight undergraduate students were given credit for an introductory psychology course for participating in two study sessions, five weeks apart, in which they completed both the Positive and Negative Affect Schedule (PANAS; Watson, Clark, & Tellegen, 1998) and the Coping Responses Inventory (CRI; Moos, 1988). The PANAS asks respondents to rate 20 items for the extent to which they felt certain emotions over the previous two weeks. The CRI asks respondents to identify "the most important problem they faced in the previous year and how often they used various strategies to deal with it" (Fredrickson & Joiner, 2002, p. 173). The results support the theory that "positive emotions - through their effects on broadened thinking - predict future increases in positive emotions" (p. 174). The same did not hold true for the reduction of negative feelings (predicting broadened thinking). These findings support the principle that emotion can be changed with emotion, and have important implications for this study. If positive emotion and broad minded thinking can reciprocally evoke one another, then could carefully eliciting and amplifying these emotions in a therapeutic context have the effect of speeding up and enhancing client perspective taking 29 and meaning making after the processing of emotion and painful experiences? In addition, this study supports the idea that positive emotion may enhance resilience and coping and have an important function in well-being beyond being a side effect of well-being and the expression and processing of painful core emotion. Bridges (2006) describes preliminary data from an ongoing research study aimed at assisting clients to resolve attachment injuries from the past. The author presents transcribed and analyzed sections of three cases that demonstrate how arousal, experiencing, expression and processing of emotion bring about corrective emotional experience and therapeutic change. The sessions were videotaped and emotion was defined and measured as follows: emotional arousal was linked to cardiovascular activity and measured by a wristwatch cardiac monitor, emotional experiencing was measured at the end of the sessions through client responses on the Derogatis Affect Balance Scale (DABS; Derogatis, 1975), emotional expression and emotional processing were rated by trained observers watching the videotapes and using the Specific Affects Coding Scale (SPAFF; Gottman et al., 1996) and the Experiencing Scale (EXP; Klein et al., 1969) respectively. The author attempted to answer three questions: What is the optimal level of emotional arousal needed for good therapeutic outcome? Do positive emotions contribute to the processing of negative emotions? Is emotional processing a dialectical process whereby emotion and cognition are integrated resulting in perspective taking and meaning making? The study findings were differential. Two clients were able to engage in a relational dialogue, become emotionally aroused, demonstrate emotional experiencing, express their emotions and process them with subsequent resolution. These same two clients displayed higher and more variable heart rates when crying and expressing sadness. When these clients 30 expressed strong, prolonged emotion it was followed by deeper emotional processing and resulted in insight and a sense of resolution. Neither client reported feeling overwhelmed. The third client, in contrast, displayed stable levels of emotion with minimal processing. This was consistent with expectations about emotional venting resulting in immediate relief (and subsequent reduction in emotional arousal). That is, venting brings relief but it is not lasting change. It was found that in two clients where emotional processing was at a deep level and emotional arousal was moderate to high, the emergence of positive emotions seemed to not only enhance a return to homeostasis (lower heart rate) but also to reciprocally deepen emotional processing and result in a broadened perspective. These observations suggest that titrating a client's emotional arousal to keep within a tight window of tolerance (Siegel, 1999) may not be necessary or even productive, especially when high emotional arousal is accompanied by deep emotional processing on relevant core themes. The author also suggests that positive emotions may play an important role in assisting clients to integrate new understandings by deepening emotional processing and broadening the client's perspective. This hypothesis is consistent with findings of Fredrickson and Joiner (2002) where positive emotions were found to increase broad-minded thinking, thereby expanding clinical understanding of the (therapeutic) function of positive emotion. However, the study findings must be viewed with caution. The participant number was low, only three client sessions were examined. In addition, the perspectives are somewhat pre-determined and limited by the use of a researcher-chosen rating scale and only expert perspectives are considered, no client feedback was sought. 31 Attachment Theory Attachment theory, as articulated by Bowlby (1980, 1988), has served to generate and answer many questions, particularly about our behaviours and emotions as we enact them in relationship. Central to attachment social emotional theory are the following ideas and concepts: attachment behaviour, attachment relationships and secure base, developmental pathways, internal working models (of self and other), the link between affectional bonds, emotion and their role in regulating affect and arousal (Bowlby, 1980, 1988; Cortina, Spring, & Marrone, 2004). Attachment behaviour is seen to be hard-wired (Porges, 2004; Siegel, 1999; Schore, 2003), as other instinctual behaviours such as feeding and sex, and goal-oriented. According to Bowlby attachment behaviours are initiated for protection and for maintaining closeness to an important other with whom we feel secure at one end of a continuum, and for assurance and acknowledgement at the other. It is defined as any "behaviour that results in a person attaining or retaining proximity to some other differentiated and preferred individual" (Bowlby, 1980, p.39). Attachment behaviours lead to the development of strong emotional bonds, initially between infants and parents and later between adults. These bonds provide the site for a relational template for young children and create strong interdependent ties with the potential for enhancing psychological well-being in adults (Fonagy & Target, 1997; Makinen & Johnson, 2006). They are activated throughout life - automatically and often out of awareness - in response to even subtle cues of separation from or loss of an important attachment figure (Lewis, Amini, & Lannon, 2000; Porges, 2004; Siegel, 1999). Secure base is a concept that Ainsworth's research contributed in support of attachment theory (Bowlby, 1988). Ainsworth recognized patterns of attachment in children based on 32 behaviour they exhib i ted w h e n separated and re-united w i t h their mother (pr imary caregiver). She observed that avai lable and responsive parents provide ch i ld ren w i t h a secure base from w h i c h they can explore the w o r l d and return for comfort , protect ion and assistance. There is n o w considerable research evidence that sensitive, w a r m and consistent responsiveness from a parent or caregiver (secure base) provides a young c h i l d w i t h important experiences o f trusting se l f w i t h others, feel ing safe, being soothed and reassured w h e n strong emotions are activated (Gerhardt, 2004; K a r e n , 1994; Siegel , 1999; Schore, 2003). Strong emot ion related to separation, loss, re-uni t ing, be ing understood or being treated w i t h sensi t ivi ty is evoked frequently w i t h i n parent-chi ld (or other significant) relationships. These experiences w i t h parents are thought to lead to expectations and beliefs about the self, others and the w o r l d , and B o w l b y cal led them internal w o r k i n g models (1980). Examples w o u l d be "I a m lovab le" (model o f self), "others are t rus tworthy" (model o f other), and "the w o r l d is safe" (model o f the wor ld) . These early posi t ive w o r k i n g models are both stable and f lexible . T h e y are stable i n that they become prototypes for relat ionship and guide behaviour when someone stronger and wiser is not present, and they are f lex ib le i n that they are affected by and can change when challenged by experience. T h i s also works i n reverse when unsupportive or even abusive experience results i n w o r k i n g models w h i c h interfere w i t h or b lock attachment behaviours, mitigate against secure base and compl ica te relationships by resul t ing i n maladaptive internal w o r k i n g models w h i c h , w h e n used overtime lead to the m i s c u i n g o f attachment figures and do not result i n the ind iv idua l being supported, comforted or protected. A more recent construct f rom attachment theory comes f rom Fonagy and Target (1997) who write about reflective function and attunement. W h e n a sensitive and responsive 33 caregiver reads and mirrors back the verbal and non-verbal expressions of the baby and young child, the child sees her/himself in the eyes of the other and similarly the child reflects back the expressions of the parent. This reciprocal communication process sets the stage for the developing self and the ability of a young child to mentalize (Fonagy & Target, 1997) or read the mind of caregivers by attending to the beliefs and conceptualizations s/he makes about the parent's behaviour. It is this process of attunement which builds the capacity for reflection on oneself and others. Bowlby did not believe that early positive attachment relationships would ensure adjustment and security but rather would offer some protection from psychopathology and at the very least serve as a referent for understanding early models and how they may be brought forward, out of awareness, into present relationships, especially at times of vulnerability and stress. We do know that the regulation of emotions (Greenberg, 2002; Siegel, 1999; Schore, 2003), beliefs about self and others and being able to repair affective ruptures in relationship are key to healthy adult functioning. "Given the transformational nature of development, it would be foolish to assert that the infant's regulatory style and representations determine those of the adult, but it would be equally foolish to assert that they are without influence. Certainly the way in which adult-as-child regulated and represented the circumstances and emotions he or she experienced accrue to the adult" (Tronick, 1989). Bowlby (1988) saw attachment theory as informing the major goals of psychotherapy which he said were to provide an environment which was safe enough for a client to explore her/his internal working models and her/his important attachment relationships with the goal of revising and updating these models in relation to new experiences which would occur in 34 the therapeutic relat ionship. H e out l ined five roles for the therapist: p r o v i d i n g a secure base for a client to explore aspects o f her/his life w h i c h are distressing, exp lo r ing the l inks between emotions, expectations and behaviours i n past and present relat ionships, exp lor ing the therapeutic relat ionship and h o w it does or does not m i m i c other relat ionships, exp lor ing h o w past experiences are related to present experiences especia l ly as they relate to parents or what she/he was taught by parents, and to examine l i m i t i n g or unhelpful w o r k i n g models i n order to enable the cl ient to update th ink ing , feel ing and act ing so it is more congruent w i t h present circumstances and results i n new experience. The relevance o f attachment theory to this study is i n h o w it informs therapy practice and th inking. B o w l b y (1988) emphasized the role o f experience i n shaping and changing emotion, relationship attachment and behaviours and internal w o r k i n g models . Th i s means that significant, charged relat ional life experience has the potential to both create and modi fy pre-exist ing relational patterns w i t h se l f and others and that this can occur i n both a posi t ive or negative direct ion. A n experience i n therapy has the same potential . Secure attachment i n the therapeutic relat ionship is not the goal o f therapy but rather a cond i t ion for therapy, especial ly therapy where strong emot ion w i l l be evoked and where o l d patterns o f containment w i l l be tested. In psychodynamica l ly oriented approaches, as w e l l as i n A E D P , the cl ient ' s experience o f such a relationship w i l l be speci f ica l ly explored and tapped as a change agent (Fosha, 2006). Client Perspectives Understanding cl ient perceptions about their therapy is important because it is the on ly reliable source o f in format ion about the meaning and value o f therapy (E l l io t t & James, 1989), cl ient and therapist perceptions o f what is significant and what is good outcome sometimes differ (Bache lor & Salame, 2000; E l l i o t t & Shapiro, 1992; Lie taer & N e i r i n c k , 35 1996) and client processes are often covert and unexpressed and occur out of the awareness of therapists (Watson & Rennie, 1994). There has been considerable research seeking the thoughts and reflections of clients about their therapy experience indicating the importance placed by the profession in client feedback and satisfaction. In fact many therapists seek client feedback regularly as part of therapy itself and do so both informally and via brief post session questionnaires (Bohart & Tallman, 1999). Up to the last decade much of this research was quantitative. There is a wide range of research approaches to client experience in the literature including quantitative and qualitative approaches, whole treatment, single session and specific in-session events. Quantitative surveys of whole treatment have given us broad categories about helpful and hindering aspects of client experience (Bachelor & Salame, 2000; Elliott & James, 1989; Gershefski, Arnkoff, & Glass, 1996; Levy, Glass, Arnkoff, & Gershefski, 1996; Lietaer & Neirinck, 1996) and suggest which factors are common across modalities such as strong therapeutic alliance. Elliott and James (1989) surveyed much of the literature available seeking client opinions about what was helpful. They crystallized the findings into two main categories: task/problem solving and relationship affective aspects. The relationship category contained helpful therapist characteristics, facilitation of client self expression and relationship support, and the task category included understanding self/insight and the encouragement of practice outside the sessions. Lietaer (1992) & Neirinck (1986) studied client and counsellor perspectives about helping and hindering processes and categorized them according to relational aspects, client process and therapist interventions. 36 In an effort to address the critique of applying predetermined categories consistent with researcher framework, Paulson, Truscott and Stuart (1999) conducted a qualitative study using telephone interviews to collect data and concept mapping carried out by participants to cluster data into themes which were then named by the researchers. This approach expanded understanding of common themes reported by Elliott and James (1989) in the areas of therapist style and therapeutic alliance. Four new themes emerged: outcomes, new learning, emotional expression and release and availability and affordability. The client category of emotional expression and release is interesting since other studies have shown that this is emphasized as important by therapists but not necessarily by clients (Lietaer, 1992 & Neirinck, 1986). Levitt, Butler, and Hi l l (2006) interviewed former clients from varying backgrounds with a range of problems, about their experiences in therapy. Participants were asked to recall significant moments in their therapy and in the relationship they had with their therapist. A grounded theory approach was adapted and a hermeneutic epistemological framework for the analysis of 26 transcribed interviews with clients resulted in the author's identifying seven clusters of meaning, with the seventh (and central core) theme encompassing the others. For each of the six categories a principle was developed which states its implication for therapy practice. The first was: client expectations are important and need to be clarified, the second, therapy context is experienced as care by the therapist, and third, structured transition between the world of therapy and the outside world facilitated progress. The fourth category, the therapeutic relationship was large. It was characterized as providing missing elements in other relationships and allowing clients to individuate from others through early dependency. It also revealed that trust is built with therapists who are genuine, respectful of clients' 37 process and goals, who demonstrate expertise, and have clear boundaries around self disclosure and procedural and administrative items. Therapist caring and emotional expression are important but need to be tempered with direction when needed, be client related and not overstep client agency. The sixth category described therapist interventions that provide a structure within which clients can self explore, be self-reflexive, be challenged by the therapist, experience emotions in order to drop defenses, and learn to tolerate feelings and change emotional experience. The central core theme was called: "clients are needing just enough structure to facilitate reflexivity while needing to feel special enough to risk revealing to be known" (p. 322). This finding reveals the dynamic tension between the desire of these clients to be authentic and open to self discovery in counselling and the threats they feel in doing so. It also suggests the conditions and processes clients say they need to fully engage in the work of therapy. Mediating this tension was described as a delicate balancing of structure and compassionate caring from the therapist. These findings are particularly relevant to the current study as they signal that clients need and value the relational affirmation and containment that is offered by a sensitive, skilled and available therapist because they facilitate the exploration of challenging issues that ultimately result in change. There are many other qualitative studies in the literature seeking client perspectives about alliance development (Fitzpatrick, Janzen, Chamodraka, & Park, 2006) and change processes in therapy (Clarke, Rees, & Hardy, 2004; Dale, Allen & Measor, 1998; Jinks, 1999; Kuhnlein, 1999; Paulson & Worth, 2002; Ward, 2005). The ones listed here primarily focused at the whole treatment level. Because the present study examines client experience at the event level, one study that also chose this unit of experience will be briefly described to illustrate more specifically how this type of research taps client and therapist actions, has the 38 potential to highlight "what to do when" (Elliott & James, 1989), and provides evidence for theory building, grounded in the phenomenon being studied (Warwar & Greenberg, 2000). Fitzpatrick, Janzen, Chamodraka, and Park (2006) interviewed 20 clients to investigate how they understood specific events that contributed to alliance development with their therapists. Clients were asked to describe elements important to them about a therapeutic relationship, expectations they had of the relationship before starting therapy and how they would characterize their current therapy relationship. They were then asked to describe a critical event that exemplified how they knew the relationship was on track or not. Responses were analyzed using the Qualitative Consensual Model (Hill et al, 2005) and arranged in five domains - descriptors of the event, meaning of the event, client contribution, impact on the relationship, and outcomes of the event. The domain of meaning captured clients' feelings that they were understood, at the center of the process, could/would be helped by this therapist and had contributed their own abilities to the process. The relationship between the domains was then described in a framework which concluded that positive events served to create a forward momentum in the therapeutic process and were associated with positive emotion, whereas a negative event evoked a negative feeling and seemed to reduce productivity. This study demonstrates how moment-to-moment events evoke emotion and impact both the client and the forward momentum of the therapy process. It also suggests what clients need to keep the relationship on track and the process moving in productive directions. Finally, three studies which specifically sought client perspectives about their emotional experiences in therapy will be summarized. Cummings (1997) conducted a qualitative study of eleven former clients recruited from public mental health agencies where they received 39 therapy for depression, substance abuse issues and anxiety. She used semi-structured in-depth interviewing to explore their emotional experience in therapy. When these participants were asked what brought them to therapy they discussed wanting to change or control problematic emotional states, painful or frightening emotions, restricted range of emotional expression or problems created by emotions. Some participants also reported a need to learn about why they felt as they did. The most common emotions they dealt with in therapy were anger, sadness, fear, shame and vulnerability. Positive emotions were experienced within the therapeutic relationship and when progress was being made, whereas negative emotions were more associated with facing hard truths or feedback and when therapy was not going well. Cummings (1997) identified eight categories of therapeutic work related to emotions that were discussed in the interviews as being helpful or not. 1. Discovering connections between feelings thoughts and behaviours, "all of a sudden I realized it was my thoughts that was creating the fear ... all I had to do was change my mind, and my thinking. And the feelings ... they just vanished" (p. 199). 2. Recognition of negative emotions: "I got an understanding about how I was feeling. It never had occurred to me that I needed to forgive my father ... that was a real eye opener for me .. ." (p. 200). 3. Experiencing [the] necessary pain of self knowledge: "I can't sidetrack this one ... we need to get into our own [emotions] to be able to understand ourselves and be able to relate" (p. 201). 4. Normalizing negative emotions was helpful because as one participant said: "You actually didn't feel like you was the only person out in the world that had that problem" (p. 202). 40 5. Experiencing intense emotion or regretting the lack of it: " there's the overwhelming crying .. .of not having let myself go and ... just finally being given the outlet to say "Yes, you are permitted, you are allowed, you can do this [crying] "I feel like she knows me, and I like her, I'm glad she's around" (p. 203). 6. Open expression of negative emotion provided it was linked to a therapeutic issue: "he really wanted me to vomit it all out... in retrospect he was trying to get me to get in touch with my emotions and provide an environment in which anything could come out" (p. 204). 7. Experiential learning was seen as helpful if it was tied to a therapeutic concern and associated emotion was regulated and completed by reflection; otherwise emotions decreased in intensity in the short term but then recurred. An example was: ".. . just relive them [previous experience] from an emotional vantage point instead of intellectualization that I had engaged in until that time" (p. 207). 8. Missing emotional work was related to not changing problematic emotional reactions and experience. It was attributed to the participants themselves hiding or their therapist's avoidance: "my last therapist didn't want to delve for the depth, he just wanted to fix" (p. 209). Stuart (2002) conducted nine in-depth interviews with clients at the end of their therapy asking them what their emotional experience in therapy was and how that experience had been helpful. Using concept mapping she identified eight clusters of experience: understanding my emotions, volatility, avoidance, negative influence of emotions, dealing with emotions, resolving emotions, integrating and connecting to the self. Stuart found that the participants viewed their emotional experience in therapy as a process which involved 41 three steps. First was the breakdown of established coping strategies which was supported by the clusters of volatility, avoidance and negative influence of emotions. Participants reported that by not dealing with the source of their distressing emotions or the negative consequences of them things had worsened in their lives leading them into therapy. They also talked about the under and over regulation of their emotions, feeling numb when feelings were over controlled and overwhelmed when feelings were under managed, both states causing distress. The second step emerges with the recognition of the need to examine and reflect on emotional experience by learning to recognize and label emotions, allowing them to intensify, and studying their meaning. This led to relief, which surprised participants. Clusters which supported this step were: understanding my emotions and dealing with emotions. The third step in the process was re-organization. As participants examined and explored emotions and experience that was previously defended against they found things changed for them, they could integrate previous disconnected aspects of their lives. The clusters involved in this step were resolving emotion, integration and connecting to the self. Participants also said, in retrospect, it was necessary to deal with emotions in order to resolve emotional distress and they believed the therapy relationship allowed them to overcome avoidance, particularly at the beginning of therapy. Lastly, Pilerio (2004) carried out the first study of clients' experience in affect focused psychotherapy. 111 participants were surveyed about their satisfaction with therapy. A l l had participated in one of three emotion-focused approaches: accelerated experiential dynamic psychotherapy (AEDP; Fosha, 2000a), intensive short term dynamic therapy (ISTDP; Abass, 2000), or emotion-focused therapy (EFT; Greenberg, 2002). Seventy-eight percent of participants reported satisfaction with therapy outcome and this was associated with 42 increased personal well-being, change in interpersonal functioning, improved self esteem and emotional awareness and competence that was long lasting. Eighty-five percent said they achieved mastery over the symptoms that brought them to therapy including depression, anxiety, work-related problems and relational issues. Other significant findings that were associated with satisfaction and positive therapy outcome were: accessing previously warded off emotions and experience in the presence of an emotionally responsive therapist, unlocking symptoms and distress, and the emotional intensity of the therapy. Therapists were very highly rated as warm, empathically attuned and emotionally engaged with participants. These therapist attributes along with affective interventions were positively correlated with satisfaction and progress in therapy. These studies provide convincing client support for what the literature in attachment theory tells us about emotional regulation being a dyadic process (Schore, 2003; Siegel, 1999), and what emotional processing research and theory say about the importance of working with emotion directly to relieve distress and promote change. They also validate Levitt, Butler and Hill 's (2006) findings that therapists need to carefully structure interventions to engage clients at the edge of their comfort zone on disowned aspects of their experience, and be emotionally available and responsive enough to assist clients to tolerate the process. Summary Missing emotional experience is related to attachment, care giving and exploratory behaviour systems described by attachment theory, emotion theory and research related to emotion-focused and experiential therapy approaches. How this type of experience can be resolved therapeutically has been described both from the perspective of the therapist and the 43 client, although specific mechanisms for change in the moment-to-moment process of therapy are still not well articulated. It has been suggested that studying significant events in the moment-to-moment process of therapy will be fruitful in this endeavour. However, there are few in-depth client accounts of moment-to-moment change processes in the literature. This study attempted to fill this gap by exploring a significant event in the experience of one man's intense, brief therapy in therapeutic enactment (TE). The next chapter describes the method and procedures used. 44 CHAPTER 3 Researching Lived Experience Research Question "What is the lived experience of a client receiving a positive missing experience in a therapeutic session?" Because there are relatively few qualitative studies exploring in depth client accounts about specific episodes in their therapy in the literature (Iwakabe, Rogan, & Stalikas, 2000; Levitt, Butler, & Hi l l , 2006; Manthei, 2006), a single case study exploration devoted to understanding the meaning a client makes of receiving a positive missing experience lent itself well to examining this question. Data analysis was be guided by van Manen's (1990) "Methodological Structure of Human Science". Research Paradigm and Method According to Merriam (1998) and Stake (1995) the kind of knowledge and understanding that may be generated from using a case study approach (to researching a client's experience of receiving a positive missing experience from a therapist) is first related to one of the main differences between qualitative and quantitative inquiry. While "quantitative researchers have pressed for explanation and control, qualitative researchers have pressed for understanding . . . " (Stake, 1995, p. 37). The goal of qualitative research is to understand the personal, lived experience of participants, much like psychotherapy itself (Silverstein, Auerbach, & Levant, 2006). A single case study design was chosen for this research because it is a phenomenon around which there are boundaries. Miles and Huberman (in Merriam, 1998) describe a case as "a phenomenon of some sort occurring in a bounded context" ... "They graphically present it as a circle with a heart at the center. The heart is the focus of the study, while the circle 'defines the edge of the case: what will not be studied" (p. 27). In other words, what is 45 studied can be delimited. In addition, case studies are descriptive, particularistic and heuristic (Merriam, 1998; Stake ,1995). The single case presented in chapter 4 generated a rich and thick description of the participant's experience. The vivid details and quotations, recalled after the event, as well as videotaped excerpts from the actual therapy session will allow readers to get a sense of what the participant's actual experience was like. The complexities of the participant's situation emerge through these descriptions and have the potential to resonate with the experience of the reader in the same way first hand experience does. The heuristic aspects of this case highlight the potential of the case to enhance the reader's understanding of a positive missing experience from a client perspective. "Insights into how things get to be the way they are can be expected to result from case studies" (Stake cited in Merriam, 1998, p. 30). The most famous example of this type of heuristic was Freud's own self analysis and detailed case histories from which he first introduced the idea of the unconscious. Many current psychotherapy modalities today utilize this formulation to explain warded off or repressed experience which continues to influence behaviour out of awareness. Particularity refers to the uniqueness of an event, situation or experience in context. Van Manen writes about phenomenology as an act of knowing about human existence through caring and being deeply interested and appreciative of the mystery of human experience. In this way he says it is a theory of the unique. Each person is unique and irreplaceable; each experience is the place of study which is not repeatable. Hermeneutics and phenomenology are considered to be the philosophical building blocks of the post positivist qualitative research methodologies (McLeod, 2001). They are embedded in a post positivist realist and essentialist ontology. In this viewreality exists beyond our thinking about it, understanding and personal meaning making is interpreted 46 through the world we live in and is essentially social, dialogic and co-constituted with others. In attempting to understand how a client made meaning of receiving a positive missing experience in a therapeutic session, it was a good fit. As with the intentions and processes of psychotherapy, the method acknowledges the relational aspects of understanding. How we come to know ourselves and the world around us is fundamentally tied to seeing ourselves reflected back through the eyes of our significant others and through our culture - the fusing of perspectives. Hermeneutics or interpretive phenomenology is derived from the philosophy of Martin Heidegger and is distinct from phenomenology which is rooted in the ontological philosophy of Edmund Husserl in several important ways. Hermeneutics is both a descriptive and interpretive approach. Hermeneutic researchers believe that understanding and meaning arise in context and as such are theory-laden. In other words, as researchers we can enlarge our theory-laden ".. . understanding or achieve a fusion of horizons (Gadamer, 2004) through allowing ourselves to learn from our immersion in the 'text' being studied and thereby permitting the world expressed by the text to speak to our world." (McLeod, 2001, p. 56). Phenomenology, on the other hand, is more of a reflective activity where the researcher attempts to separate off her preconceived understandings, immerse herself in the text and allow the essential "what-ness" or essence of the phenomenon emerge. The phenomenological researcher looks for what is common and self-evident, and asks: What is the essential structure of the experience? It aims to build a thick, evocative description of the phenomenon as met in the lived world. Whereas a researcher employing a hermeneutic approach examines the world as encountered and asks: What is the meaning of the phenomenon in this situation, in all its complexity? It aims to accomplish the impossible -"... a full interpretive description of some aspect of the life world" (van Manen, 1990, p. 18). 47 According to van Manen (1990) human science is a retrospective activity, with theory emerging after reflection on practice. A person cannot introspect during an experience because as he/she does, the experience is already shifting. Rather, van Manen says, one retrospects, and so it is with researching lived experience, we know the experience of another through their recollections. Van Manen's Methodological Structure of Human Science (1990) was used as a guide for collecting data and analyzing this client's interview. The six activities he describes are: 1) turning to a compelling phenomenon in a committed way; 2) investigating experience as we live it rather than as we conceptualize it; 3) reflecting on essential themes; 4) describing the phenomenon through the art of writing; 5) maintaining a strong orientation to the phenomenon throughout the writing; and, 6) balancing the research context by considering parts and whole. The method implies a linear structure on the surface but instead offers a flexible map for researchers to use as they navigate the complexities and movement of the research process (van Manen, 1990, pp. 30-31). Researcher Subjectivity In introducing the idea of the fusion of horizons for understanding research findings Gadamer (2004) meant that the historical horizon of the researcher would fuse with the present horizon of the particpanfs interpretation, bringing together the familiar and the unfamiliar. He stressed the need for researchers to reveal their fore-understandings or biases and assumptions as part of the interpretive process. In this study my personal background, experience in therapy, values, goals, theoretical stance, and personal background frame my understanding of missing experience and therapy process, and comprised the historical 48 horizon. While I attempted to be reflexive "... a person trying to understand a text is always projecting" (Gadamer, 2004, p. 269). Personally, I have engaged in several types of therapy as a client over the years and I have found that experiential work allowed me to release encapsulated emotion and past experience in a safe way. I felt accepted and valued, and this allowed me to be more authentically present for my own clients. I believe that for meaningful therapeutic work to occur, both therapist and client must be fully engaged at an emotional level so that the client can feel safe and known. The hermeneutic stance about the notion of researcher prejudice is that the researcher's task is to reveal one's 'taken-for granted' background. It is assumed that efforts to understand necessarily originate from a 'position' (Strong, 2003). I have been moved and captivated by both watching therapists provide positive missing experience for clients and by experiencing it myself. My own personal history of not being adequately supported as a child no doubt amplifies my commitment to understanding and wanting to study such an experience. I expected that receiving a positive missing experience would be significant for a client and I assumed receiving such support and affirmation would have the potential to challenge one's constructs or belief systems, for the better. While attempting to balance my role as an interviewer and my training as a counsellor, I was both enabled and challenged by my subjectivity. On one hand I had previous knowledge and experience with the research phenomenon, and knew what I was looking for. On the other hand, I was attempting to be sensitive and open to what Brian had to say about his therapy experience. In this dynamic process I reflected his words back to him, with some level of interpretation, in order to keep the interview focused on the research question. This raised the issue of leading or directing. For a hermeneut, listening is an interpretative act 49 (Kvale, 1996, p. 135). One example of this that arose during the interview was: Brian described being very surprised by how spontaneously his rage had emerged in one scene he re-enacted with a surrogate father. He used the words "spontaneously acting congruent" to describe his expression of rage. I responded with: "yeah, from your core . . ." He repeated the word core and then several minutes later took up the word again to refer to an inner energy. During the reading of the transcript, the second expert researcher and I agreed that in this case Brian used the word because he liked it. This particular instance of interpretive listening and responding had a benign effect, the influence was neutral. It did not change the meaning of what Brian had said. My presupposition that he was referring to a primary or core affect emerging was in fact validated by him. Although I believe he was at the edge of that awareness himself, he did not use the word until I introduced it. The word resonated with him. This example illustrates one aspect of strength and potential challenge within researcher subjectivity. Procedures The following procedures correspond to van Manen's six activities for conducting phenomenological hermeneutic research (1990). Chapter 1 and the discussion above on researcher subjectivity outline the first activity: turning to a compelling phenomenon in a committed way. The subheadings that follow and are entitled: selection of the participant, data collection plan and interview protocol, and transcription, along with chapter 3, entitled review of the literature, detail the second activity: investigating experience as we live it, rather how we conceptualize it. The subheadings entitled data analysis and member checks are the subheadings under which van Manen's activities three, five, and six are described: reflecting on essential themes, maintaining a strong orientation to the phenomenon 50 throughout the writing, and balancing the research context by considering parts and whole. The fourth activity, describing the phenomenon through the art of writing, is seen under the subsection entitled: representation of findings. Ethical Considerations Approval from the U B C Behavioural Research Ethics Board (BREB) was obtained (Appendix F). Five ethical issues emerged as being important.- informed consent, respecting the boundaries of the participant-researcher relationship, confidentiality, wellbeing of the participant(s) and safety and privacy of the data. Ensuring ongoing informed consent was critical since Brian was a volunteer. Informed consent is a process, not merely an act, and because of its contractual nature Brian was aware he was free to exit the study at any point. Inherent in informed consent is safety of the client. Since Brian's educational video has been used many times in the public domain, he expressly asked me to use his real first name in this document. We had two conversations about this issue. He assured me he has felt very respected and protected in this project. The texts have been carefully protected and will be stored according to the U B C BREB agreement. In member checks Brian was asked to verify the text as capturing his experience. Similarly, a second reader and researcher provided verification of the transcription and interpretations. During the interview I was mindful that my training in counselling and role as a researcher intersected and attempted to remain in the researcher role. Selection of the Participant Purposeful sampling (Merriam, 1998) was used to select a participant. Expert, certified therapists who run therapeutic enactment (TE) groups, and who use positive missing experience during the integration phase of therapy, were asked to circulate a written 51 description of the research, in the form of a recruitment letter (Appendix A) to former clients who fit the inclusion criteria. The written description invited persons to participate and to contact me directly by telephone or to indicate in writing their willingness to be contacted. Brian telephoned me indicating his interest in the study and willingness to participate. In this telephone exchange I followed a telephone protocol script (Appendix B) which listed the items to be covered. This included establishing his eligibility, explaining the project and time commitment, discussing informed consent and risks. His eligibility was established based on meeting the following inclusion criteria: 1) being 21 years or older; 2) having been a client in a Therapeutic Enactment (TE) process where a qualified therapist offered a positive missing experience during the integration phase of a session; 3) having a videotape of the therapeutic enactment; 4) having had the consent of other group participants to make the videotape; 5) agreeing to participate in the study and being available for three interviews, and, 6) being willing to view the videotape and discuss the therapeutic session in a research interview. The following exclusion criteria were established by the therapist: 1) not meeting inclusion criteria; 2) anyone whose therapist advised him/her not to participate, and 3) anyone who felt they may become too upset and require intervention after or during the interview. We met briefly at my home the next day in order for the participant to receive a set of reflective questions to help prepare for the interview (Appendix C). At that time Brian loaned me the videotapes of his enactment session, two interviews conducted with the therapists at four days and two months post enactment, and a copy of an educational videotape he had made of his enactment. This allowed me to view the tapes prior to the interview. Brian's participation in many respects represents a unique case (Merriam, 1998): he is an experienced client and he is a trained counsellor. His reasons for doing his enactment were 52 primarily personal, but he also set out to videotape his enactment with the intention of making an educational video of the process and he was interviewed twice after the enactment. Although follow-up interviews are usual in the method, these interviews were videotaped. A unique case, such as this is information rich - it revealed a great deal about the phenomenon of positive missing experience that might not have been evident in a typical case. Data Collection Plan and Interview Protocol The time commitment for the participant was a 20-minute telephone screening and information meeting, a three-hour interview, a post-interview follow-up email, two 30 -minute follow-up meetings and one email exchange. The site of the interview was my home. The participant had recently moved and we decided that the confidential offices at the university were too impersonal for the interview. The meeting started with discussing and signing the informed consent (Appendix D). The semi-structured interview began with an orienting statement. I am interested in hearing about your enactment experience and, in particular, your experience at that point in the session when the good father surrogate came to comfort you. I imagine that you have been impacted by the experience of receiving such comfort, and I would like to understand your experience as fully as possible. Please speak as freely as you like. I may ask you to clarify or expand on something. If you feel uncomfortable at any time you may pass on a question, or stop the interview at any time. We will also have an opportunity to watch that segment of your videotape together and for you to reflect again on what your experience was like. 53 I tried to let the participant speak as uninterrupted as possible, to let his experience emerge. When necessary, I asked facilitating questions (Appendix E) to remain focused on the research question. Some examples of these were: "What led you to do an enactment?" "How has the experience impacted you?" "How do you know this?" "Looking back on the experience what stands out as being important?" At the end of the interview I asked one final question: "The need for comfort and validation has been talked about as being an important part of completion after strong emotions are expressed in a therapy session, what are your thoughts about this?" "What is your experience of this?" I asked at the end because it was a leading question, directing Brian to one of my assumptions. I wanted him to know about my assumption and I was also curious about how he would respond. Despite critiques, leading questions can be useful both in checking "the reliability of the interviewees' answers as well as interviewers' interpretations. ... the issue is not whether to lead or not to lead, but where the interview questions should lead, and whether they will lead in important directions, producing new, trustworthy, and interesting knowledge" (Kvale, 1996, p. 159). In addition to the data arising from our audio-recorded interview, video-tapes of Brian's enactment and follow-up interviews, there were several other sources of data. My own notes were kept in the form of a journal containing a log of steps in the research, and insights. Recording and Transcription The interview was audio-recorded and self-transcribed verbatim using my own transcription key. Non verbal cues, particular para-verbal aspects of the participant's speech, body movements and expressions were highlighted using Lapadat and Lindsay's (1990) approach (1999) to transcription. This produced a text of fourteen hundred lines. 54 Data Analysis Data was analyzed and managed in the following ways. The first step after transcription involved reading the text several times, in its entirety, to hear what Brian had said and to get a sense of the whole without altering the meaning. A large worksheet was developed with columns so that while being immersed in the text I could begin to discriminate meaning units, placing them in the second column next to numbered lines of text. The meaning units were the first part of reduction, an attempt to get at the structure and content of what was said, giving shape to the underlying meaning of the text (van Manen, 1990). The meaning units are not units of structure alone but have meaning embedded in them. Moving back and forth between the parts (meaning units) and the whole text was a continuous process and is what is referred to as entering the hermeneutic circle (Gadamer, 2004; Patterson & Higgs, 2005). This is where I attempted to grasp the meaning of the whole text by attending to the parts, and then by understanding the meaning of the parts I was able to comprehend the meaning of the phenomenon as a whole. The reduction is much like a funnel where initial fine meaning units are reduced to broader categories or themes. Larger themes emerged with reflection on the text, literature and in conversations with a second reader and an expert, second researcher. Thematic statements were chosen to describe and support the themes through a process of returning to the text line by line and asking questions suggested by van Manen (1990) such as: What phrases stand out as thematic? What statements seem essential to the meaning of the theme and the whole experience? What does this sentence reveal about the phenomenon? Initially there were eleven themes. During repeated rounds of reflection and collaboration three of these were collapsed into one theme and two were deemed incidental and not essential to the meaning of positive missing experience. This is a form of 55 theme testing: "In determining the universal or essential quality of a theme our concern is to discover aspects or qualities that make the phenomenon what it is and without which the phenomenon could not be what it is" (van Manen, 1990, p. 107). The themes took their names largely from Brian's words and his evocative metaphors. Themes were organized into a schematic (Figure 4.1, p.70) which attempted to capture the unfolding of the experience, and the flow of experience, as Brian described it. Member Checks I contacted Brian by telephone and emailed him a copy of the themes and tentative schematic design. We subsequently met face-to-face for 30 minutes to discuss his impressions and reactions. He had several questions about how the themes might fit together in the schematic but agreed the themes represented his experience accurately. At that time I also gave him a copy of the summarized metaphors he used in describing his experience. Prior to the second check I sent Brian a hard copy of the entire chapter 4 findings. He read them over and offered two incidental corrections about story details, both of which were included in the final version. He was pleased and surprised by the way his experience had come together and been represented in the themes and schematic (Figure 4.1, p.70) and said it accurately and respectfully represented his experience. Representation of Findings Writing is a central activity in hermeneutics. It is the method, according to van Manen (1990), and requires that the text will stimulate reflection, be compelling, involve the reader directly and reflect both Brian's and my interpretations in a single voice. This made for a lengthly chapter of findings. I decided to include many long, direct quotations to ground the interpretations and remain true to Brian's words. Collaboration with a second reader, an 56 expert, second researcher, and the member checks informed my final interpretation, but I as the researcher/interpreter had final authorship. Criteria for Worth of the Study Qualitative researchers aim to be sensitive to the nature of being human and to social cultural contexts (Denzin & Lincoln, 1998). To this end methodology must both be true to these aims and articulate a pathway that can withstand critique related to its relevance and subjectivity. I used two criteria: trustworthiness and pragmatic usefulness. Trustworthiness according to Guba and Lincoln (1985) is about being able to persuade readers that the findings of the study are worth paying attention to. The activities that validate this study's trustworthiness are: prolonged engagement, persistent observation, triangulation, member checks, peer review and disclosure of researcher biases (Guba & Lincoln, 1985, Merriam, 1998). I spent considerable time before staring this project reflecting on positive missing experience, learning about it, receiving it in a therapy training environment, and talking about it to colleagues and others who have received this type of resourcing in a therapeutic situation. Consequently, I was well versed in the phenomenon prior to meeting with the participant. I immersed myself in listening to the audiotapes, watching the videotapes, reading the text, and finally, in the writing. The writing of the findings chapter was a solitary activity and extended over a full month. Persistent observation involved returning to the audiotapes and the videotapes several times during the analysis to validate the salient qualities which emerged from the text. Triangulation as it relates to the present study is a term used to describe the convergence of multiple sources of data and the views of different readers (Creswell, 1988) to support the development of the themes. In case study design multiple sources of data are considered important (Stake, 1995) because different 57 vantage points can provide the opportunity to validate, revise and/or adjust interpretations. In this case, because the client perspective was considered so vital, therapist input was not directly sought. Rather, the educational videotape was utilized as a source of information as it was narrated by both Brian and the lead therapist. In addition, a level of depth in the analysis was achieved that balanced off not having sought other perspectives on the actual experience, such as from group witnesses or therapists. Member checks were carried out to verify that the themes and findings reflected the participant's experience. Peer review was carried out by asking a second reader, who is a colleague and expert TE practitioner, to examine the themes and to read the findings chapter. This reader suggested that three themes be collapsed into one and agreed with excluding the two non essential themes. Finally, I articulated my biases, assumptions, personal experience and theoretical orientation in relation to positive missing experience at the outset of the study. These activities strengthened the trustworthiness of the findings. Pragmatic usefulness is the second criterion of worth. It is a term that refers to the usefulness of the findings. Can they be used by others? The findings have implications at several levels: participant, training and education, and practice. This criterion is addressed in relation to training and education, and practitioner levels in chapter 5. In relation to the participant, the findings offer an explanation of a segment of his experiential processing in a therapy session. Brian said the way the findings were presented affirmed and consolidated his experience. He used the metaphor of an accordion to describe what he meant. Reading the findings chapter with the themes and schematic had expanded the event, helping him see the flow of his experience, rather than remembering it as events or scenes. Like playing an accordion, this process created an expanding movement bringing back fresh memories of the 58 experience, "changes in harmonic tone, melody and flow." In addition, any reader may recognize a piece of his/her own emotional experience in the findings and find it helpful in explaining how one experience shifts and moves into another. Summary The methodology which grounded the study has been presented, and the actual procedures used to obtain the findings have been described in order to make the research steps transparent. In the next chapter the study findings and conclusions are presented. 59 CHAPTER 4 Metaphors of the Positive Missing Experience Introduction Through this research study I have had the privilege of getting a glimpse into the lived experience of one man's intense, brief, therapeutic process after receiving a positive missing experience during a therapeutic enactment (Westwood & Wilensky, 2005). This chapter attempts to describe the meaning of his experience through the combined lenses of the participant and the researcher. As Gadamer (2004) stated "a person who is trying to understand a text is always projecting" (p. 269); we are always studying ourselves, and so it is with this study - Brian's story: my story. In our short time together we realized we have several things in common. We are both experienced clients, we both share a desire to illuminate aspects of therapy change process and share what we have experienced and learned with others, and we are both involved in the business of therapy - Brian as a practicing counsellor and myself a counselling student. Our own personal family histories and learned ways of containment have surprising common threads. And so in this study our voices come together in describing Brian's experience of receiving a positive missing experience in therapy. In listening to him reflect on his experience, in sitting next to him as we watched part of the session on videotape together, in transcribing the interview, in reading and re-reading the text of the interview I have immersed myself in his words attempting to understand. The following section situates Brian, the participant, both in his own life and in the therapeutic enactment work he planned and completed in July, 2002. 60 Brian Brian is a tall, soft-spoken, attractive man who looks younger than his forty-eight years. His eyes are alive and he smiled broadly at me as he sat on my front porch watching me drive up. He arrived a few minutes early. We decided to meet at my home since Brian had moved back to Vancouver just days before. He was not fully settled in his new place and we decided we did not want to use an office at the university for the interview. It seemed too impersonal. We settled into comfortable chairs with tea and chatted casually for a few minutes before we began. It was while we were discussing the consent form that Brian explained he did not want to use a pseudonym. When Brian decided to do this therapeutic work, he wanted it to be a piece of work that was authentic and real for him. He did not want to cover up his identity and since he planned to create an educational videotape from the session, a pseudonym did not make sense to him. Brian first learned about therapeutic enactment (TE) as a graduate student in counselling psychology when he offered a personal scenario with his mother-in-law for demonstration. He resonated immediately with what he learned from having a relationship dynamic put into action. His interest was piqued. He attended TE workshops and received training in the method. Over a period of about two years Brian witnessed and participated in many enactments, often taking on roles for others. Another factor that influenced Brian's decision to do an enactment was wanting to make a contribution to the field by producing a documentary about TE in order to widen the audience and interest in what he believed to be a powerful, brief change intervention. 61 During this time Brian continued to meet with his former professor to discuss the idea of making a documentary film. As he became more familiar with the method, participated in and saw other people's enactments and the changes in them afterwards, it became clear to him that he wanted to do an enactment for himself. Brian was an experienced client. He had been in therapy many times to deal with anxiety and panic attacks. Through these therapy experiences Brian had gained considerable understanding and many strategies to help him deal with his anxiety. He could articulate it all very well at a cognitive level, but he felt he never got to the source of it. He recognized that the theme of low self confidence he continued to deal with and its behavioural manifestations - freezing, hyperarousal, striving to please others - were quite entrenched coping strategies that sometimes interfered with his relationships. Brian had also identified an organizing theme in his life related to these coping mechanisms and was able to link it directly to his early experiences in his family, specifically to his relationship with his father. This organizing belief was "I am not lovable as I am". He felt he had struggled with this for years and although his previous therapy experiences indicated this was not true, he was unable to shake this entrenched feeling that deep down inside something was wrong with him. After all, his father's dismissive stance and unpredictable outbursts towards him must mean something was wrong with him. He felt it must be his fault that he did not receive what he so wished for - the love and support of his father. Being bright and resourceful, Brian quickly took up a watchful stance around his unpredictable and sometimes violent father, becoming expert at spotting subtle cues and energy shifts that might signal danger or reactivity. Brian knew he did not ever want to be angry, nasty or abusive like his Dad and remembers being watchful and considerate, noticing 62 and responding to the needs of others. His spontaneous, fun-loving nature prompted him to entertain and lighten the atmosphere rather than retaliate with anger. These strategies worked for Brian. They not only matched his own kind, humorous, and positive nature, others responded positively to him. Out of awareness and over time these smart, adaptive and natural responses became habitual re-enforcers of a theme: "I am lovable when I am funny and entertaining"; "I am lovable when I am helpful and care for others". Being hypervigilant taught Brian to be a keen observer of others, it helped him feel safe. Unfortunately it also kept him circling around his earlier memories of interactions with his father. His patterned ways of managing a very stressful and sometimes dangerous past were still operating. He identified and named four parts of himself that he recognized as symbolic in his interpersonal coping (management) strategies: hypervigilance, performer, caretaker and counsellor. Through his experience with enactment he began to understand the concept of repair. His goal was to return to a traumatic event and to receive the comfort and support of a good father. He did not want this to be his own father. Rather, he wanted someone representing his Dad to watch what should have been done, to see how he needed to be fathered. He believed this would provide him with an experience he never had, and that it might unlock something and serve as a resource or new foundation upon which to draw. He also wanted to better understand how his coping strategies worked both for and against him in relationships. He carefully planned the enactment with two therapists he trusted. Brian selected people to take the roles of himself as a young eight-year-old, himself as a fifteen to seventeen-year old, his father, his mother, his wife, and a surrogate good father. He also chose four people to represent the four parts of himself he identified earlier - his hypervigilance, his performer, his caretaker and his counsellor selves. He met with each person inviting them to participate 63 in his enactment and briefly explaining the role he wanted each to take. These individuals and some other trusted friends formed the group in which Brian did his therapeutic work. Brian selected two key scenes from his earlier life to enact that would bring alive the trauma he experienced in the relationship with his father. The first scene was at home when he was fifteen years old and was physically beaten and thrown down the stairs by his father for drinking from his Dad's pepsi bottle which his father reserved for mixing drinks. The second scene occurred when Brian was seventeen. Brian seriously injured his knee while watching a football game. His father discounted and ignored the severity of Brian's injury and demonstrated only frustration and disappointment with his son's inability to get up and not be hurt. He packed Brian into the family station wagon, and required him to wait for two and a half hours in the car until the game was over when he was finally taken to the hospital for treatment. Brian endured silently and up to the date of the enactment had never expressed either his physical or emotional wounding at being abandoned and humiliated/shamed. Brian also planned a sculpture in which he would be able to see how the four parts of himself directly impact his life. The other details he left to the therapist directors, including the role the good father would play, knowing they would weave him and other essential elements in as the enactment progressed. Despite the planning and Brian's previous experience with enactment his anxiety grew as the session day approached. With a self selected group and two trusted therapists, safety was quickly established and the enactment began without much warm up. The sequence of the three-hour session, as viewed on the videotape(s), included the following thirteen segments. 64 1. The group started with introductions and with each person stating their reason for choosing to be a part of Brian's enactment. In addition, each person explained what they needed to leave behind in order to be fully present for Brian. 2. The enactment began with Brian re-connecting to a part of himself he had locked away for decades. Brian brought his story into the group by walking around the center of the circle with one of the therapists and talking about what he planned to do. This allowed him to find his central place in the group and to leave some of his anxiety behind. 3. a. Brian introduced the person playing his eight-year-old self by bringing him into the center of the circle with himself and the therapist. This role was introduced to provide Brian with a resource symbolizing comfort and safety. Concretizing and externalizing his gentle and innocent self at eight years of age and knowing that this child self would be held by the chosen "good father" provided a safe place for Brian to return to for relief when he needed it during the enactment. This was a touching and impact/full scene as Brian reconnected to feelings of intense sadness and longing, and a strong desire to protect his young, innocent self. The use of another person to double in and play the part of the client at key moments in TE allows the client to watch scenes and action at a distance. In this way new and different perspectives on interactions and dynamics are gained, client fears are reduced, and the possibility of re-traumatization is contained (Westwood & Wilensky, 2005). Doubles (as with others taking on roles) were carefully directed by the therapists to ensure that interactions represented what Brian explored and described with the therapists in planning the enactment. 65 b. Next, Brian introduced the person who would play both his fifteen and seventeen-year-old selves. c. Brian introduced four parts of himself which he believed might interfere with him being able to stay in his present experience during the enactment. These were hypervigilance, performer, caretaker and counsellor. This allowed Brian to see these qualities and behaviours embodied in someone else, experience how they moved and interacted with others in the group, and gave him a clearer picture of how they were impacting his life. During this exploration Brian found his voice in telling each part how they were to remain subdued until he called upon them again. It was the emergence of the voice he needed for the next scene where he confronted his father. 4. Brian spoke to his wife and mother about what he was about to do, letting them know he only wanted them to watch so they could understand his experience. 5. Brian introduced his father, initially having difficulty connecting to his father's voice and how he would talk. While walking in the center of the circle with the therapist and the person he asked to play the role of his father, Brian gradually connected to the intensity of his anger. In this scene he confronted his father about being beaten over a minor incident when he drank from his Dad's pepsi bottle, something he had never done before. 6. Next, the therapists asked Brian to do a role reversal where Brian took the role of his father and the man playing the role of his father became Brian. This was done to uncover Brian's felt sense of how his birth, when his parents were newly married and his mother was only a teenager, may have impacted his father. This was a surprising piece as Brian did not realize it was he who voiced his father's insecurity and sense of 66 being displaced even four days after the enactment. He thought it was a member of group who suggested it. 7. A sculpture was created with hypervigilance and caretaker parts to illustrate how these behaviours kept Brian closely circling around his father. Hypervigilance was on constant watch for danger and violence while caretaker was longing for love and seeking connection. This powerful tableau demonstrated why Brian felt so trapped by the dynamics of the relationship with his father. 8. The scene from the football field where Brian was injured and abandoned and humiliated by his father was next enacted. Here Brian re-lived the pain of the injury and the deep wounding which resulted from being abandoned by his father when he was left in the family station wagon alone for two and a half hours before he was taken for treatment. The surrogate good father was directed to enter once Brian had given full expression to his pain and grief. This intervention allowed Brian to complete his emotional expression of pain and grief as he literally vomited up the old trauma from his body. It is here that the study question begins to look at the lived experience of Brian receiving a positive missing experience. 9. Brian was held and reassured by the good father and he was corrected when he told the good father he wanted to be a good son. He was told he is loved regardless of good or bad. Brian let out an audible sigh as his body relaxed and he sank fully into the support of the good father surrogate. Later in this scene Brian sat between the surrogate good father and his eight-year-old self and made a commitment to protect his young, gentle and innocent self. He later referred to this scene as the love train. 67 10. The four parts of the self (hypervigilance, performer, caretaker and counsellor) were brought back into a sculpture. Brian directed them to sit around him at distances and locations he thought would work for him in the future. Brian stepped outside the sculpture to get a visual memory of what he learned. In the middle of this Brian spoke to his father and said he hoped his Dad had learned something about his son by watching. In particular Brian hoped his Dad realized that being manly can include being sensitive and caring. 11. Next Brian spoke to his mother and wife about ways things might be different and how their relationships may change as a result of the enactment. 12. The group members were guided through a symbolic dropping of the roles they played in order to help them re-ground in themselves so they could be fully present for the debriefing of the enactment. 13. Debriefing consisted of all participants speaking about their own personal experience of the enactment, with no analysis. The group and session was then closed. These fifteen segments of the session can be linked to the process stages described in the inverted " U " diagram of Figure 2.1 (p. 17) of a therapeutic session (Kurtz, 1990). Segment 1 and 2 begin the process of contacting Brian's experience and story. The group is formed and Brian takes his place as an individual doing therapeutic work in a group context. This is the ground work of building an inclusive, safe and meaningful context in which therapeutic work can begin. Segments 3 through 8 are a dynamic interplay of accessing Brian's deeper emotional, sensorimotor experience and the processing of these states. In the key scene of segment 8 the positive missing experience is provided in the person of the surrogate good father and this marks the end of major processing and the beginning of integrating the 68 experiences. The integration phase carries forward into segments 9 through 11 with segments 12 and 13 marking completing. These phases are discrete theoretically but do overlap and fold back onto one another experientially. The focus of the present study, the deliberate and strategic offering of a positive missing experience, begins in segment 8 and ends with segment 11. The following section contains a description of seven themes which emerged at the horizon of Brian's reflections and interpretations and my own. Themes Seven themes emerged from the interview with Brian. While the themes are presented separately, it is important to know that each is linked contextually to the others and is to some degree pre-determined or emergent in the previous processes, events and emotional states. As a result many detailed personal quotes from the text of the interview are offered to illustrate the uniqueness of each theme. In these rich descriptions one begins to understand the meaning of Brian's experience as the patterns (of experience), which are the themes, emerged and unfolded. The schematic presented in Figure 4.1 (p.70) suggests a flow of experience as well as progression and a sequence over time. While each theme is presented as an important or essential feature of the positive missing experience, they cannot be easily separated from one another. Each theme arises as distinct from the others. In addition, the phenomenon of the positive missing experience itself is only one part of Brian's complex, experiential therapeutic session; a session which Brian enacted within a group. Theme one: longing/receiving is central to the construct of the missing experience because it names the desire and need for what has been missed and then received. As such it 69 is intrinsic to the theoretical notions of the other six themes. Brian's own words capture this: "it's both the destination but it's also, it's also the energy of the whole process . . ." For this reason the longing/receiving theme is placed at the top of the figure and the other themes rest one upon the next. Longing/receiving is the beginning and the end; it both roots the others and streams through them. Although each theme appears to follow another sequentially, some overlapped experientially. This is particularly so with the three themes of embodied sense of an intact core, vantage point, and things start falling into place. They are therefore placed touching one another to illustrate how each supports and extends the other(s). Figure 4.1 Themes of the Positive Missing Experience 70 Theme One: Longing and Receiving The name of this theme brings together the inextricably intertwined human need for love and connection with the attuned sensibility and desire to respond with care to another - to need love and to be loved. Longing is a term which often signals the voice of the deeper self connecting to needs and desires. The coming together of the two is the essential relational experience. This theme encompasses what Brian sensed he was missing in his life and development - the missing experience - and what he felt he needed in order to move forward with a sense of more confidence and ease - receiving the positive missing experience. Each is the reciprocal of the other, like a lock and key, yin and yang. What is missing is recognized, provided and received. In Brian's situation the longing is about unfulfilled love, missing the experience of being loved and lovable in the eyes of his father and free to express his own love for his father. In his own words he said he had tried many forms of therapy in the past, he had learned many things but "there was always this sense that there was something internal that was always operating that I couldn't get to." He wanted to be able to understand and manage his hypervigilance, anxiety and panic better. He also wanted to see how his caretaker, counsellor and performer selves so reliably and automatically emerged in his relationships. He instinctively knew what he needed and planned his enactment to experience the good father in the hopes it would be "the piece that hadn't been done yet. (Hoping) that I was going to get something that I had never got before." Brian uses a powerful metaphor to capture this elusive pairing: that it was, k i ' , you know, click, click, click, it was filling these cylinders that have been, these cylinders that of sort of wanting, that have been there just ready. It's like 71 you know, I've been ready all my life to give (and get) this kind of love and it's just, has never happened. Brian described his father as self centered, volatile and periodically physically abusive. In relation to his father he described himself as: "being in fear, of this little, dynamic, ah, almost explosive man that could, uh, at the drop of a hat, all of a sudden he'd come right in your face. So there was a lot of fear, a lot of freezing." He was "very overpowering ... you had to be on egg shells and there were certain cues ...". He struggled to recall any instance of physical closeness with his father: so, you know, this issue with my father and, and all that kind of yearning and wanting and trying ... that the only thing that was really desired was just to be loved. And then the flip side of that was not getting, or at least not getting to the way I wanted. Immediately before the segment of the session under study, Brian had confronted his father in the enactment for beating and kicking him over a minor incident. During this, Brian's anger and rage were spontaneously aroused, experienced, expressed and then processed to completion. He was able to link the fear, terror and rage he had felt at the time and speak to his father about the impact upon him. Next Brian was asked to lay on the floor assuming the position on the football field where he had injured himself. The therapist then asked Brian to give voice to the pain he had experienced and not expressed. It was at this point the good father entered. When remembering how close the good father surrogate was in the enactment Brian said: my father has never, ever come that close to me, ... maybe when I was a boy, a baby, ... but I have no memory of having my father's face anywhere near me. I never had that 72 experience. Not in that context, I mean, I, you know, I've had partners and romantic interests ... this was more, uhm, the male thing ... Brian was missing his father's love, acceptance, support and reassurance which was exemplified in the enacted scene on the football field when Brian was injured and his father responded by saying "oh he's ok, he's just goofing around like he always does". He did not understand/acknowledge Brian's fears, pain, and embarrassment. Brian was at that moment alone and he remained silent and unmoving while he was taken to his father's car to wait for the end of the game before going to the hospital. As we watched the videotape clip of the positive missing experience Brian smiled when he saw the good father surrogate jumping from his chair the moment he heard Brian's cry, only to be held back by the therapist "because it was important for me to keep getting some of that out." He said: "that's exactly why I picked that man, right, cause he, you heard that scream, he was off his chair, he was coming..." The good father instinctively knows what to do and he does it. It is in this way of being that what is longed for is given and received. The lock finds its key, the yin nestles next to the yang, the empty container fills. In the following words Brian captures his embodied experience of what he received from the good father. I was feeling all the things that I felt when the injury first happened, and yet, because ... I was laying down and he was his, his face was really, really close to mine and his voice ... where I was laying was like a little echo chamber in there, so his voice was very resonant and ..., it filled me it wasn't just that I could just hear him in this ear, it was all around me. I was able then to totally ... just totally and absolutely let go. Just I don't have to think about anything, I don't have to hold this anymore, I'm not alone, um, I don't have to worry about shame, I don't have to worry about guilt, I 73 don't have to worry about fear, I don't have to worry about disappointment cause this person is now here and is going to make everything ok. ... The following metaphor speaks to the energy and aliveness of the connection Brian experienced when he received what he had been longing for. ... yet there was a hand on my back cause he came in really close and he knelt right down so I can feel, and I could feel his head on my head, he was that close, I could feel his breath, I could hear his voice, that close, I could feel his um, his hand on my shoulder and then there was a, the only way to describe it there was a vibrational energy, it was like, um, my field and his field came together in what would be called an appropriate, an appropriate, uh and the other word would be, um, healing, I guess, interaction or connection. But there was like this, this, um, this little tiny uh, ridge of energy that was between us that was crackling, that was warm, that was uh, That was uh, that had this energy of, of, uh, well healings not the right word but it just... I felt myself it was like I was enveloped with this, um, like a force field of just containment that was warm, right that was, um, that was right. But it was a, this was like a completion of something that has never been there, that I think I've always wanted. A major piece of Brian's work in the enactment focused on having missed out on the experience of being understood, seen, accepted and loved by his father. Rather than having his behaviours and feelings recognized, understood and tolerated he was frequently ignored, berated and sometimes severely punished. Sometimes his father was unable to tolerate Brian's strong feelings, even the playful, seeking and striving ones. In addition, when misunderstandings or more serious ruptures in the relationship occurred his father was unable 74 to initiate any sort of repair or effort to rebuild the relationship. Brian learned to manage his feelings and depend on himself by being watchful or hypervigilant, by entertaining and being funny in order to smooth things over, and by looking out for the needs of others, caretaking. In this way he conformed to some form of ideal Brian who would be loved because he had few needs. However practical and adaptive these strategies were in the past, they were formed as part of a defense, a containment of deeper and more primary emotions and needs. Over time they served more to keep Brian comfortable and, paradoxically, began to interfere with relationship rather than enhance connection. From a therapeutic point of view the therapists carefully matched what was missing with an experience of what was needed - a good father surrogate who gave direct physical, verbal and emotional support and care. This was strategically offered after the scene described previously where Brian confronted his father, expressing rage he had never expressed before. It is this embodied provision of the missing experience that communicated to Brian that he is lovable. His feelings of anger and pain were recognized. They could be held, they made sense, they were acknowledged as legitimate. The pain was soothed and relieved. Brian did not have to contain any of his suffering, his confusion lessened, he was less overwhelmed by his fears and immediate pain, he was not alone. This is a positive missing experience. By deliberately offering Brian a new relational/emotional experience after he expressed his anger and rage towards his father and while experiencing the pain of injury, he is able to move forward. The experience of receiving from a caring, available and responsive other in the person of the surrogate good father provided exactly what was previously missing. As a result, Brian was able to release old, stored pain and grief. It's almost as if the things frozen inside after years of managing them by being hypervigilant, by caretaking, entertaining or 75 counselling were thawed and began to flow. He did not have to rely on old containment patterns, he could allow his emotions into his immediate experience. This affirming process has the potential to bring about therapeutic integration and resolution (Alexander & French, 1946/1980; Fosha, 2000a; Hartman & Zimberoff, 2004). The experience of having something that was previously not available or taken in sets in motion an opportunity to experience both the way it was with the way it is; to experience and express conflicting emotions associated with years of "not having/not receiving" and the new experience of "having/receiving." This was Alexander & French's (1946/1980) idea of a corrective experience - helping clients to recognize and free themselves from past influences in present patterns. Experiencing something so positive and so wished for is often also painful. The two experiences come together creating a state where what wasn't possible is possible. Brian's words about this follow. ... , it was exactly what I wanted. It was no artificiality to it, it was, it was no, oh again, this is just an abstract thing, this is a, this is a symbol to the father I always wanted. At that moment that was my father, and at that moment everything that was being said to me, and the touch, and the breath that I could feel, his warmth is, was real as anything I've ever experienced. In a sense this theme is foundational to the others. As Brian so aptly stated: the good father: "it's both the destination but it's also, it's also the energy of the whole process." When he came in response to Brian's cry of pain, things really started moving. Theme Two: Things Start Moving The second theme is things start moving. With the arrival and reassurance of the good father Brian described things moving in his body: energy mobilizing, emotions emerging, 76 bodily sensations coming into awareness, muscles contracting and relaxing, thoughts coming and receding, awareness shifting. A poignant example of this follows. What Brian experienced at this point was the cracking of his defenses against letting himself feel and acknowledge these powerful feelings of overwhelming pain, loss and aloneness - feelings that were too large and threatening to let into awareness in the past. With the support, mirroring and physical holding of the surrogate good father Brian no longer needed to contain his despair, he was not alone and so things started to move, the pent up emotion began to emerge. .. .the pain felt more localized (he had injured his knee) in my knee. Before that the pain was just seemed like it was all from the top of my head to the tip of my toes. And then, when the good father came and started to talk to me, I felt him close and the reassurance and that he was here when it just seemed to be, the pain was where it should be in the knee. But I didn't have any of this pain in my, in my core, I didn't feel this pain in my spirit. The pain became more localized in his awareness and this made sense to him, the pain was where it belonged, in his injured knee. Brian used metaphor again to express his understanding of what occurred. There are three motion filled images which speak for themselves. In the first he describes the movement as tightening followed by loud vocal sounds. The invitation and permission from the good father to let his pain go, in fact to give it to him seemed to open Brian's expression of pain. And there was a feeling of relief and release so when he said you know, you're, it was just magic, remember when you were eight and you used to hurt yourself and 77 squeeze my fingers and give me your pain, give me all of your pain and (I) started to squeeze that, uhm, then there was this, just this tightening that went on in my body and I started to, um, actually started as a groan but then it became more of a of a roar and that was just this and then became a scream and then from the scream I started to vomit. I actually felt I was bouncing off the, I felt that I was actually bouncing up and down and at a couple of points before I started vomiting, it felt like I uh, I was like an elastic band, a real taut elastic band so if it, this little twang that would happen here then the little ripples that would go all the way to the end and, and it felt like I was very.. .it's a funny feeling. Brian surprised himself with this scream and roar: "my whole life I never made a noise like that." The human soul has been referred to as a wild animal (Palmer, 2004). When injured it will often hide out, licking its wounds, roaring and snarling when approached. and it was kinda like this feeling of uh, flow and it was a , it was a feeling of relief, but at the same time a feeling of tension, this feeling of a, of a surging energy that was just building and building and building and then all of a sudden I started to vomit and that was a very strange experience because it was almost like all that energy that, that that roaring, that screaming in the body just going up and down, up and down, up and down I didn't know where that was going to go but I just kept going with it, it just felt like that keep, just keep getting and he kept saying it: let it all out, let it all out and I was letting it (and) all of a sudden, it was like someone just pushed a little button, and it, oomph, like ... the vomit reflex ... it just opened up and I actually thought I was going to be vomiting matter. I thought I would, it would be, it would be physical. 78 He explained what he thought started to move. I think that, uh, you know, there was so much that was held in from that moment on ... so much pain, ... so much anguish, disappointment, uh, bitterness, regret, sorrow, grief, guilt, disappointment, ... and expectation that I wanted to be taken care of, all of that was there and I think it just, it was inside me all of those years so that felt as raw but yet as um, right as anything I've ever experienced (um, hm) cause it was like when that opened up and I started vomiting it was from the tip of my toes to the last follicle on my head. It just felt like this whole channel wide open, this purging, this sort of release was going on. ... it was this, kinda of whee yeow it's almost like a colonic, you know, you just flush it all out. ... "Oh, yeah, uh, I, for days afterward, lots of movement! The responsiveness, care, and holding of the good father initially had a releasing effect on Brian. In a way it served to counteract his usual containment pattern. He was de-contained, he was coaxed to let out all his pain, he was urged to give his pain to the good father by squeezing his hand. At the same time the good father let Brian know he was able to hold him, he was able to share the pain. It was not overwhelming, it was possible to have the pain and be re-assured that he would be helped. With this kind of support, affirmation and acceptance Brian was able to literally vomit up his past trauma. Once the pipe opened old pain, grief and despair also emerged and flowed out. This powerful response to the loving kindness of the good father was immediate and in retrospect was announcing therapeutic integration (Fosha, 2000a, 2000b). 79 Theme Three: Alchemy of Repair The third theme is alchemy of repair. The New Oxford Dictionary of English (1999) describes alchemy as ".. . the medieval forerunner of chemistry based on the supposed transformation of matter. It was concerned particularly with attempts to convert base metals into gold or find a universal elixir [of life]" (p. 40). Earlier we heard Brian talk about a vibrational energy that crackled between them. This theme is infused with fire and incandescent references. Brian's language is peppered with words like electric current, bonfire, burning energy, burnt stuff, fuse box, electrical wiring. As in alchemy where ordinary metals are transmuted by fire into gold, we hear Brian say that when he came together with the good father the energy created was like a bonfire, enough to burn old debris. Like the phoenix rising from the ashes, the old base metals are forged into gold in a fire ignited by relational sparks. The idea of something being corrected is introduced when the attentive good father interrupts and reassures Brian when he tells him he wants to be a good son, that he is prized regardless of good or bad. This is like sweet balm. The sigh and relaxation in Brian's body were immediately seen and heard on the videotape. A corrective emotional experience has been described by Alexander and French (1946/1980) as exposing a client to a previously overwhelming situation under more favorable circumstances, namely with a therapist or other group member who is supportive and kind rather than critical or neutral. Deliberately providing what was missing through the person of the good father was a corrective emotional experience since Brian had the opportunity to respond in a new way. This is how Brian described that moment: 80 these scripts are very old and I make a statement about being good enough and he, he corrects me and there's a sigh, there's a release in my body (he literally sighs at this moment of telling) where it's just like 'whew' ... I can let go of that. So, you know, even after I had that experience of vomit(ing) and everything, I still, you're still hanging on to those old schemas. This exchange seemed to open up a channel for Brian to receive the affirmation at a deeper level and to allow him the confidence and trust that he could reciprocate this affection. The relational circle was completed, he was in full connection. that was very powerful .. .getting what I wanted, but probably even more important, meaningful and powerful is to be able to love back. ... And that's something that probably I , not probably, that I always wanted to do, to love my father that way. ... This is just off the top of my head now, but probably without that I wouldn't feel the same level of self love. ... It's almost like dealing with an electrical current. You gotta have the, the whole, the whole circuit has to be otherwise nothing can move this way. So I'm getting love and it feels good ... and I'm being prized, but it's almost like half the circuit and until I can turn it around and give it back there's no flow there. This touching exchange of affection had a healing or reparative impact on Brian. He had a sense of something being cleared, pruned, flushed away. In this moment he could trust the natural flow within himself and he could drop his trusty guards - his protective self-descriptions as hypervigilance, caretaker, performer and counsellor. He felt lovable and worthy. 81 you know it's like a very central point in the plumbing there was this faulty piece of pipe that wasn't completely busted, ... there was water flowing, but it was, uh, rusted, ... and there was a leak and it caused stagnant water and there was mold growing and, and so this area was always like that even though there was no indication that there was something wrong with the system. ... it's like that piece of pipe has been, uh, fixed and all that moldy water has been cleaned up and that area is now intact. I still have the same flow but I don't have this wound ... this self, this persona ... of unworthiness ... being unlovable ... there was like a relaxation. I don't have to question anymore. The healing connection that was described earlier is an important element here. Healing implies the re-activation of self restoring, natural capacities and energies. At the beginning of the interview, while describing his many experiences in counselling, Brian used the analogy of having a messy yard, of raking everything into a huge pile. The pile continued to get larger and larger, more compacted and he could no longer stick a rake in it. The alchemic forces are at work in this metaphor of a bonfire which Brian used near the end of the interview. I think it's like a big bonfire was lit in that pile and all of that... energy and everything and so a lot of that burnt but there is a residue, there's ash and there's uh, marks and debris that's left after the fire went out and that has um, been kind of spread out kind of like you would do I guess, after you, if you had a big bonfire and spread out the ash and everything, and let it go back in the soil. Let it, let it kind of um, become whole again. So you know, so, you know, maybe that begs the question is there more raking that has to be done or another bonfire but it doesn't, it doesn't feel like that, but that, using that metaphor that things are growing from that, things 82 ... have been, been pruned. ... Well I really believe that it repaired ... this faulty pipe, moldy ground, but this, this wound. After a brush fire the gray and black-ashed soil is nutrient rich. Nature will gradually take her course in restoring the original vegetation. Brian felt something new and fresh inside himself. Another metaphor related to fire followed directly after the bonfire. yeah, it's very much like i f you've had this old, if, you know, you have this old fuse box and the wiring is really old and you've had a few electrical fires and, and you've gone in there and you've mickey-moused it and you've, and you, you can see the burnt stuff and some of these wires are frayed, it's like going in and completely rewiring everything with really, really top quality stuff, done professionally. You know that it's got a, it, it, it meets all the standards and that it's gonna work and you're not going to have this, this mess, you're not going to have a short circuit, you're not going to have an overload. Things aren't going to burn out. So now, the wiring is intact. It doesn't mean that it always leads to uh, you know everything being beautiful or everything is wonderful there's still, life still happens. But the central, the central wiring now is healthy. Brian had a clear sense that being cared for and held by the good father would be and was a major piece of his work. In fact he said; "it's both the destination but it's also, it's also the energy of the whole process. The energy of the good father was kind of the energy I was already using, even before I got there, even without knowing it." Pure gold. The metaphor of the bonfire illuminates the transformation which occurred when Brian expressed his deep pain and grief through bodily shaking, muscle contraction, weeping, roaring and finally retching in the attentive, loving presence of the good father. The 83 tremendous power of such a connection and affirmation literally ignites and potentiates Brian's ability to express feelings that were previously too frightening to either experience or voice. He was able to be vulnerable enough to express his pain, fears and his affection. What happened here corresponds to what Siegel (1999) describes in the window of tolerance. There is just enough activation to keep Brian on the proximal edge of his awareness, just enough emotional and physiological arousal for him to experience what he had previously avoided, but not so much that he retreated into old patterns of containment. The fires are hot enough to melt the defenses, and release the flow of held material. This seemed to usher in a cognitive/emotional/somatic/relational shift in Brian where he experienced a trust in his own sense of reality, of not having to question himself. He was able to physically relax into himself. This powerful relational experience is now available for Brian to use and build on in his relationships. He has connected to the elixir of his own life, himself. Pure gold. Theme Four: Embodied Sense of an Intact Core The fourth theme is the embodied sense of an intact core. As Brian took in the nurturance from the surrogate good father natural healing energies were at work. Being in touch with aspects of himself that had been hidden; he was able to feel his authentic, core self. This was not a real self but a real experience of the self (Fosha, 2000b). From this deep place of authenticity Brian rediscovered who he had always been. He used a powerful metaphor to describe a sense of clearing things, settling into himself, of touching down inside his authentic self, reconnecting to what was always there. And so, when it happened, it was just uh, so ... That's why I felt so real, I think, that's why it was just so, uh, intense and so spontaneous, because it's, you know, it's like the plane has been circling to land, it knows, it knows that once it lands what it's 84 going to do but it, you have to get the clearance, you have to, actually bring the plane down to land and that's, we were in that, in that pattern, it just, everything was natural. When we have an experience of ourselves as being deeply authentic, even when it is painful, we often experience a sense of our own truth. As Brian reflected on this metaphor he remembered how real and right this all felt and continues to feel. In his own words he said: "I didn't have any of this pain in my, in my core, I didn't feel this pain in my spirit, I didn't feel this confusion in my head, I didn't feel any of that. I felt, uh, I felt, uh, that everything was right." He repeated: " . . . that speaks to how, pure isn't the right word, or maybe how right everything was." Brian also expressed a sense of being new, re/newed, connecting to the untouched core of himself exemplified in the sweetness of the eight-year-old Brian, who was so present at the outset of the enactment. He described this: "at the same time it brought in um, um, a feeling, a sensation, a, a new self that has never been there." He explained this further by talking about an embodied feeling of being whole and intact and being able to count on this solid inner sense of himself. So I don't have to doubt myself, I don't have to say, uh, you know you're unworthy or you're, you're, um, there's something wrong with you or you're unlovable. The sense that I'm lovable, the sense that, that I'm worthy of, of that I'm of that kind of care, the sense that I, I've experienced it, that I've felt it, and felt how good it is, recaptured that 8 year old self, held that really, really close, nurtured it, knows how important that is. That's all nicely intact in the centre. He continued. 85 It's not like there's this core issue here of worth, this core issue of acceptance or self love, that is a, an intact resource. That's an intact self, that's an intact memory, that's an intact experience that I, I don't have to question, I can bank on. Brian further explained the sense of trust and confidence he had in his embodied experience of his core self. So, wh', i f it's the wire analogy, because the wires are all intact and I can trust it, I can go and turn on any light I want, or I can plug any appliance in, into the outlet, know that it's going to work, know that it's not going to have any detrimental effect. It's not going to start another little fire. So I can do whatever I want whether it's a video camera or I'm painting or whatever I'm using in that electrical outlet, I can use it with great gusto and great assuredness and, and not have to think about what is the impact it caused, what's gonna happen, when I plug that thing in, because I can't trust it. This phenomenon is eloquently described by Diana Fosha (2000a, 2000b, 2004) in a discussion of metatherapeutic processing in which certain affects emerge as markers of transformation. Fosha maintains that healing affects emerge spontaneously when emotional pain is soothed, and when a person is emotionally responded to in just the right way for the situation. She refers to two types of emotion - "feeling 'moved,' 'emotional,' or 'touched' which (she thinks) appear intimately linked with the recognition of the transformation of the self toward greater authenticity, and feelings of 'love, gratitude, appreciation, and tenderness' (which) specifically arise toward the affirming other" (p. 80). Brian's own relational capabilities emerged spontaneously, both in relation to the good father and to himself. His words, kisses, affectionate gaze, and voice tone on the videotape vividly 86 conveyed this transformation. After viewing the videotape he described a new confidence he felt in himself, a trust that he knew he was ok, he was intact. Going where it had been unsafe to go (into the shadow or hidden aspects of the self) reveals those "parts of ourselves that we fail to see or know" (Johnson, 1991, p. 4), and these are not infrequently insights, creative impulses, good qualities. They feel new. Connecting to the positive, the worthiness inside his own shadow marks the transition to healing. Being able to articulate this speaks to its integration. Theme Five: Vantage Point The fifth theme is vantage point. The New Oxford Dictionary of English (1999) defines vantage (point) as "a place or position affording a good view" (p. 2045). When Brian was sitting safely in the arms of his good father the therapists asked him to bring in his eight-year-old self double. The three sat together - father behind, Brian himself in the middle being held and holding onto his younger self. This segment of the tape was infused with lightheartedness, an ease that was not previously evident. The following passages contain Brian's words about this position. that containing piece of sitting there on the floor with the good father, arms right around, I was able to ah, you know bring the little part of me, so I was sitting in the middle feeling the weight, and the, arms and the breath of my good father behind me but also holding on to the little one in front of me. And it was k i ' , it was almost like from that, from that vantage point, everything slowed down and everything felt um, very safe, very warm, very um, accessible. Like it was like, you talk about the cat-bird seat,... well that's an expression, I can, you know cat bird is the best seat when you see everything and you have control over everything, you're in the cat bird seat. 87 Interestingly, Brian was unable to say where he learned about the catbird seat. The expression is idiomatic and is the title of a story written by James Thurber (1942). In this story the phrase is used and attributed to Red Barber a baseball announcer in New York at the time. In Thurber's story: "sitting in the catbird seat means sitting pretty, like a batter with three balls and no strikes on him." Brian continued with this theme. you know, like, it was just literally the throne that now ... the throne, the throne would be the other thing. So sitting there you know, in this, in this seat of entitlement, and everything is my kingdom, everything is, everything is mine, everything. I'm accessible to everything I have control over. And there was, there's no question about that, there's no uncertainty about that, there's no uh, insecurity about that, there's no dissenting voices, there's no uh, there's no voice of, of wondering if, having to justify, so can in that sense of warmth and security can just then, take the next step, which is to this is what I want. This is what I'm going to do next. I think that that is, I think that's very true ... of what happened. Because uh then, you know, I was almost energized, sitting there, even though I was very tired, Brian chose the images of a tuned piano and a pianist to further describe this experience. It beautifully illuminates the relationship between the positive missing experience and having access to a bigger perspective, a vantage point. ... I think it's very much like, uhm, a tuned piano, it's very much like a resonated chamber that's, that's been properly uh, placed and uh, properly, you know everything that happened after that experience with the good father and everything, uhm, made the frequency really, really pure. ... you know if a master or i f a pianist sits down at the piano and it's, it's ready to go, then the music comes out of them 88 they don't doubt, that's what they were, so they just pound the keys and go: wow look at how, look at how amazing that is. And that's kind of, you know, when I got to that point everything was tuned, everything was layed in front of me and I just could sit down and start going. This metaphor is rich. When Brian connected to his embodied sense of himself he had a sense of what was true for him. This truth sense is a positive affect and as such seems to allow for perspective taking (Fredrickson & Joiner, 2002; Fredrickson & Branigan, 2005). Brian told me that it did just that. The tuned piano speaks to the knowing good father who responds in just the right way to his son. This is attunement. This tuned/ness allows the pianist to rely on the instrument, to allow the music to come when he presses the keys he knows. The metaphor beautifully ties together receiving a positive missing experience, reconnecting to a sense of an embodied intact core (what is known by and to the self), and having a vantage point where things are seen clearly, in perspective. In Brian's words: "when you get something at that really core that just kind of, um, settles things and you can feel for the first time in your body that you matter, and that you're worthy and that you're loved, from that place other things are more possible." And then things start falling into place. Theme Six: Things Start Falling into Place The sixth theme is things start falling into place. While sitting in his catbird seat Brian was asked by the therapists to consider and do a number of things: to place the four individuals, who were taking the roles of his defense strategies (of hypervigilance, caretaker, performer and counsellor) around him according to where he wanted them; to speak to his mother and wife; and to speak to his younger self about protection. Watching himself on the 89 videotape in this safe position he talked about how surprisingly easy it was to do these things, despite his fatigue. ... you know sitting together with a the good father behind me and my eight-year-old self in front of me. I just felt really, really good. It felt warm. It wasn't a surprise there. And bringing the parts of myself back, it wasn't really a surprise there just kinda flowed. I think from after that whole, sort of really dramatic stuff with the good father, I think it was just kind of, I'm not going to say it was, it wasn't anti-was very warm, it was very, um, very relaxed, it didn't have any, any, I don't have any remembrance, of pain or discomfort or felt that uh, you know, I could probably fall asleep, there's a couple of points where I wantedto fall asleep. Especially when I was being held by the good father and then any, the tasks afterwards which was to, you know, to tell myself especially tell myself what I would do to protect that self, bringing back the parts of myself, talking to my mother, talking to my wife at the time, about what would be different. A l l of those things just seemed to be natural and right, and just the culmination of the stuff we'd already done. He reflected about this again, expressing his curiosity and surprise at the flow of his decisions, the accuracy with which he placed the four defenses, positions which he recognized to still be accurate five years later. I remember thinking when I was watching this afterwards: sure answered quickly for all these questions. There's a lot of questions coming at me. Didn't even think about it, just kinda like, like it was, just the most natural thing in the world. .. .This was a, a bit of a surprise after I saw how quickly I, uh, bring em all, bring em all in, cause it seems like I was completely in tune, kind of really congruent, and uh, really ah, sure 90 a sort of, just kind of confidence I don't usually have, cause I sort of knew exactly where I wanted them and how they were gonna all work and didn't agonize over it or there wasn't a lot of doubt. ... I had no idea how it would come back into sculpture again it just seemed to go click, click, click, to be very natural. Yeah, and even as I say now, I wouldn't make any changes to it. Its actually a, a perfect kind of alignment for those 4 parts. This theme expresses Brian getting his agency back, he was able to bring back parts of himself and put them in a sculpture around him. He chose exactly the distance from himself he preferred and was able to speak to each part of himself about what he valued and wanted to keep as well as what he wanted less of from each of them. He spoke to his mother, his wife. He set boundaries around himself. He made a promise to himself to keep the intact core, represented by the eight-year-old Brian, safe. He seemed to have regained his sense of response/ability. These are his words: having the experience of feeling the love and giving the love it was like a, like a, you know, boom, boom, boom, ... (things) falling into place and I, and then there's this level of confidence and uh, self assuredness and just... There's no, there's no little niggling voices of doubt. ... What do you call it, a covenant, or whatever you call (it)? I was able to go further with that because then that, that, that just uh, that just deepens it but it makes it more concrete, makes it more tangible, because I've actually now said in words what I'm going to do. Receiving a positive missing experience, having a surrogate good father respond to him in exactly the way he wished for, helped Brian move from processing his emotions and the inherent messages in them to a place of therapeutic integration and completion. He was able 91 to see, understand and place himself in "right" relation to parts of himself and to significant others. He had a plan of what he needed to do to move forward with his new understandings. Insight was coming and he had some ideas about what to do with it. Theme Seven: Insight Comes The seventh theme is insight comes. This theme contains the understandings and awareness Brian shared as a direct result of experiencing being with the good father. Here is how Brian characterized the outcomes of this experience: One of the things that happened since then is its, see i f I can describe this properly. (Pause 10 sec) I use the word urgency but urgency may not be the right word, but I ' ll start there. Um, it's taken away this charge that was there, it's kind of, maybe it's anxiety maybe it's, it's watch, maybe it's anticipation, maybe it's just, I don't know what it is, but this feeling of, of, no., of, uh, something's not complete, something's not right, I'm missing something, I'm, I'm defective, I'm, I'm in need. ... but at the core level there's a feeling that as a, as a man, as a, as a person that I'm intact. He had also been able to realize that he was not responsible for not getting what he needed from his father. This has helped him accept his father as he is, and give up the faint hope of receiving what likely will not be given. The sense that I'm lovable, the sense that I that I'm worthy of, of that, of that kind of care, the sense that I, I've experienced it, that I've felt it, ... there isn't this, um, instability that comes from, doubt, that comes from a wound that says I wonder if it's me. I wonder i f I'm deficient, I wonder if there's some flaw in me that means that it's my fault that I didn't get what I so deserved. He described this further. 92 Additionally ... my relationship with my father ... he is what he is. But I don't have this, it's almost like this urgency that suddenly we gotta, we gotta fix this or I've gotta say something to him, or I gotta get something from him. It's now an acceptance of that's the way that he is, it has nothing to do with me and, if he passes away tomorrow, and I'm left without my father, I won't be sitting back with this feeling, I wish I had of, or I wish I, there might be a sense of oh, that would have been nice, so that's fair. I sure would like to have had that experience. ... So I'll be very, very clean when he goes and won't have this feeling of, um, I, I'm missing something, take him for face value and I give what I can. ... Now when I'll interact with him if he, I get annoyed or I look at him and say boy, you know, you're so shallow or you're so wrapped in yourself or whatever it is. It doesn't then become a dart that goes back into that central key wound. That's intact. And it becomes more of a Huh, you know, that's, that's what it is. That's you and this is me. And there's not like a sense that something ah, (needs) to be done. So, ... that's maintained. That feels really, really good because, you know, it's almost like I've disconnected this, this yearning or this sense of anxiousness that something had to happen between him and I before I was going to be ok. Now I'm ok. And then whatever happens between him and I . . . it can happen. He talked about maturing, "I also feel a sense of um, both pride but also, um, um, I almost said maturity", learning the difference between his responsibility and the responsibility of others. You know, it dawns on me now that this was probably after I did this it's very much the beginning of the end of my marriage. I just realized that now, just the way I said 93 that. ... And after this piece of work I did feel changed, and, knowing I still had lots to do but, not wanting to go back to the way that I was and, and uh, so where before in our relationship I would be more tolerant of things. It wasn't that I became more difficult, or more conflictual or anything like, I just held the line. And I didn't, I didn't feel that I had any reason or, to change and I wasn't going to. And after coming this far and going through this. This was me. I mean, I was always there to listen up to that point. But I realized that it wasn't my responsibility and there wasn't anything I could really do, it was her story. And so, even though I was very clear about what I was doing, I think from her perspective it felt like I was pulling away. Cause I was always so, trying really hard to, to help all the time. On the educational tape he made about his enactment, Brian summarized the outcomes of this experience in three words: "composure, strength, and completeness." He said he got something he longed for, it was an intact bodily memory and he had moved forward in his life as a result. Some Additional Thoughts Consistent with enactment research and experiential work (Baum 1994; Black, 2003; Brooks, 1998; Greenberg, 2002; Gendlin, 1996)) Brian said he was immersed in the experience very quickly. He was surprised by his own spontaneity and the things "that came out o f him. He commented repeatedly how real and natural it all felt and this surprised him because normally he is very planful and in control of things. In fact in most enactments he had attended he had played a significant organizational and administrative role. Brian also spoke frequently about how surprised he was about the length of the enactment because his sense was that it went by very quickly. 94 Another interesting feature Brian reported many times was how he was unaware of others except people he was directly interacting with in the moment. In fact in segment ten, when he was laying on the floor expressing his intense pain and grief his seventeen-year-old double was holding him. He was unaware of this until he watched the videotape. He said he was frequently only aware of the presence and voice of the therapist(s) when they were at his side or talking to him. Although mentioned over and over this phenomenon has not been included in a theme category as it seems to be more related to the experiential nature of the session and method and does not impact the meaning of the construct of the positive missing experience. At the outset of the interview I asked Brian what the most significant parts of the enactment experience were. Brian spoke to the following, in this order: reconnecting to his eight-year-old self, confronting his father, releasing the trauma and pain on the football field and experiencing the good father. Summary The therapeutic goals and intense, brief therapy experience of one man have been summarized and the seven themes, which emerged from my interview with him and watching the tapes myself, have been described in depth. A schematic (see Figure 4.1, p.70) is presented with the intent of weaving the themes together and answering the question: is there an arc of experience here? This question will be explored in the next chapter within a discussion of the study findings and their implications for theory, practice and future research. In addition, the study limitations will be discussed. 95 CHAPTER 5 D i s c u s s i o n Introduction Although considerable research has been carried out on emotional processing there are few in-depth client accounts of the moment-to-moment experience and the therapist voice has tended to dominate. In addition, there is extensive literature looking at whole treatment and session change processes from the perspective of both the therapist and client. However, at the event level there is much less qualitative research devoted to client perspectives on their moment-to-moment experience of a specific therapy event. This study begins to fill that gap by exploring one man's experience of receiving a positive missing experience in a therapeutic session and demonstrates that this area of study is fruitful and deserves ongoing attention. The literature on emotional processing is similarly dominated by the voice of the therapist. When client perspectives are sought, it has been mainly through questionnaire, or a structured post session interview with pre-determined categories and questions. In this chapter I will suggest how this research begins to fill that gap and contributes to the literature. I will also discuss its implications for practice and further research, and I will identify the limitations of the study. Implications for Theory The major finding of this case study is the emergence of an implicit process in the participant's event experience. While components of emotional processing have been identified and validated in previous research (Greenberg, 2002, Greenberg & Pascual-Leone, 2006), and stages of client in session moment-to-moment process have been described based on analyzed videotaped sessions (Brinegar, Salvi, Stiles, & Greenberg, 2006; Clarke, 1996), 96 there are few, i f any, descriptions of event process experience articulated through the client lens. The process in this case has seven distinct themes: longing and receiving, things start moving, alchemy of repair, embodied sense of an intact core, vantage point, things start falling into place and insight comes. Although these themes were phenomenologically distinct, they suggested a sequence or process and overlapped experientially. The event was embedded in an emotionally engaged and action-oriented session where the client was emotionally aroused and immersed in present experience, and it was preceded by the processing of primary anger to completion. The session itself was contained within a cohesive group where members were known to one another. Brian was in sense primed by the arousal, expression and processing of his previously warded off anger and rage. This validates what the clients in Stuart's (2002) study said: that emotional work begins with the breakdown of coping strategies which prevent primary emotions from being expressed fully, is followed by emotional awareness, expression and reflection on the emotion. This leads to relief and self re-organization follows. The positive missing experience process was set in motion by the invitation (by one of the therapists, who was male) to Brian to give voice to his previously warded off pain, and by physically positioning Brian in the original scene on the football field. The context of the safe group, strong therapeutic alliance and previous direct emotional work fulfilled Stuart's first two steps. The study findings validate Fosha's theory of transformational affects (2000a, 2000b) which arise out of the client's experience of therapeutic change. Fosha (2006) believes that focusing on the experience of change as a last step in therapy evokes the transformational affects, and that processing these will strengthen identity through the client asserting their 97 personal truth and by having it affirmed. Procedurally the approaches differ considerably. However, the process articulated in chapter 4 describes Brian, at his best, traversing the transformational process from mourning himself (what he did not have held in relief against what he was being given), to receiving affirmation (letting in the experience that brought about relief and change in his sense of self). The study validates central aspects of attachment theory. The presence and accurately attuned responses of the surrogate good father, or attachment figure, provided by a group member who had been selected to play the role by Brian, matched Brian's need and longing for love. The good father surrogate was not coached in this instance as he was an experienced group member. It is interesting to note that in response to Brian's unfettered core emotion, he responded accurately and spontaneously. This was the healthy caregiving system being activated in the symbolic other matched with Brian's readiness and activated attachment behaviour system. This might be considered as an example of a corrective attunement experience (Lewis, Amini, & Lannon, 2000; Score, 2003). The evocation of the positive missing experience process appears to be congruent with what attachment theory and neuroscience tell us about repairing attachment breaks (Makinen & Johnson, 2006; Siegel, 1999; Schore, 2003), both at the level of self to self experience, and in current relationships. This process also describes an example of what Iwakabe, Rogan, and Stalikas (2000) suggest: that therapists can complete an arc of potential when they carefully match their interventions and emotional availability to clients' needs and expressions of emotion. The temporal flow of client experience was evoked by a careful tracking of the client's experience and knowledge by the therapist about what the client needed. 98 Deliberate, strategic affirmation, which included responding to a deep need for assistance, protection, acceptance and affection, was offered at just the right moment. What is evidenced in this process is that the affirmation itself set in motion a cascade of events. It served to help Brian further drop his defenses, be willing to be vulnerable and tolerate previously avoided aspects of his experience and release stored grief and trauma (things start moving). As a result, the process inside Brian moved forward. Once he expressed and released his pain and grief, another internal shift occurred (alchemy of repair). Things started to re-organize; he was able to return the affirmation and affection, something he had felt too vulnerable to do previously. He connected to and had a felt sense of himself as being whole, intact (embodied sense of an intact core). Gratitude and tenderness emerged for both himself and the surrogate good father. These are the healing affects Fosha (2000a, 2000b, 2006) identifies as markers of receiving affirmation; meaning that what was so needed and desired is taken in, for the better. Providing the positive missing experience is a concentrated version of affirmation, I believe, and served to speed up the process. In addition, because it was not verbally processed at the time or meta-communicated about as is the case in AEDP, the process may have been more efficacious. Vantage point and things start falling into place appear to demonstrate the effect of positive emotion - undoing the arousal of negative emotion (Fredrickson & Branigan, 2005), encouraging broadminded thinking and exploration (Fredrickson & Joiner, 2002) and positive appraisal under stress (Moskowitz, Folkman, Collette, & Vittinghoff, 1996). Brian, at this point in the process, was experiencing a sense of mastery (Fosha, 2000a, 2000b, 2006). He felt confident, proud of what he had done, and he was aware that something inside him had shifted significantly. With this re/newed sense of self he talked about having a big 99 perspective, and he used the metaphors of the cat bird seat and a throne to speak about it. From this vantage point things came easily, he had a sense of flow and clarity about what he wanted and needed to do in his life. The emotional tone was of satisfaction, pleasure, and a sense of his own truth. I believe these positive emotions emerged spontaneously, were somehow recruited by Brian from his undefended core self, or they were evoked possibly by the affirmation from the surrogate good father, or Brian himself. At this point it was notable how easily Brian was able to implicitly utilize his insights and learning to organize the parts of self, predict how relationships might change and know what next steps to take. This suggests paying close attention to positive emotion in sessions and amplifying them, or at least bringing them into focus, may evoke more positive emotion, which we know from research broadens perspective, and may also anchor the client in integration longer, thereby enhancing therapy outcome. Implications for Practice The findings have important implications for practice and training. They provide a map of client emotional experience in process. The schematic in Figure 4.1 (p.70) describes distinct emotional phenomena of release and expression of stored grief, pain, and despair, and their sensorimotor and relational correlates. As the experience shifted to a calmer phase the process demonstrates how reflective processes assist the client to make sense of what has occurred. This map provides practitioners with a guide for what to expect in emotional processing and helps to conceptualize what a client is experiencing in a moment-to-moment emotional event. The findings highlight the importance for therapists in all approaches to learn about emotions. In particular it is important to know about action tendencies, physical, non-verbal 100 indicators, as well as "when it is emotion needs to be mediated by cognition and when cognition needs to be mediated by emotion, and what interventions are suited to both instances" (Greenberg, 2004, p. 1). In addition, learning how to help clients access and experience contained or dissociated emotions and soothe overwhelming ones is essential if the therapist intends to reap the benefits attributed to the therapeutic relationship. This is a powerful intervention and I believe it is one that is underutilized. TE is a short and very intense whole session intervention which is unique in its rapid change outcomes. However, deliberate support can have enormous benefits when provided in a dyadic therapy. This case example illustrates how one person experienced the process and provides a tentative schematic for how to proceed and what might occur for the client. If affirmation is carefully matched and timed to the client needs and underlying working models, then it has the potential to probe or challenge old, maladaptive core beliefs and, at the same time, do so in a nourishing way. The client will then be faced with both what they unconsciously long for and do get or do not take in. At the very least it has the potential to evoke an interesting learning experience for both client and therapist about attachment and caregiving systems within their relationship. Using affirmation and positive missing experience has the potential to evoke more positive emotion (Fredrickson & Joiner, 2002) and broaden perspective taking and thinking. This may help clients anchor and integrate their session learning by seeing themselves and their distress in a bigger picture. In addition, the ethics and benefits of leaving a session with a sense of well-being, accomplishment or a sense of having connected to a personal truth are obvious and were certainly evident in this study. 101 One additional implication for practice is directly related to TE and may be applicable to other therapy approaches. The study findings suggest that the process of viewing a session videotape and/or interviewing a client afterwards had beneficial effects. The participant in this study expressed this vividly when he referred to the interview process and reading of the findings chapter being like playing an accordion. As the accordion is expanded, what is in the folds becomes visible. He said it provided a new framework for legitimizing and consolidating his experience. By bringing back the experience into the present, he had a sense of awe and pride in what he had done; it offered him an opportunity to reflect on what he got out of his therapeutic work, and how it had impacted his life. This additional finding suggests there may be a need and benefit for both TE and ASD to do more follow-up with clients. A similar interview process or helpful inquiry may be a promising method. Some TE research has indicated that clients have not wanted to view their videotapes immediately after the enactment or do detailed debriefing (Morley & Keats cited in Black, 2003). It may be that additional follow-up at 3 or 6 months would be worthwhile for client integration and consolidation. Implications for Further Research and Future Steps The study findings point to several directions for future research. There is a need to expand the scope and design of further studies in this area. Tapping the perspectives of client, therapist and significant others in the life of the client would validate all perspectives, including the perceptions of others about changes in the client as a result of therapy processes. In addition, a comparison of positive missing experience between different therapy approaches would validate its benefits more completely (starting with Hakomi ASD and TE as sites of exploration would be a first step in this direction). Alternate research 102 methods for such studies might include: multiple case study design with a hermeneutic approach to analysis, portraiture (Lawrence-Lightfoot & Davis, 2002), or a narrative approach (Lieblich, Tuval-Mashiach, & Zilber, 1998; Clandinin & Connelly, 2000). Pursuing the impact of positive emotion merits more study. So much attention is directed at distressing emotion because it is often the source of what brings people to therapy. However, exploring aspects of positive phenomenon shifts perspective to what is working and what is naturally built into our response systems for well-being and coping. Pursuing questions such as: How is positive emotion evoked? or Is positive emotion evoked or does it arise spontaneously? or Is amplifying a positive emotion productive, and why? are suggestions for further study. There is a need to include more theoretical frameworks in considering future research questions and planning. Including more research findings from neuroscience as they relate to affect regulation, approach mechanisms in the right brain versus withdraw mechanisms in the left, attachment theory, and change theory processes would further the understanding of clients' experience of affirmation and positive missing experience. Finally, it may be useful to reframe positive missing emotional experience in terms of corrective attunement and to further refine the construct to distinguish between positive missing experience and deliberate affirmation. Limitations of the Study Because I explored a single case there is no possibility to generalize the findings. I believe the thick, rich descriptions and metaphors of the client experience will resonate with readers to the extent they may consider how the findings relate to their particular setting and client(s). This may stimulate enough interest in the construct and intervention to read more 103 about it, use parts or all of it in their thinking and/or practice, or, even to get training in the method. The decision to select a construct and intervention from one therapeutic approach and study it in another can be easily challenged. The rationale rested on the notion that the difference between TE and ASD (phenotype variation) was less important than considering the intervention part of an integrative approach that might be used across modalities. In addition, since emotional processes are now considered as an integral part of all therapy modalities, it was used as a further rationale to support the sampling decision. The sampling was purposeful and included a man who was not only a counsellor but also an experienced client. Although this conferred benefits in that he was very articulate and understands the therapy process, he had the advantage of understanding therapy and emotional process, and this no doubt had an impact on his goals and perceptions. Other participants may not be as able to articulate such details or may not articulate similar ones. The confounds of the group may well have affected the findings and in fact amplified a process which is subtler in a dyadic context. Another limitation is related to the impact of the interview on the experience of the participant. It is possible that the interview itself and watching the videotape with me changed Brian's perceptions of the experience, out of his awareness, and that this interpretation does not accurately represent his original experience. Brian had viewed his tape many times because he made an educational video. However, he had not viewed the original session tape for over three years and said the interview itself had not changed how he understood his experience, despite having a new insight while watching the videotape. 104 The last comment related to study limitations is that this study represents my intensive analysis of one case in an area that I am highly interested in and committed to understanding, and which reflects my theoretical preference. Although the vivid passages quoted grounded my interpretations, I chose each one and they most likely reflect my own subjectivity. 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Integral spirituality: A startling new role for religion in the modern and postmodern world. Boston: Integral Books. 114 A P P E N D I X A : Recrui tment Let ter T H E U N I V E R S I T Y O F B R I T I S H C O L U M B I A U B C Department of Educational and Counselling Psychology, and Special Education 2125 Main Mall Vancouver BC Canada V6T 1Z4 Tel 604-822-0242 Fax 604-822-3302 I am a master's student in counselling psychology at the University of British Columbia (UBC) looking for a volunteer to participate in interviews about his/her experience in Therapeutic Enactment. I am particularly interested in finding out about what it was like as the lead (client) to receive specific, positive resourcing (near the end or near the completion of the enactment) from a therapist. The resourcing may have been something like holding, being talked to gently and validated, or some other form of comfort and support. I am asking qualified, experienced therapists, like yours, to pass on this invitation to participate in my study to former clients to whom they offered or facilitated such resourcing in a therapeutic enactment. I hope to learn more about this type of intervention from hearing about your experience. If you have been in a Therapeutic Enactment, have had this type of experience, had your session videotaped, think you might be willing to talk about your experience and watch a segment of you videotape with me, please contact me or indicate on this form your willingness to be contacted by me via telephone. Please send an email to Dianne Westwood at: m&dwestwood@ telus.net or telephone Dianne Westwood at 604-228-0870. If you prefer, please print your name and telephone number and sign below indicating I have your permission to contact you personally. I, am interested in participating in this study and (print name) give my permission for Dianne Westwood to contact me at Project Title: A case study exploration into the lived experience of a client receiving a positive missing experience from a therapist Principle Investigator: Dr. Maria Buchanan Co-investigator: Dianne Westwood (telephone number) to discuss the study. (signature) Version December 12, 2006 page 1 of 1 115 A P P E N D I X B : Telephone Selection Interview Scr ipt When I receive a call, email or written permission to contact a person interested in participating in the study, I will read the following statement to him/her: "Thank you for your interest in my study. I would like to give you a few details about the study and then figure out i f you are eligible. Does that sound OK?" "This study focuses on your therapy experience in Therapeutic Enactment. I am particularly interested in the part of the enactment when, as the client, your therapist offered you specific comfort, support; validation after you had expressed strong, difficult emotion(s). It may have been near the end of the session. I imagine that you have been affected by this enactment experience. The main question I am interested in answering is: "what is the experience of a client who receives positive resourcing or support from a therapist after the expression of strong, difficult emotion?" I'm now going to ask you a few questions to confirm that the study is a good fit for you." "Do you have any questions?" 1. Have you been a client in a Therapeutic Enactment process where the therapist offered positive resourcing as I just described? 2. Do you have a video-recording of the session? 3. Did you obtain the consent of the other group participants to make the video-recording? 4. How old are you? 5. Do you have the support of your therapist to participate in the study? 6. Are you available for three interviews (1 s t 90-120 minutes, 2 n d 30-45 minutes, and 3rd 30-45 minutes) and a face-to-face information meeting to discuss study details and informed consent? 7. Are you ready and willing to discuss your Therapeutic Enactment experience, view a segment of the videotape with me, and discuss it? If the individual says no to any of the above questions or is younger than 21 years of age, I will thank them for their interest but say the study's criteria and their experience do not match. If the individual meets the criteria then I will arrange for a face-to-face information meeting of 30-45 minutes in length to discuss details of the study, address questions and concerns, to obtain informed consent, and to offer a journal with a set of reflective questions to prepare for the first interview. Version December 13, 2006 1 of 1 116 APPENDIX C: Journal Questions for Reflection Prior to the First Interview You might want to spend some time before we meet reflecting on your Therapeutic Enactment experience. It might be helpful for you to write about it, talk about it with a friend or just spend some time thinking about your experience on your own. Some questions which may be helpful in recalling the experience: • Write about or notice any feelings, thoughts or even body sensations or awareness that you have when you start remembering the enactment work you did. • What led you into the enactment? • After this time, what stands out about this experience? • Given that the study purpose is to understand your perspective about receiving support, comfort, validation from your therapist, what can you remember about this part of the enactment? • Looking back, what stands out about the experience of comfort, i f anything? • What are your thoughts, feelings about the experience now? • How has this experience impacted you? Version December 13, 2006 1 of 1 117 APPENDIX D: Consent Form T H E U N I V E R S I T Y O F B R I T I S H C O L U M B I A U B C Department of Educational and Counsellin Psychology, and Special Education The University of British Columbia Faculty of Education 2125 Main Mall Vancouver BC Canada V6T 1Z4 Tel 604-822-0242 Fax 604-822-3302 www.ecps.educ.ubc.ca Consent Form A Case Study Exploration into the Lived Experience of a Client Receiving a Positive Missing Experience from a Therapist Principle Investigator: Dr. Maria Buchanan, U B C Department of Educational and Counselling Psychology, and Special Education (Counselling Psychology Program, 604-822-4625) Co-Investigator: Dianne Westwood, U B C Department of Educational and Counselling Psychology, and Special Education (Counselling Psychology Program, 604-228-0870) The research conducted for this study will be part of a master's thesis eventually made available to the public. Purpose: The purpose of this study is to explore the experience of a person who has received a positive missing experience (positive emotional resourcing) from a therapist. The objective is to gain a more in-depth understanding of a client's perspective about such an intervention by a therapist. Study Procedures: As a participant in this study you will be involved in a 1.5 to 2 hour, audio-taped interview with the co-investigator on your experience of receiving a positive missing experience from a therapist. A summary of your interview will be returned to you in order to assure accuracy. A brief (approximately 30-45 minutes) interview will be requested of you to obtain your feedback about the summary. Version December 13, 2006 1 of 3 118 In addition, a summary of the final results of the study will be given to you in order to validate if the final results reflect your experience and another brief (30-45 minutes) interview will be requested to discuss the same. The total amount of time required of you is approximately 3.25 to 4.5 hours. Any questions you have regarding the procedures may be directed to the co-investigator. Potential Risks: Talking about your experience in the Therapeutic Enactment process may involve recounting painful or emotionally sensitive events, situations. You may be at increased risk for experiencing strong emotions such as sadness or embarrassment while speaking about your therapy. Should I touch on areas that are too uncomfortable or distressing, you can indicate this and we will move on to other things, or i f you prefer stop the interview. You can withdraw your participation at any time. The interview is meant to be reflective and not therapeutic. If issues arise that need therapeutic attention, you are encouraged to address these with your doctor or therapist. A list of appropriate and affordable counselling services will be provided to you before the interview begins, in case you decide you would benefit from counselling support. Potential Benefits: The potential benefits of talking about your therapy experience include gaining insight(s) into your experience that you did not previously have, and sharing your experience may be helpful to others. Confidentiality: A l l efforts will be made to ensure your identity remains confidential. You will not be identified by name in any reports of the completed study. Direct quotes from the interview(s) may be reported in the findings of this study, but these quotes will not reveal any identifying information. A l l printed documents and audio-tapes will be kept in a locked file cabinet and all electronic files will be password protected. Remuneration/Compensation: You will be reimbursed for the cost of transportation to and from the interviews by the co-investigator. Contact Information about the Study: For further information about this study you may contact Dr. Maria Buchanan, the Principle Investigator at 604-822-4625. Contact for Concerns about being a Research Subject: If you have any concerns about your treatment or rights as a research subject, you may contact the Research Subject Information Line in the U B C Office of Research Studies at 604-822-8598. Version December 13, 2006 2 of 3 119 Consent: Your participation in this study is entirely voluntary and you may refuse to participate or withdraw from the study at any time. Your signature below indicates that you have received a copy of this consent form for your own records. Your signature indicates that you consent to participate in this study. Subject Signature Date Subject Name (printed) Version December 13, 2006 3 of 3 120 APPENDIX E: Interview Guide Orienting Interview Statement: "I am interested in hearing about your enactment experience and, in particular, your experience at that point in the session when your therapist offered you specific comfort or support after you expressed some of your more difficult emotions. I imagine that you have been impacted by the experience of receiving such comfort, and I would like to understand your experience as fully as possible. Please speak as freely as you like. I may ask you to clarify or expand on something. If you feel uncomfortable at any time you may pass on a question, or stop the interview at any time. We will also have an opportunity to watch that segment of your videotape together and for you to reflect again on what your experience was like." Main interview question: "What is your experience of having your therapist support and comfort you after you expressed strong, difficult emotion(s)?" Possible facilitating questions: • What led you to do an enactment? • How has the enactment impacted you? • How do you know this? • Looking back on the experience what stands out as being important? • What are your thoughts and feelings now about the comfort and support you received? • Has there been any impact in your life from this experience? • How do you know? • Looking back on this part of the enactment, what part did it play in your thoughts and feelings about the outcome of your therapeutic work? • The need for comfort and validation been talked about as being an important part of completion after strong emotions are expressed in a therapy session, what are your thoughts about this? What is your experience of this? Version December 13, 2006 1 of 1 121 APPENDIX F: Certificate of Approval BREB, UBC U B C The University of British Columbia Office of Research Services Behavioural Research Ethics Board Suite 102, 6190 Agronomy Road, Vancouver, B.C. V6T 1Z3 CERTIFICATE OF APPROVAL - FULL BOARD PRINCIPAL INVESTIGATOR: INSTITUTION / DEPARTMENT: UBC BREB NUMBER: Mar ia Buchanan UBC/Education/Educational & Counselling Psychology, and Special Education H06-03771 INSTITUTION(S) WHERE RESEARCH WILL BE CARRIED OUT: Institution I Site | UBC Point Grey Site Other locations where the research will be conducted: If private and confidential space at the U B C Point Grey Site cannot be obtained, the study interviews may take place an appropriate, private and confidential site mutually agreeable to the researcher and participants, such as the participant's home. CO-INVESTIGATOR(S): N/A SPONSORING AGENCIES: N/A PROJECT TITLE: A Case Study Exploration into the Lived Experience of a Client Receiving a Positive Missing Experience from a Therapist REB MEETING DATE: CERTIFICATE EXPIRY DATE: January 11,2007 January 11,2008 DOCUMENTS INCLUDED IN THIS APPROVAL: DATE APPROVED: January 22, 2007 .Document Name | Version | Date Protocol: Research Proposal Consent Forms: Final December 13, 2006 Study Informed Consent D o n n l 3 ' December 13, 2006 2006 Advertisements: Recruitment Letter Questionnaire, Questionnaire Cover Letter, Tests: December— . ™ ^ m onoe December 12, 2006 l z , ZUUo Interview Guide December^ . „_ ____ H O onno December 12, 2006 U , ZUUO Telephone Selection Interview December— . ^ n n ^ 12 2006 D e c e m b e r 1 2 > 2 0 0 6 Journal Questions for Reflection December- . „ _ onno A r\ o n r i - December 12, 2006 1Z, ZUUb The application for ethical review and the document(s) listed above have been reviewed and the procedures were found to be acceptable on ethical grounds for research involving human subjects. 122 Approval is issued on behalf of the Behavioural Research Ethics Board and signed electronically by one of the following: D r . Pe t e r Sued fe ld , C h a i r Dr. Jim Rupert, Associate Chair Dr. Arminee Kazanjian, Associate Chair Dr. M . Judith Lynam, Associate Chair 123 


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