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Episodes of change in experiential systemic marital therapy : a discovery-oriented investigation Ferrada, Natacha 1999

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EPISODES OF CHANGE IN EXPERIENTIAL SYSTEMIC MARITAL THERAPY: A DISCOVERY-ORIENTED INVESTIGATION by NATACHA FERRADA B.A., Simon Fraser University, 1985 M.A., The University of British Columbia, 1990 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR i OF PHILOSOPHY in THE FACULTY OF GRADUATE STUDIES (Department of Counselling Psychology) We accept this dissertation as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA April; T999 © NATACHA FERRADA, 1999 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, 1 agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of t / f , y c ^ j / s q ^ i The University of British Columbia Vancouver, Canada Date 44*01.0$ DE-6 (2/88) ABSTRACT This investigation sought to discover, identify and describe in-session change episodes in marital Experiential Systemic Therapy (Friesen et al., 1989) through a naturalistic discovery-oriented methodology. This study responds to calls made regarding the need to study complex and intricate processes, such as psychotherapy (Greenberg, 1986), via discovery-oriented methods (Mahrer, 1988). The observational analysis of 40 videotaped-sessions, of three couples, revealed the presence of ten episodes of change. The actions and interactions of the members of the therapeutic system in these episodes were analyzed via the grounded theory method of analysis. This analysis generated a conceptual framework describing the internal structure of change. The resulting conceptual framework consisted of a core category named synergetic shifting. This category refers to an interactional process in which the partners with the assistance of the therapist moved away from rigid, distancing and alienating interactional patterns toward interpersonal flexibility, compassion and affiliation by working through blocks hindering the couples' engagement and intimate connection. Synergetic shifting consists of four client and three therapist categories. Within the progressive nature of synergetic shifting, the client categories were: (1) owning one's part in the relational conflict; (2) couple contacting: restricted and limited; (3) couple working through blocks to intimacy; and (4) couple engaging compassionately. The therapist's actions and interactions were categorized under supporting, transitional and shifting operations. iii T A B L E OF CONTENTS ABSTRACT ii TABLE OF CONTENTS iii LIST OF TABLES xi LIST OF FIGURES xii ACKNOWLEDGMENTS xiii C H A P T E R I. P U R P O S E OF T H E STUDY 1 Aim of the Investigation 4 Research Questions 5 Overview of Design and Methodology 5 Explanation of Terms 10 Experiential Systemic Marital Therapy 10 Chemical Dependence 10 Recurrent Change Episode.: 11 Conflictual Relational Marker 13 Client and Therapist Actions and Interactions 13 New Patterns of Interaction In-Session 13 Internal Structure of Change Episodes 14 Significance of the Study 14 C H A P T E R II. REVIEW OF R E L A T E D L ITERATURE 1 7 Research Strategies in the Study of Psychotherapy 17 The Meaning of Outcome 18 The Meaning of Process 19 Historical Overview of Process Research 20 Conceptual Shift in Psychotherapy Process Research 26 Focus on Events 28 Context Specific Microtheory 31 Methodological Shift in Psychotherapy Process Research 32 Discovery Oriented Psychotherapy Research 34 Description in Psychotherapy Research 34 Levels of Description 35 Observational Perspective 37 Explanation in Psychotherapy Research 38 Research Approaches 38 Empirical Pattern Identification 39 Theory Testing 40 Performance Analysis 40 Discovery Oriented Methods 43 The Process of Change In Marital Therapy 48 Quantitative Research on the Process of Change in Marital Therapy 48 Qualitative Research on the Process of Change in Marital Therapy 51 Research on the Change Process of Experiential Systemic Marital Therapy 55 Summary of the Review 59 CHAPTER III. METHODOLOGY 61 Design 62 Investigative Procedure 64 Participants 64 Subject Inclusion in TARP 64 Therapists 66 Participant-Observer 66 Researcher's assumptions on the Process of Change 67 Experiential Systemic Therapy 68 Systemic Dimension 69 Symbolic Dimension 70 Experiential Dimension 70 Guiding Principles of ExST 71 Phases of Therapy 72 Selection of Cases 73 Description of Instruments 74 The Alcohol Dependency Data Questionnaire 74 The Symptom Checklist-90-Revised 75 The Dyadic Adjustment Scale 76 The Weekly Situation Diary 77 Decision Criteria for Case Selection 77 Demographic Description of Couples 80 Couple 2010: High Improver 80 Couple 2036: Mild Improver 81 Couple 2080: Minimal Improver 81 Identification and Selection of Change Episodes 82 Criteria for Identification of Change Episodes 83 Selection of Change Episodes 84 Overview of Grounded Theory Method 85 Historical and Theoretical Background 87 Description of the Method of Analysis 90 The Analytical Process 91 Conceptual Integration 95 Criteria for Evaluating a Grounded Theory Investigation 95 CHAPTER IV. RESULTS: OVERALL THERAPY CONTEXT 98 Brief Overall Context of the Therapy Process 98 Outline of the Psychotherapeutic Process for the Three Couples 99 Couple 2010: High Improver 99 Couple 2036: Mild Improver 102 Couple 2080: Minimal Improver 104 Introduction to the Change Episodes 108 Description of the Change Episodes 111 Episode* 1 112 Episode # 2 112 Episode #3 114 Episode # 4 115 Episode # 5 116 Episode # 6 117 Episode # 7 118 Episode # 8 119 Episode #9 120 Episode # 10 121 CHAPTER V. RESULTS: CONCEPTUAL MODEL OF CHANGE 123 Conceptual Model of Change 123 Synergetic Shifting 125 Occurrence of Categories within the Change Episodes 127 Phase One: Owning One's Part in the Relational Conflict 130 Contextual Conditions Related to the Emergence of Phase One 131 Explaining Subcategories: Phase One 135 Distancing 135 Reflecting 136 Expressing 137 Acknowledging 139 Therapist's Operations: Phase One 140 Supporting Categories 141 Accepting Client's Experiences and Actions 141 Empathizing and Validating Client's Experiences 142 Shifting Operations 143 Reifying Experiences 144 Linking the Couple 145 Encouraging Self-focus and Self-connection 145 Utilizing Client's Metaphors and Language 146 Challenging Actions and Interactions 147 Therapist Perseverance 148 Phase Two: Couple Contacting: Restricted, Limited 150 Contextual Conditions Related to the Emergence of Phase Two 151 Explaining Subcategories: Phase Two 154 Distancing: Flipping/Fear/Anger 154 Conflictual Messaging: Accusing/Distancing 155 Brief, Restricted Contact 157 Therapist's Operations: Phase Two 158 Transitional Operations 158 Bridging the Couple 159 Supporting Operations 160 Shifting Operations 160 Encouraging Direct Interaction 161 Modeling Interaction 162 Linking the Couple 162 Challenging Actions and Interactions 163 Phase Three: Couple Working Through Blocks to Intimacy 164 Contextual Conditions Related to the Emergence of Phase Three 165 Explaining Subcategories: Phase Three 170 Disclosing, sharing tales of abuse, betrayal 170 Unlocking Blocks/Ghosts/Demons 172 Transforming Stories/Metaphors 173 Letting go of Blocks 174 Therapist's Operations: Phase Three 176 Supporting Operations 177 Transitional Operations 178 Shifting Operations 179 Linking the Couple 179 Encouraging Interaction 180 Reifying Client's Experiences 181 Challenging Clients 182 Utilizing Client's Language and Metaphors 182 Phase Four: Couple Engaging Compassionately 183 Contextual Conditions Related to the Emergence of Phase Four 184 Explaining Subcategories: Phase Four 189 Interacting Freely 189 Accepting, Supporting 190 Physical Expressions of Intimacy 191 Therapist's Operations: Phase Four 192 Supporting Operations 193 Transitional Operations 193 Bridging the Couple 194 Encouraging Spontaneous Expressions of Support 195 Summary 196 CHAPTER VI. DISCUSSION 197 Findings Related to the Research Questions 197 Overview of Findings Related to the Research Questions 198 Episode Completion 198 Proximal Versus Large "O" Outcome 200 Implications of the Study 202 Theoretical Implications 202 Clinical Implications 207 Transitional Operations 211 Links between Clients' and Therapist's Actions and Interactions 212 Frequency of Therapist's Operations 213 Integration of Findings to the Literature on Marital Change 214 Shifting 214 Emotional Domain 216 Cognitive Domain 217 Behavioral Domain 218 Experiential Change 219 Other Related Clinical Findings 219 Intrapersonal to Interpersonal Shift during Marital Change.... 220 Perseverance 220 Limitations of the Study 221 Generalizability 221 Objectivity 224 Internal Validity 225 Reliability 226 Evaluation of Grounded Theory Investigation 227 Other Methodological Considerations 228 Suggestions for Future Research 229 Conclusion 231 REFERENCES 233 Appendix A: Participant Family's Consent Form 245 Appendix B: Therapist Competency Form 247 Appendix C: Weekly Situation Diary 250 Appendix D: Illustrations: Categories and Subcategories 262 xi LIST OF TABLES Table 1: Obtained Scores on DAS, SCL-90-R and ADDS for Couple 2010 79 Table 2: Obtained Scores on DAS, SCL-90-R and ADDS for Couple 2036 79 Table 3: Obtained Scores on DAS, SCL-90-R and ADDS for Couple 2080 80 Table 4: Emergence of Change Episodes in Sessions 110 Table 5: Occurrence of Categories within the Change Episodes 128 xii LIST OF FIGURES Figure 1: An Overview of the Therapeutic System 73 Figure 2: Conceptual Model of Synergetic Shifting 124 ACKNOWLEDGMENTS I would like to express my deep appreciation for the couples who had the courage to risk and to engage in the journey of therapeutic discovery with me. I feel honoured by their willingness to let down their protective guard and to share their stories. They have been my guides throughout this learning process. I would also like to thank Dr. John Friesen, the principal investigator of the Alcohol Recovery Project (TARP), for allowing me to use the TARP data for this investigation. Without his collaboration and assistance, this study would not have been possible. I wish to thank my committee for their excellent advice, careful reading and consistent patience. I thank my supervisor Dr. John Friesen for his engaging and thoughtful ideas and comments and his commitment to scholarship. Also, I thank Dr. Beth Haverkamp for her inspirational and thoughtful insights and her consistent encouragement. As well, I thank Dr. Donald Fisher for his generous wisdom and readiness to share his methodological expertise. Finally, I thank Dr. Marv Westwood for his valuable insights and constant support. I wish to thank my father, Eduardo Ferrada for his ever-lasting trust in me and my mother Elsa Arrauz for her support and encouragement. Finally, I wish to acknowledge my son, Eddie for his love and support, and my daughter Nadia for her love and understanding. I truly appreciate your patience with me throughout the duration of this project. 1 CHAPTER I PURPOSE OF THE STUDY As an applied science of human change (Kiesler, 1971), psychotherapy may be defined, in its broadest sense, as an interpersonal process aimed at bringing about change within the affective, cognitive, behavioral, attitudinal, and relational domains of experience. Marital therapy, as a subspeciality of family therapy (Alexander, Holtzworth-Munroe, & Jameson, 1994; Gurman, Kniskern & Pinsof, 1986), also seeks to facilitate change in the various domains of experience by altering the interactions between members of the dyad so as to improve functioning to a desired state. Given that the essence of the psychotherapist's task is to facilitate desired change in clients' lives, an important psychotherapy researcher's task, then, is to investigate both the process and result of this collaborative endeavour (Lambert & Hill, 1994; Strupp, 1978). Accordingly, empirical strategies with a focus on the investigation of outcome, that is, the results, and the examination of process related to outcome have been devised. Regarding the investigation of the results, considerable attention has been devoted to the study of the effectiveness of psychotherapy following Eysenck's (1952) challenge on its ineffectual effects. Currently, however, researchers manifest relative satisfaction with the question of its effectiveness at both the individual (Lambert & Bergin, 1994) and couples/ family (Alexander et al. 1994; Gurman et al. 1986; Jacobson & Addis, 1993) levels. 2 Concomitant with these efforts, researchers have also examined facilitative aspects of the process of psychotherapy change measured at termination. Here, the focus has been on linking the domains of process and outcome by searching for key ingredients which may facilitate the process of change within various settings, client populations, therapeutic modalities and therapist characteristics. As indicated by Strupp (1978), the field has moved beyond inquiries regarding its effectiveness to questions such as: what is it that facilitates change, how is change facilitated, and how can we best link process to outcome measures. The questions of what is facilitative in psychotherapy and what are the mechanisms under which change in psychotherapy occurs continue to intrigue both researchers and clinicians alike. Indeed, in the last four decades, the area of process and process-outcome studies has burgeoned considerably (Orlinsky, Grawe, & Parks, 1994). Significant and consistent findings have been reported on the link between process-outcome particularly as it relates to the identification of variables that may predict positive and/or negative outcomes. However, despite a significant accumulation of findings, the field has failed to provide a clear understanding of the basic mechanisms of change and the essential ingredients of the process of change (Greenberg, 1986; Greenberg & Pinsof, 1986; Rice & Greenberg, 1984). Moreover, the field of psychotherapy research has been intensely concerned with prediction and evaluation and, consequently, has failed to acknowledge description and explanation as two equally valid modes of generating knowledge (Greenberg, 1986; Greenberg, 1991). Thus, some researchers argue that the field has been experiencing a paradigmatic shift (Kiesler,1983, cited in Greenberg & 3 Pinsof, 1986) as it moves from hypothesis-verification to hypothesis-generation (Hill, 1990; Mahrer,1988) research due to the limitations and inadequacies of the traditional paradigm in examining the phenomenon of therapeutic change (Orlinsky etal . , 1994). As proposed by Rice and Greenberg (1984), this new perspective assumes a methodological shift from verification to discovery and a conceptual shift from process research to change process research. The conceptual shift implies that in order to understand the mechanisms of change and how psychotherapy produces change, a focus on the change process itself may be more relevant, productive, and clinically meaningful (Greenberg, 1986 a). As well, by investigating the process of change itself, the focus of the research moves away from studying what occurs in therapy in general to a process of identification, description and explanation of change within the context in which it occurs. Congruent with this new perspective, and within their respective undertakings, both clinicians and researchers alike, acknowledge the occurrence of rare but significant and meritorious moments of change within the psychotherapeutic process (Kelman, 1969). Various authors (Elliott, 1983, 1984, 1989; Mahrer & Nadler, 1986; Mahrer, Nadler, Sterner, & White, 1989; Rice & Greenberg, 1984) have suggested that it is to these significant moments of change that the psychotherapy researcher must attend in order to meaningfully understand the change process. Yet, despite this claim and the significance placed on understanding the change process in psychotherapy, few systematic investigations within the area of both individual and marital therapy have been conducted. 4 In fact, psychotherapeutic process investigations in the area of marital therapy are meager and thus, still in their infancy (Alexander et al., 1994; Gurman et al., 1986; Pinsof, 1981, 1986, 1988, 1989). Furthermore, investigations regarding the process of change in marital therapy (Greenberg, Ford, Alden, & Johnson, 1993; Greenberg, James, & Conry, 1988; Holtzworth-Munroe, Jacobson, DeKlyen, & Whisman, 1989; Johnson & Greenberg, 1988) are fairly recent undertakings. Indeed, only a handful of studies (Dubberley-Habich, 1992; Greenberg et al. 1988; Manson, 1997; Newman, 1995; Sweetman, 1996; Wiebe, 1993) have utilized the new conceptual and methodological framework proposed by Greenberg and Pinsof (1986) for the investigation of the change process in marital therapy. Therefore, research on the process of change in marital therapy is one of the areas in urgent need of investigation particularly through discovery-oriented methodologies (Mahrer, 1988) if the field is to advance in its understanding and generation of knowledge rather than its mere prediction and/or evaluation of treatments (Jacobson and Addis, 1993). Aim of the Investigation Given the scarcity of process research in marital therapy, the lack of research tapping into its mechanisms of change, the identified suggestion to understand the change process itself, and the current need to describe and explain these processes, the purpose of this investigation was to explore the change process of Experiential Systemic Marital Therapy (ExST) (Friesen, Grigg, & Newman, 1991). Specifically, the aim was to explore, discover, identify, understand, 5 and explain the in-session change episodes of three couples treated with marital ExST through an exploratory, naturalistic, discovery-oriented line of enquiry. The study intended to generate a conceptual framework outlining the process and structure of the change episodes. The psychotherapeutic conditions, therapist/clients operations, and consequences resulting from these operations were generally expected to comprise the possible structure of the change episodes. Research Questions In order to address the purpose of the investigation, the following research questions were generated. 1) Are there observable, identifiable, and recurrent in-session change episodes in couples treated for alcohol abuse with Experiential Systemic Marital Therapy? 2) If yes, what are those observable, identifiable, and recurrent change episodes? 3) What is the internal structure of those change episodes? 4) What are the therapist and client operations that facilitate change within the episodes? Overview of Design and Methodology The kind of questions posed in this study called for a qualitative, exploratory, and discovery-oriented type of methodology. A multiple-case design study (Yin, 1989), with adherence to the canons and methods of naturalistic enquiry (Denzin & Lincoln, 1994) and grounded theory analysis (Glaser & Strauss, 1967) were 6 employed. Congruent with the naturalistic research tradition, the researcher took the role of participant-observer; that is, the researcher conducted a posteriori observation and analysis of videotaped marital therapy sessions in which she was the therapist working with the identified couples. The multiple-case-embedded design within a natural setting and the grounded theory method of analysis were believed to be the most appropriate and relevant for this investigation because they allow for the intense exploration of complex, contextual, and complicated human and social processes, such as change processes, as they occur in their natural environment. In the field of marital and family therapy research, the multiple case design has been suggested as useful for the investigation of the change process within a particular theoretical model of change (Wynne, 1988). In addition, as a method of analysis, grounded theory has been identified as a valuable and appropriate method for psychotherapy process investigations (Elliott, 1983, 1984; Mahrer, 1988; Moon, Dillon & Sprenkle, 1990; Moon & Sprenkle, 1992; Rennie, Phillips, & Quartaro, 1988). In this study, three cases (couples) representing three distinct patterns of change in marital satisfaction at post-test on the Dyadic Adjustment Scale (DAS) (Spanier, 1976) were selected for the investigation. Because this study intends to explore the presence of change episodes in these three distinct patterns of change at post-test, a multiple-case design with theoretical replication, is deemed suitable. Accordingly, the pre-test-post-test difference scores on the DAS for seven couples with whom the therapist-researcher worked were ranked-ordered. Based on the DAS scores, the couples' pattern of change were identified as high, medium and 7 minimal improvement. The high improver case revealed the largest improvement on the pre-post-test difference couples' scores on the DAS, with a combined couples' difference score of 34 points. This contrasted with a combined pre-post-test difference score of 10.8 points for the medium improver couple and with a combined pre-post-test difference score of 5.15 points for the minimally improved couple. In addition, the pre-test-post-test difference scores of the three couples on a measure of alcohol dependency, the Alcohol Dependency Data (ADD) (Raistrick, Dunbar, & Davidson, 1983), and a measure of intrapersonal distress, the Symptom Checklist-90-Revised (SCL-90-R) (Derogatis, 1983) were examined in order to evaluate the consistency of change patterns identified through the DAS scores. The data sources for this study consisted of a library of 40 videotaped marital therapy sessions, extensive information on three standarized measures, and self-report data on daily functioning provided by the couples while engaged in marital therapy. The data sources were generated by a large scale investigation, The Alcohol Recovery Project (TARP), intended to explore the effectiveness of individual and marital Experiential Systemic Therapy (ExST) (Friesen et al., 1991) with male alcoholics. The findings of that investigation showed that, while a large proportion of couples improved, some deteriorated at termination (Friesen, Conry, Grigg, &Weir, 1995; Grigg, 1994). Once the couples were selected, the 40 videotaped therapy sessions were thoroughly and systematically observed by the researcher so as to acquaint herself with the data and the therapy process. Also, since the researcher was one of the 8 therapists involved in the TARP project and therefore, familiar with ExST, her biases and assumptions regarding the change process in couples therapy were documented prior to embarking on the analysis. The episodes selected were based on criteria for selection of change episodes generated prior to the selection process. An initial selection of possible episodes was compiled in videotape form for revision and evaluation by the researcher and the study's supervisor. Once agreement on the selected episodes was obtained, transcription and the actual analysis were conducted. The grounded theory method of analysis is a qualitative, processual, contextual, and interactional method which attempts to generate theory grounded in the data (Glaser & Strauss, 1967; Strauss & Corbin, 1990). Further, it is particularly suited for investigations on processes that evolve over time, especially processes of change (Glaser, 1978), because of the processual nature of the methodology. Consequently, it allowed for the investigation of change over time by describing and explaining the connections and phases inherent in the psychotherapeutic change episode. In addition, the grounded theory method is best suited for investigations of phenomena lacking in conceptual and theoretical maturity (Morse & Field, 1995; Stern, 1980). At present, investigations on the process of change and empirically derived explanatory models on the process of change in marital therapy are largely undeveloped. Since the primary purpose of grounded theory is to generate explanatory models of human behavior, the researcher seeks to identify patterns and the relationships among these patterns (Glaser, 1978,1992). This was done through 9 the comparative method of analysis in which pieces of the data were compared with one another. The analytical process in grounded theory is both hierarchical and recursive (Morse & Field, 1995). First, the researcher is simultaneously engaged in data collection and analysis in that, as initial recurring patterns begin to emerge from the data, the researcher collects further data through theoretical sampling, rather than probabilistic sampling, in order to eventually saturate the emerging categories. Second, the method requires the systematic categorization of data while limiting theorizing until patterns in the data begin to emerge from the process of categorizing. Third, the analytical process requires that the researcher engages in data collection, coding, memoing, determining a core category and recycling back to earlier steps of the process in terms of the analysis and generation of a core category. Therefore, at every step of the process, the emerging categories and conceptual order are tested against the data through hypothetical approximations and revisions (Polkinghorne, 1991). In addition, the researcher is required to maintain an open attitude to discovering and learning what is there to be discovered about the process from the observations of clinical phenomena (Mahrer, 1988). This brief overview of design and method of analysis employed to answer the research questions and generate a general model outlining the process of change as reflected in the episodes was intended as a general introduction. Chapter three offers an extensive explication and elaboration of the design and method. 10 Explanation of Terms The purpose of the investigation, research questions and methodology presented in this chapter introduced various concepts. In the following section, a definition of terms is offered in order to facilitate and develop common understanding and familiarity. Experiential Systemic Marital Therapy (ExST) ExST was developed for the treatment of individuals, couples, and families afflicted by drug and/or alcohol misuse. This treatment model is an integrative approach tending to the multiple layers of relational experience manifested at the intrapersonal, interpersonal, and the larger context (Friesen et al. 1991). Change is facilitated and promoted by accessing and journeying into the emotional, cognitive, behavioral, and physiological realms of experience through systemic, experiential, and symbolic means. As an interpersonal process, change emerges out of the dynamic interaction between the therapist and clients within a collaborative, spontaneous, creative, goal-oriented, and present-tense stance. ExST assumes that problems evolve out of a complex network of interconnected relationships which are rigid and static and thus, problems are relational in nature. Chemical Dependence The participants for the present study were part of The Alcohol Recovery Project (TARP) investigation. As such, an important inclusion criterion for participants was the husband's dependence on alcohol while the wife was the non-alcohol abusing partner. The males in this study satisfied the DSM-III-R (1987) 11 diagnostic criteria for severe Psychoactive Substance Dependence. A severe Psychoactive Substance Dependence includes symptoms markedly impairing occupational functioning, social activities and/or relationships with others. Recurrent Change Episode To date, episodes of change in marital therapy have not been clearly defined or identified. However, a few attempts at identifying and describing episodes of change from the theoretical perspectives of Emotionally Focused Therapy (EFT, Greenberg & Johnson, 1988) and ExST have been suggested. For instance, from the theoretical stand of EFT, good moments of change are characterized by greater depth of experience and affiliative interaction in conflictual episodes. These two aspects are accompanied by a process of "softening" of the blamer in the relationship. From the point of view of ExST, therapeutic change is conceptualized as relational novelty. Relational novelty is the process whereby clients experience greater interpersonal flexibility as new and more integrated ways of being in relationship emerge. This process is associated with greater depth of experiencing and affiliative interaction. Greenberg (1986) operationally defined a change episode as an identifiable and distinct psychotherapeutic occurrence consisting of the client problem marker, the therapist operation(s), the client's actions and interactions and the immediate session outcome. The client problem marker is an indication or statement by a client to the therapist which suggests to the therapist that the client is in a particular problematic and/or conflictual state. The therapist operation(s) refers to the actions 12 and interactions, including interventions initiated by the therapist, in order to facilitate resolution to the problematic situation. The clients' actions and interactions refer to the ongoing responses and interactions with the therapist in relation to the therapist's interventions. The in-session outcome refers to the resolution of the problematic situation which may be manifested as cognitive reorganization, integration of conflictual tendencies, new ways of relating to self and/or others, or softening of parts of self. Regarding this investigation, a change episode is defined as the transformation of ineffective, unsatisfactory and recurrent patterns of interaction between the partners into new and different ways of being and relating with each other in the session. The change episode distinguishes itself from the rest of the therapy through four distinctive characteristics. First, observable evidence of a verbal and/or nonverbal nature by one or both members of the marital dyad indicates that the client(s) is (are) in a problematic or conflictual condition requiring intervention on the part of the therapist in order to transform those problematic and/or conflictual conditions. Second, observable evidence suggests particular actions, interactions, or interventions on the part of the therapist addressing those conflictual conditions. Third, observable evidence indicates specific and ongoing responses and/or statements on the part of the client(s) to the therapist interventions. Fourth, an observable immediate outcome is identified in the form of a new way of being and relating in the session which is more satisfying and gratifying to the partners. 13 Conflictual Relational Marker The conflictual relational marker is defined as the point at which a problem or conflict was signaled as needing attention. Specifically, a signal was displayed in which one or both members of the dyad were verbally or non-verbally challenging recurrent relational patterns that were ineffective and unsatisfactory. The conflictual marker was expressed either verbally or non-verbally through statements or messages suggesting misunderstanding, confusion, detachment, alienation, distance, defensiveness, stuckness, pain, tension, and expressions of powerful and strong emotional arousal (e.g., tears, anger). Client and Therapist Actions and Interactions The client and therapist actions and interactions refer to the ongoing dialogue and activities engaged in by the members of the therapeutic system in order to address the conflictual condition of the couple. As such, they also include particular therapist's interventions and activities intended to generate a new pattern of relating or being in relationship for the couple. New Patterns of Interaction In-Session The new ways of being and interacting of the partners refer to observable indications which displayed satisfaction, contentment, flexibility, and understanding between the spouses. Regarding the initial conflictual situation, the couple interacted in more affiliative, gratifying, and satisfactory ways. 14 Internal Structure of Change Episode The internal structure of the change episode refers to the regularities and flow of the actions and interactions of the members of the therapeutic system in the co-creation of change. As such, it comprises the psychotherapeutic conditions, the client and therapist actions and interactions and the subsequent consequences. The internal structure is a representation characterizing the salient actions and interactions of the participants as they engage in the change process. Significance of the Study The need for investigations on the process of change in marital therapy through discovery-oriented methods has been identified as of paramount importance (Jacobson & Addis, 1993; Mahrer, 1988). However, only a limited number of studies have pursued this line of inquiry. This study is important and valuable for a number of reasons. First, as a process research investigation, with a focus on in-session recurrent change episodes, it will begin to illuminate the mechanisms of change in couples therapy. Secondly, because of the naturalistic, qualitative and processual nature of the method, it is definitively discovery-oriented. Thirdly, the discoveries may have valuable and useful information for researchers and practitioners. For researchers, it may provide a conceptual framework and context for quantitative research and some explanation for sometimes unexpected quantitative results. For practitioners, it may offer clinically relevant, meaningful, and rich information and insights which may facilitate understanding of clinical situations. Fourthly, the information generated from the study may offer valuable sources for the generation of hypotheses. In addition, it will expand and refine the 15 process of change as practiced in ExST. Finally, it will satisfy a personal curiosity regarding the dual role of taking part in a naturalistic investigation which asks questions similar to the ones asked by a psychotherapist. That is, while in couples therapy, one may ask what are the patterns that this couple is engaged in, what are the most appropriate interventions given the particular conflict or issue at hand, how to intervene given the operating conditions, and at what point to intervene, in discovery-oriented research, the questions of interest are "What patterns can I identify in the problem and how are these problems related?" (Artinian, 1986, p. 16). Having thus far introduced the study, the following chapters of this dissertation include a comprehensive review of the relevant literature on change process research, a thorough presentation of the design and method, a full description of the results, and a discussion of the conclusions emanating from the results of this investigation. The major topics to be covered in chapter two are: (1) a relevant review of the literature on individual therapy process research, particularly as it relates to the new paradigm in psychotherapeutic process investigations; (2) a review of process research in marital and family therapy from the perspective of the new paradigm; and (3) a review of change process research from the theoretical perspective of ExST. Following the review of the literature, chapter three describes the design and methodology utilized in this investigation. This chapter will describe in detail the various steps followed for the selection of the couples, the identification and selection of the change episodes, a description of the researcher's biases regarding the change process in marital therapy, an overview of Experiential Systemic Therapy, and a description of the qualitative method of analysis. Relevant sections will include the identification of couples and change episodes, theoretical assumptions about change in marital therapy espoused by the researcher, historical and theoretical tenets of grounded theory analysis, data collection and analytical procedures, rationale for the utilization of the method, and issues related to the scientific rigor of the study. Chapter four will describe the results of the investigation. Finally, chapter five will summarize and integrate the results with the current literature on the process of change in marital therapy. In addition, chapter five will also discuss the limitations of the present investigation as well as make suggestions for future research. 17 CHAPTER II REVIEW OF RELATED LITERATURE The review of the literature addresses three related areas to the investigation. First, a thorough review of the empirical strategies utilized in the study of psychotherapy is offered in order to provide a context to the present discovery-oriented study and to attest to its importance and validity. This review presents the most salient historical aspects of psychotherapy process research. Second, a review of process research in marital therapy is offered. This review focuses on how the process of marital therapy has been studied and the findings generated from these investigations. Third, a review of the process research studies which have sprung from the theoretical perspective of Experiential Systemic Therapy is offered given their relevance for the present investigation. Of particular interest for the present study is a review of how change episodes in marital therapy have been studied, identified, defined, and explained. Research Strategies in the Study of Psychotherapy The development of research in both individual and marital psychotherapy has progressed along the lines of what is known as outcome and process research. With the advent of electronic devices such as the tape recorder, Mowrer (1953) envisioned the possibility of studying the process of psychotherapeutic conversations, suggested outcome and process research as two valid and viable empirical strategies for its investigation, and provided an initial definition of both 18 strategies. Outcome research was defined as the measurement of the nature and extent of significant aspects of change before and after treatment. Process research was defined as the microscopic analysis of the ordinary course of therapeutic events (Mowrer, 1953). Currently, the distinction between outcome and process research has been a source of debate amongst researchers due to differences in definition and interpretation of outcome and process (Greenberg, 1986; Hill & Corbett, 1993; Orlinski et al., 1994). For example, because process and outcome are closely intertwined activities (Hill & Corbett, 1993), variables are conceptualized as process in some instances, while at other times they are treated as outcome (Orlinski & Howard, 1986; Orlinski et al., 1994). Nevertheless, the field of psychotherapy research has developed these useful conceptual abstractions for the purpose of organizing the observational and measurement materials generated in the conduct of its study. The Meaning of Outcome Outcome research refers to the investigation of change that occurs as a result of the process of psychotherapy. In outcome research, the focus is on the magnitude and strength of change (Lambert & Hill, 1994). Historically, outcome has been measured by indexes of change that occur between pretherapy and posttherapy assessments. Thus, Orlinski and Howard (1978, 1986) and Orlinski et al. (1994) have argued extensively for the measurement of outcome by the evidence generated outside the client-therapist relationship or at termination. Greenberg and Pinsof (1986), on the other hand, have suggested that attention be given to immediate and intermediate outcomes. The argument here is that changes 19 made inside the therapy session, such as client insight as a consequence of therapist interpretations or softening of internal conflict following the use of a Gestalt two-chair technique, are valid and appropriate outcomes. The Meaning of Process Historically, the term "process" has had different meanings in psychotherapy process research. In presenting a process conception of psychotherapy, Rogers (1961) investigated the process by focusing on the stages of change taking place in aspects of the client psychological functioning such as client's manner of experiencing, relationship to problems, and ways of relating to self and others. Aspects of the therapist's behavior were not considered as part of the therapeutic process; rather the therapist offered conditions purported to be facilitative of the client's process. Similar to Rogers's conception of process, Rice and Greenberg (1984) suggested a conception of process research in which the focus of the investigation is on the process of the change event itself. By segmenting therapy according to theoretically predefined criteria of change events, the researcher scrutinizes the process and generates a conceptual model of change. The assumption inherent in this definition is that outcome is part of process in that, by focusing on the change process, one concurrently focuses on the outcome of the event. Orlinski et al. (1994) provided a similar definition of process research but a different approach for the measurement of its outcome. Thus, the authors asserted that process research refers to an empirical strategy which attempts to determine those aspects of the therapeutic process which may be helpful or harmful to clients 2 0 by linking what actually occurs in psychotherapy with the final result of the endeavour. Still another way in which researchers ( Benjamin, Foster, Roberto & Estroff, 1986; Elliott, 1984) have conceptualized process research is with reference to any or all events that may be observed in therapy sessions in terms of actions, perceptions, thoughts, feelings and interactions of clients and therapists usually occurring inside the therapy sessions. Here, one focuses on the process of the event without making any prior distinction between helpful and hindering events. According to Orlinski et al. (1994), this approach to descriptive process analysis is taken when the researcher does not have a strong a priori hypothetical notion about the sources of change in psychotherapy. Others (Hill & Corbett, 1993; Lambert & Hill, 1994) have defined process research as what occurs during psychotherapy sessions by examining therapist behaviors, client behaviors, and interactions between therapists and clients. Historical Overview of Process Research In a review on the historical development of process research methods in individual psychotherapy, Hill and Corbett (1993) observed that the field has progressed through what they identified as three paradigmatic shifts. The authors identified these as: the early naturalistic process research period from approximately 1940 to 1970, the period of analogue research during the 1970s and 1980s, and the period advancing the utilization of naturalistic, qualitative methods in the late 1980s and 1990s. 21 The early naturalistic process research period was facilitated by the technological advancement of the audio-recorder, as it offered the possibility of recording and detailed examination of therapy sessions. In 1938, Frank Robinson pioneered the first program of process research in counselling psychology by recording sessions in order to provide supervision to his students and allow students to hear themselves (Hill & Corbett, 1993). The results of sessions recorded over a 10-year span generated a first set of categories on the process of therapy. For instance, Porter (1943) generated a category system for client and counsellor behavior which encompassed categories such as silence, interpretation, reflection, and tentative analysis. At this time, Carl Rogers also initiated research on the process of psychotherapy and developed a theory to guide and explain his research. Thus, in his book Counseling and Psychotherapy (1942), he suggested that, if the therapist clarified and expressed the feelings of the client, a shift from negative to positive experience would follow. This in turn would generate awareness and insight and would thereby facilitate positive action on the part of the client. Roger's second theoretical phase began in 1951 with the publication of the book Client-Centered Therapy. Here, his theoretical position shifted in that in addition to the clarification of feelings, the therapist was required to maintain a belief in the potential and the capacity of the client to work through his/her own situation. During this time Rogers published his classical theoretical notions on the necessary and sufficient conditions of therapeutic change. 22 A prominent theoretician and clinician, Rogers valued the scientific method and was committed to the objective study of the psychotherapeutic process. Based on his theoretical notions and his regard for objectivity in the scientific enterprise, a number of researchers developed objective instruments to measure various aspects of the process of psychotherapy and to validate Rogers's theory. Thus, observational measures such as The Experiencing Scale (Klein, Mathieu-Coughlan, & Keisler, 1986), a measure of client affective involvement in therapy, and The Client Vocal Quality Scale (Rice & Kerr, 1986), a linguistic measure of client emotional involvement in therapy were generated. As well, Barrett-Lennard (1962) developed the Barrett-Lennard Relationship Inventory to evaluate the perceptions of clients and therapists in relation to Rogers's theoretical notions such as therapist empathic understanding, level of positive regard, and congruence. As researchers and theoreticians were actively engaged in the testing and validation of ideas and instruments, Eysenck (1952) shocked the psychotherapeutic research community by claiming to demonstrate the ineffectiveness of psychotherapy. Based on his review of psychotherapy research, he argued that, compared to neurotic clients who had never entered therapy, the rate of improvement for neurotic clients who had received traditional (nonbehavioral) psychotherapy was equivalent after a 2-year period. Eysenck's (1952) overriding conclusion was that "The figures fail to support the hypothesis that psychotherapy facilitates recovery from neurotic disorder" (p.323). Such a powerful and shocking conclusion was the major thrust behind the next 30 years in psychotherapy research. 23 Given that the efficacy of psychotherapy was in doubt, the focus of investigation moved swiftly into the area of outcome research. Thus, throughout the 1950s, 1960s and 1970s, the research focus was to demonstrate the effectiveness of psychotherapy and generate evidence for the effectiveness of particular schools of therapy. Hill and Corbett (1993) argued that researchers felt compelled to investigate the effectiveness of the endeavour prior to investigating the components or aspects of the process that facilitated its effectiveness. In so doing, researchers have amply demonstrated the effectiveness of psychotherapy (Bergin & Lambert, 1978; Lambert & Bergin, 1994; Lambert, Shapiro & Bergin, 1986). Indeed, in the latest review on the effectiveness of psychotherapy, Lambert and Bergin (1994) concluded that a variety of psychotherapies have demonstrated significant statistical and clinical effects with a diverse population of clients; that, with the exception of addictive disorders, the therapeutic effects tend to be maintained; and that interpersonal and affective factors such as trust, warmth, acceptance, and human wisdom are significant stimulators of client improvement. Thus, the overall conclusion is that psychotherapy is effective as it helps people change at a faster and more significant level compared to changes which may occur naturally within the person's environment. With a satisfactory answer to the question of the effectiveness of psychotherapy, the next question that researchers prepared to investigate was "Under what conditions will this type of client with these particular problems be changed in what ways by specific types of therapists?" (Bergin & Garfield, 1971, p. xi). Recently, Orlinsky et al. (1994) identified the question as: "What is effectively 2 4 therapeutic about psychotherapy?" (p. 270). Both questions address the process of psychotherapy and its relationship to outcome by attempting to identify and determine variables and processes particularly helpful and/or harmful to clients. In so doing, and congruent with the conceptual and methodological assumptions of outcome research on controlled observation and measurement, generalization, prediction and verification (Kiesler, 1971), investigators have sought to answer these broad process-related questions. Consequently, the progression of process research ensued within the quantitative methodological tradition by linking process and outcome. The efforts afforded to the process-outcome area of research have generated some definitive findings (Orlinski et al., 1994). In their extensive, encyclopedic review of research linking process and outcome, Orlinski et al. (1994) evaluated a total of 2350 findings published from 1950 to 1992. Most of these findings were published in the period 1986-1994. Because some of the findings reviewed appeared to be consistently replicated, the authors considered them to be well established facts in the relationship of process to outcome. Some of the definitive findings demonstrated that 11 process variables were strongly connected to outcome measured at termination. Also, significant associations were found across multiple perspectives (client, therapist, rater). These variables were identified as client suitability, therapist skill, client cooperativeness versus resistance, global therapeutic bond/group cohesion, client contribution to the bond, client interactive collaboration, client expressiveness, client affirmation of the therapist, reciprocal 25 affirmation, client openness versus defensiveness, therapeutic realizations, and treatment duration. However, despite the general findings described above, the vast accumulation of studies and findings, and the significant volume of data generated by process research, various process researchers (Greenberg, 1986; Greenberg & Pinsof, 1986; Rice & Greenberg, 1984) have expressed discontent with the conceptual and methodological approaches utilized and the subsequent application of findings. These findings are based on the assumption of homogeneity of process (Kiesler, 1971) and reported findings have little relevancy for practitioners (Hill & Corbett, 1993). Moreover, although process research attempts to understand, describe, explain, and classify the important events in psychotherapy (Orlinski et al., 1994), often, only the measurable events have been investigated (Hill, 1990). Indeed, methodologically, the focus of process research has centered on the evaluation and prediction of phenomena to the detriment of its understanding, description, and explanation (Greenberg, 1991). In addition, researchers have argued that in order to understand how psychotherapy produces change, we need to focus on the change events themselves. That is, instead of investigating the psychotherapeutic process in general by attempting to determine, evaluate, and predict possible variables which may help and/or hinder the psychotherapeutic process for clients, the focus of research needs to address the change process itself and its related dynamics so as to understand its mechanisms. For instance, a valuable finding identified by Orlinski et al. (1994) in their review was that client collaboration is 26 associated with positive outcome. However, it does not tell us how and/or when client collaboration occurs, how it is facilitated and what are the specific components or properties of client collaboration. The conceptual and methodological discontent with the predominant paradigm in psychotherapy process research has generated what Kiesler (1983, cited in Greenberg & Pinsof, 1986) named a paradigmatic shift in psychotherapy process research. Conceptual Shift in Psychotherapy Process Research The conceptual shift in psychotherapy research was originally identified by Kiesler (1983), further developed by Rice and Greenberg (1984) in what was described as events-based research, and more recently as sequentially-patterned significant change episodes in psychotherapy (Greenberg, 1991; Greenberg & Pinsof, 1986). These authors recommended a shift toward the investigation of events, particularly the process of change events, with the aim to understand how change occurs in psychotherapy and develop context specific microtheory about the mechanisms of change. The shift in conceptual understanding of process research in psychotherapy emerged out of the integration of the process and outcome traditions (Greenberg & Pinsof, 1986). As indicated above, process and outcome research were conceptualized as separate empirical strategies. Process research referred to what occurred within the spatiotemporal domain of the session and outcome research referred to client improvement or deterioration outside the session, usually at termination. Gradually, researchers realized the need to link process and outcome in order to facilitate advances in the field. Kiesler (1986) indicated that, regardless 2 7 of whether the researcher's emphasis was on process or outcome research, he/she had to include measurements of both. The linking and measurement of both process and outcome generated basically two strategies: (1) the measurement of process at some point in the therapy and outcome at termination or follow-up; and (2) the averaging of process measures throughout the course of therapy and measurement of outcome at termination (Greenberg & Pinsof, 1986; Rice & Greenberg, 1984). Greenberg (1986), Greenberg and Pinsof (1986), and Rice and Greenberg (1984) have argued extensively on the limitations of these strategies. Basically, the first strategy assumes that any event at any point in the process is consistently related to outcome. However, the complexity of the psychotherapeutic process along with other intervening events (inside or outside therapy), and the accumulation of factors that may play a significant role in outcome at termination, are important elements which are usually ignored. The second strategy assumes homogeneity in the process; that is, it assumes stability and similarity of events and experiences for the participants across the time span of therapy. Greenberg and Pinsof (1986) suggested that both strategies assume what Kiesler (1971) identified as the myths of homogeneity. Thus, rather than continue to assume that all moments in psychotherapy are interchangeable, or that the process is uniform, it is suggested that psychotherapy researchers investigate both clients' and therapists' experiences in the context of the therapeutic events in which they occur. That is, the overall amount of client experiences, therapist operations (empathic reflections, interpretations), or client and therapist interactions are not as important as the 28 context, timing, and meaning of those actions and interactions for the participants. The authors argued that what is more relevant and therapeutically significant is the pattern of variables as they occur in a particular therapeutic event rather than the simple occurrence of isolated variables significantly associated to outcome at termination. In their introduction to Patterns of Change. Rice and Greenberg (1984) succinctly argued that: A basic difficulty with most of the process research that has been done is the underlying assumption of homogeneity of process. The typical approach has been to select samples from one or more sessions for rating, and to summarize ratings across samples for a single session, or even across sessions.... Clearly, process varies overtime and different processes have different meanings in different contexts. Aggregating processes as though all process during therapy is the same involves a uniformity myth from which psychotherapy research has been suffering. All process in a psychotherapy is not the same, just as all clients, all treatments, and all therapists are not the same... Different processes occur at different times in therapy and have different meanings in different contexts (p. 10). Focus on Events In events-based research, the focus is on understanding the workings of therapy by focusing on the internal relationship among variables and the process of change itself within the in-session context rather than relating single process variables to some external variable. Thus, an important principle of this strategy is the study of process in the context in which it occurs through the analysis of identifiable and recurrent moments. Furthermore, the target units of study are important client-change events occurring within the session or concurrently outside the session (Kiesler, 1986). 29 Events based research was envisioned and generated during the late 1970s by a number of researchers from different clinical orientations. These researchers were Greenberg (1984) with a Gestalt Therapy orientation, Rice (Rice & Saperia, 1984) with a Client-Centered orientation, Mathieu-Coughlan (Mathieu-Coughlan & Klein, 1984) with an Experiential Therapy orientation, and Luborski (Luborski, Singer, Hartke, Crits-Christoph, & Cohen, 1984) with a Psychoanalytic Therapy orientation. These researchers joined their efforts and collectively collaborated on the application of this new conceptual approach to psychotherapy research. This resulted in the publication of Patterns of Change: Intensive Analysis of Psychotherapy Process by Rice and Greenberg in 1984. A second volume with a focus on events based research was The Psychotherapeutic Process: A Research Handbook by Greenberg and Pinsof (1986). This handbook was intended as a resource for psychotherapy researchers and as an update to the previous compendium on process research measures, The Process of Psychotherapy: Empirical Foundations and Systems of Analysis by Kiesler (1973). While both volumes presented a variety of observational and self report measures for psychotherapy research, Greenberg and Pinsof s (1986) volume discussed in detail significant aspects of the conceptual and methodological underpinnings of events research. According to Greenberg (1986), an event is a therapeutic episode consisting of the client problem marker, the therapist operation(s), the client performance, and the immediate in-session outcome. The client problem marker is an indication or statement by the client which suggests to the therapist that the client is in a 30 particular problematic or conflictual state. The therapist operation refers to the interventions initiated by the therapist in order to facilitate resolution of the problematic state. The client performance consists of the ongoing client responses and interactions with the therapist in relationship to the interventions. Finally, the in-session outcome refers to the resolution of the conflict which can be manifested as cognitive reorganization, integration of conflictual tendencies, experiential novelty in relationship, or softening of parts of self. As reflected above, a significant aspect of change events process research assumes that outcome can be conceptualized as measurement occurring as a result of particular interventions. In fact, Greenberg (1986), Greenberg and Pinsof (1986), and Rice and Greenberg (1984) distinguished between three different types of outcome: immediate, intermediate, and final. Immediate outcome refers to change that is clearly evident within the session as a result of particular interventions and/or interaction amongst the participants. Intermediate outcome refers to changes measured through session outcome measures, usually at the end of the session. Final outcome refers to measurement taken at the end of treatment and follow-up. Ultimately, according to the authors, a thorough understanding of therapeutic change will be obtained when outcome at these three levels is simultaneously related to each other. When focusing on significant change events the researcher is attempting to answer questions such as: 1. What client in-therapy performances, or markers, suggest themselves as problem states requiring and ready for intervention? 31 2. What therapist operations are appropriate at this markers? What therapist operations will best facilitate a process of change at this marker? 3. What client performances following the markers lead to change? What are the aspects of the client performance that seem to carry the change process, and what does the final in-therapy performance or immediate outcome look like? (Greenberg, 1986, p. 6). Proponents of events-focus research assume that, by investigating these and related questions, the researcher will be able to stay closer to what actually does occur in therapy. Also, the investigation of specific therapist operations (reflection, interpretation), specific strategic episode contexts (reprocessing a critical incident) and specific relationship contexts (therapist perceived as empathic) will facilitate and enhance knowledge of the change process. Context Specific Microtheory The claim that psychotherapy research lacks clinical theory which is context specific has also been suggested as a limitation in the advancement of the field. Greenberg (1986, 1991), Greenberg and Pinsof (1986), and Rice and Greenberg (1984) have suggested that events-based research facilitates the generation of context specific clinical microtheory. Moreover, Kiesler (1986) claimed that, in order to understand the mechanisms of change, ideally we should rely on our current theories of psychotherapy; however, because they are too general, abstract and limited in the provision of guidance for the identification and discovery of significant change-process events; a need exists to develop and discover "miniature" theories of change events over the course of therapy. The generation of clinical microtheory may facilitate the identification and selection of moments of change. Greenberg and Pinsof (1986) claimed that clinical 3 2 theory may guide the researcher in determining where and what to look for in empirical investigations. In fact, a number of investigations have initiated the creation of context specific microtheory from the perspective of specific theories. Rice and Saperia (1984) for instance, generated a theoretical model of client resolution of problematic reactions from the theoretical perspective of client-centered therapy. As well, Greenberg (1984) utilized task analytic procedures to understand the resolution of an intrapersonal conflict from the perspective of Gestalt therapy. Elliott (1984, 1989), on the other hand, discovered significant change events in psychotherapy from the perspective of participants rather than from theory by utilizing the Interpersonal Process Recall and Comprehensive Process Analysis. Given that theoreticians and practitioners have gradually moved away from unitheoretical stands and toward theory integration in psychotherapy, and that currently there are approximately 400 different types of psychotherapies being practiced (Lambert & Hill, 1994), it may be imperative to generate empirically derived theories based on clinical practice rather than continue to prove or disprove theories which may have little applicability and usefulness to practitioners. Methodological Shift in Psychotherapy Process Research Like the field of psychotherapy research in general, the area of process research has been predominantly concerned with how to do better research rather than how to better understand psychotherapy (Orlinski et al., 1994). This concern for method over the understanding of phenomena continues to be the focus of attention in some quarters (Greenberg, 1991). In their efforts to understand how to do better research, investigators' methodological tendencies have been toward the 3 3 favoured and/or received research paradigms. The field of psychotherapy research has been dominated by the logical-empiricist quantitative investigative tradition and a culture of "scientism" (Greenberg, 1991, 1986). The culture of "scientism" has not only dictated how phenomena should be investigated, but it has also prescribed the quantitative-logical empiricist tradition as the scientific method and, therefore, superior to other investigative traditions. Various researchers (Greenberg, 1986, 1991; Greenberg & Pinsof, 1986; Mahrer, 1988; Rice & Greenberg, 1984) have argued that while proof, verification, testing of propositions and prediction are important aspects in the development and understanding of psychotherapy; discovery, exploration, description, and explanation are also essential to the scientific understanding and generation of knowledge in psychotherapy. Furthermore, it is suggested that true prediction and testing of propositions may be significantly facilitated and enhanced if, and when, rigorous description and explanation of phenomena are engendered. Furthermore, it is argued that in order to investigate how change occurs, how it works, and what leads to change in psychotherapy; a focus on discovery, context, patterns, and meanings is more appropriate and relevant due to the nature of the psychotherapeutic process (Greenberg, 1986, 1991; Greenberg & Pinsof, 1986; Mahrer, 1988). Indeed, psychotherapy is a highly complex, contextual, multifaceted, and multivariate process in which isolating variables for the purposes of manipulation, control, and random sampling is likely to limit the advancement of the field, to generate tenuous associations, to impede investigation of the essence and richness of psychotherapy, to ignore its complexity, and ultimately to report 34 irrelevant and unsubstantive findings for practitioners. In fact, a consistent lack of relevance of research findings to practice (Hill & Corbett, 1993) has been expressed extensively by clinicians. Discovery-Oriented Psychotherapy Research Given that psychotherapy research has overly emphasized verification to the detriment of discovery, a focus on the discovery of phenomena must be the subject matter of psychotherapy research, and thus, the task of psychotherapy researchers (Greenberg 1991; Greenberg & Pinsof, 1986; Mahrer 1988). These authors advanced the proposition that the description and explanation of phenomena through the identification of events, especially significant events, is what ultimately facilitates the discovery of underlying regularities and the construction of models which account for those regularities. A focus on description and explanation of underlying regularities of what actually occurs in psychotherapy, particularly the mechanisms of change, will in actuality bring psychotherapy research back to its scientific roots (Greenberg, 1986, 1991). Description in Psychotherapy Research In psychotherapy process research, description of the phenomenon of interest, that is, client change episodes, so as to understand the mechanisms of change, encompasses a description of the event itself along with the context in which that change occurs. In addition, this entails description of actions and interactions as they occur in the situation. Thus, rather than describing an event as a single dimension, for instance, reflective empathy, the researcher must describe the event 35 multidimensionally. Greenberg (1986) provides a clearly descriptive example of a therapist engaged in an intervention: An empathic reflection focused on a client's feeling of confusion, delivered in a "warm" voice by a therapist leaning toward the client, following a confrontation of a discrepancy in what the client is saying and doing, delivered in a supportive manner, by a therapist shifting position (p. 714). Levels of Description There are many levels in which a psychotherapeutic event may be described. The level of description refers to both the size of the unit to be described and the nature of the unit. Researchers have proposed various levels depending on the type of research, the questions asked, and the constructions of interest. For instance, Greenberg (1986) suggested a distinction among four levels of description: content (utterance), speech act, episode, and relationship. Content refers to what is actually being talked about or explored. Speech act refers to what a person is doing to another by saying or doing something, that is, the effect which one person's message or action may have on another. For instance, some examples of speech acts are advise, direct, inform, support, interpret, and threaten. Episodes refer to a meaningful sequence of interaction which the participants view as a distinct whole and thus, episodes form a distinct unit. The relationship level refers to the qualities of the relationship that the participants ascribe to. Elliott (1991) proposed a five dimensional model for the descriptive unit of analysis in process research. First, a description of the perspective of observation or the point of view (client, therapist, nonparticipant observer) from which the therapy is described must be included. Second, a description of the focus of 36 observation, which could be the therapist, the client or the therapeutic system, needs to be presented. Third, a description of aspects of the process, namely, content, action, style or quality of the communicative act must be observed. Fourth, a description of the unit level (sentence, speaking turn, episode, stage of treatment, treatment) is to be delineated. Fifth, a description of the sequential phase, that is, context, process, and impact or what happened before, during and after the unit level must be addressed. Orlinski et al.(1994) distinguished as many as nine levels of descriptive analysis for psychotherapeutic process and outcome. These nine levels are: (1) liminal (micromomentary processes, e.g., gaze shift); (2) momentary (moment-by-moment processes, e.g., specific utterances, interactive turns); (3) situational (session processes, e.g., rupture and repair of alliance); (4) daily (session-sequential processes, e.g., intersession experiences); (5) monthly (phase/short course processes, e.g., short-term treatment episodes); (6) seasonal (medium course processes, e.g., medium term treatment episodes, 2-24 months); (7) perennial (long course processes, e.g., 2-7+ years); (8) developmental (multi-treatment processes, e.g. sequential treatment episodes); and (9) biographical (therapeutic career, e.g., total treatment history). Whatever level of analysis and nature of descriptive unit the researcher chooses for his/her investigation, the relevancy and importance of the context in the description of the event must be clearly articulated. 37 Observational perspective In addition to defining the unit of description, process researchers must also decide on the observational perspective from which the study is conducted (Elliott, 1991; Lambert & Hill, 1994; Orlinski et al., 1994). Thus, one may observe and assess the process from the perspective of the participants, that is, the client and the therapist, and from the perspective of nonparticipant observers. Usually, therapy process from the perspective of the participants has been assessed through rating scales and post-session questionnaires, while nonparticipant assessment has been conducted through observation of video-recordings of therapy sessions (Orlinski et al., 1994). Orlinski and Howard (1986) argued that the phenomenon of therapy differs according to who observes the process. Elliott and James (1989), in discussing the strengths and weaknesses of the three perspectives, suggested that this is not only a methodological consideration but that the perceptions differ and must be accounted for in the research. Hill, Helms, Tichenor, Spiegel, O'Grady, and Perry (1988) reported that clients and therapists differ in what they perceive as helpful in the therapy process. Although noting that the two perspectives offer different ways of looking at the process, Hill et al. (1988) were noncommittal in terms of choosing one perspective over the other. Furthermore, whereas originally it was assumed that nonparticipant observers had less biases about the process, it is now believed that nonparticipant observers have as many biases as clients and therapists (Lambert & Hill, 1994). These biases seem to differ according to the level of involvement in the process of therapy. 38 Explanation in Psychotherapy Research As indicated above, explanation in psychotherapy research has been greatly neglected. Although researchers have attempted to explain events by seeking to investigate associations between process variables and outcome, that is, explaining why something is likely to occur or under what conditions an event is likely to occur, explanation about the nature and properties of psychotherapeutic events has been lacking. Discovery oriented explanation in which the nature and structure of psychotherapeutic events, the operations under specific situations, and the properties and dimensions are fully interconnected will generate new knowledge and facilitate clinically relevant understanding of the mechanisms of change (Greenberg, 1986 a). This means that data require interpretation in order to have meaning and explanatory significance. Research Approaches There are four research approaches identified within this new paradigm of psychotherapy research. Greenberg (1986) identified performance analysis (Rice & Greenberg, 1984), empirical pattern identification (Gottman, Markman, & Notarious, 1977) and theory testing (Sampson & Weiss, 1986) as three approaches which highlight the investigation of intensive analysis of process in order to elucidate the internal pattern of variables rather than the aggregation of variables. An additional approach is discovery oriented (Elliott, 1984; Mahrer, 1988; Rennie, Phillips, & Quartaro, 1988). These four approaches highlight the discovery of patterns within significant and potent events in order to describe and explain the mechanisms of change. Greenberg (1986) suggested that empirical pattern identification, theory 39 testing and performance analysis are based on two underlying assumptions. These assumptions are (1) the focus of the investigation must be on recurring events, and (2) theory is utilized to guide one's observations. While empirical pattern identification and theory testing utilize quantitative methods of analysis, performance analysis and the discovery oriented methods proposed by Elliott (1984), Mahrer (1988), and Rennie, Phillips, and Quartaro (1988) are qualitative in nature. Empirical Pattern Identification Empirical pattern identification utilizes statistical methods to find probabilistic sequences by collapsing the occurrence of sequences over time in order to obtain an overall representation of what occurs in therapy. For instance, in an empirical pattern analysis investigation, Gottman, Markman and Notarious (1977) analyzed the sequential interaction patterns of clinic couples and nonclinic couples using Markow chain analysis. The authors showed that clinic and nonclinic couples differ in their patterns of communication and problem solving tasks. Greenberg (1986) argued that, although sequential analysis is useful in the identification of sequential dependencies (the probability that x occurring given that y has occurred) among a number of variables, this approach does not facilitate the isolation of the phenomena that represent the process of change because it aggregates data. As well, through this approach, the option of refining and modifying categories generated as well as discovering new categories as one moves along is impossible because dependencies are discovered only in the behaviors represented in the coding system which one originally started with. 40 Theory Testing In a theory testing approach, the researcher intensively analyzes process patterns at specific moments in therapy so as to test the explanatory power of theoretically derived hypotheses. Thus, although the option for analyzing highly significant moments of therapeutic change is possible, the purpose is to test rather than discover or generate theory. For instance, the testing of the explanatory power of two competing theories or hypotheses is a significant feature of the research approach implemented by Sampson and Weiss (1986) at the Mount Zion Psychotherapy Research Group. Sampson and Weiss (1986) utilized a method in which they inferred, through reasoning from theory, instances in which one theory predicts one finding and a competing theory predicting a different finding. Then, based on the application of objective measures and ratings of observations, the researcher determines which theory is in better agreement with the actual observations. The events studied are recurrent, relevant and readily observable by practitioners. Performance Analysis Rice and Greenberg (1984) suggested a rational performance analysis approach to the intensive analysis of process psychotherapy. Greenberg (1984) and Rice and Greenberg (1984) suggested the task analysis method as appropriate and effective for the study of complex human performance. In task analysis, the researcher attempts to understand how a problem is solved by specifying the components of competence in successful performance. Greenberg (1984) suggested five strategies for the task analysis of therapeutic events. These are the 41 description of the task, the specifications of the task environment, the rational task analysis, the empirical task analysis, and the model construction. The description of the task entails the identification and the clear and thorough selection and description of the client's task to be performed. The client's performances are regarded as indicators or "markers" of the usually affective tasks in which the client is engaged (Greenberg, 1984). The appearance of these indicators suggests that the client is ready to work on a particular task, to discover some solution, and to attain a particular goal. The indicator or "marker" is the "when" of the event. This may be a conflictual experience, a problematic reaction or incomplete affective task (unfinished business) which the client may need resolution. A discriminable therapeutic event is demarcated by the marker, the "then" of the event or the therapist intervention, and the subsequent client processing. The specification of the task environment refers to the delineation of suitable therapist's interventions in order to facilitate the resolution of the task. The rational task analysis is performed by the investigator through reflections on the task to be solved in order to discover possible strategies and components of resolution. Here, the investigator engages freely in thought experiments in order to obtain the essence of the resolution and generates a framework for understanding the client performance in the resolution of the task. The empirical task analysis refers to the description of the actual moment by moment performance of the client engaged in the resolution of the task. The empirical task is compared and analyzed in relation to the rational task analysis. Through an iterative process between the rational and empirical task analysis, the researcher generates a performance model 42 which is the best predictor of the client's therapeutic process when dealing with a particular type of task (Greenberg, 1984). Various researchers have utilized task analysis as their method of investigation. Greenberg's (1984) work on intrapsychic conflicts represented a significant effort in utilizing task analysis (Clarke & Greenberg, 1986; Greenberg, 1980, 1983, 1984; Greenberg & Clarke, 1979) as a method in the intensive analysis of the mechanisms of change and the generation of a conceptual model accounting for those processes. Rice and Saperia (1984) also utilized task analysis in order to understand the resolution of clients' problematic reactions to particular situations from the theoretical standpoint of person-centered therapy. Heatherington and Friedlander (1990) expanded the method of task analysis by applying it to the multi-person level of family therapy. Based on the analysis of taped sessions of structural family therapy, the authors suggested that task analysis can be successfully applied to the study of multiperson events in family therapy. Although rational performance models have been strongly championed by Greenberg and his associates as the mode of enquiry for psychotherapy process research, particularly the mechanisms of change, this approach has been criticised for its underlying assumptions. Packer and Addison (1989), for instance, argued that rather than guiding the domain of study toward action in context, the rational approach of task analysis attempts to reconstruct a competence model that underlies the performance. As such, the rationalist task performance analysis places greater importance on the internal structure of competence rather than the connections between actions and setting, or the aspects of context which bear 43 meaning to the actions and interactions of the participants. Besides, the character of explanation takes the form of a reconstruction of the structures underlying performance which limits understanding of human action (Packer & Addison, 1989). Discovery Oriented Methods Contrary to performance analysis, in which the researcher constructs a performance model through the derivation of events and actions from a particular clinical theory (Gestalt therapy, Person-Centered Therapy), discovery oriented methods (Elliott, 1984, 1989; Mahrer, 1988; Rennie, Phillips, & Quartaro, 1988) attempt to describe and explain what occurs within psychotherapy from a nontheoretical stance. That is, events or occurrences and experiences of participants are identified with an open attitude and open frame of reference in order to learn about the observations. In addition, psychotherapeutic events are described and explained from a pantheoretical (Hill, 1990) perspective in which the researcher utilizes multiple clinical theoretical perspectives to understand phenomena and generate hypotheses with the ultimate goal being the development of theory. Elliott (1984) utilized a discovery oriented research strategy to investigate significant change events in individual psychotherapy which combined Interpersonal Process Recall (IPR) and Comprehensive Process Analysis (CPA). This research strategy to change events is based on four underlying operating assumptions. As a purely qualitative strategy, the first assumption is that research on the psychotherapy process must start with the experiences and perceptions of the participants (clients and therapist). The observational perspective may be from 4 4 the participants themselves (phenomenological) or from trained observers (behavioral). Secondly, client and/or therapist experiences and perceptions are more useful when they are anchored in observable, specific behavioral (verbal and nonverbal) events through the interpersonal process recall. Thirdly, research on the process of psychotherapy needs to highlight significant change events, or turning points in which something changes for the client rather than continue with the usual method of random sampling and averaging across the process. The fourth operating principle assumes that since significant change events are rare, infrequent, and highly complex; they should be investigated in a thorough and comprehensive manner when they occur. Elliott's (1984) discovery oriented strategy comprises two procedures: The Interpersonal Process Recall (IPR) and the Comprehensive Process Analysis (CPA). The IPR is an interview procedure in which a taped session is separately played back to the client and therapist in order to identify significant change events by rating the helpfulness of each therapist response. Then, both therapist and client select the two most significantly helpful and hindering interventions. Another way in which the interpersonal process recall is utilized is by requesting, from both client and therapist, a qualitative description of significant change events; that is, a description and elaboration of how the significant event unfolded. Once the researcher has identified the significant event, the comprehensive process analysis is initiated. The comprehensive process analysis procedure (Elliott, 1984, 1989) consists of a definition of the interactive episode and its context, transcription of both the 45 episode and the data obtained through the IPR, measurement of process variables, that is, the assessment of the episode through a battery of quantitative or qualitative process measures, and the final integration of the data by analyzing common characteristics or themes in narrative form or in a summary table form. It is suggested that the crucial step in the analysis is the systematic description of significant change events through a battery of process measures. In one study, Elliott (1984) identified insight as a significant, recurrent and potent change event in psychotherapy. Based on the selection of four insight events, Elliott (1984) applied both procedures and generated a tentative model of insight events. In another study exploring significant change events, Elliott (1989) utilized comprehensive process analysis and defined awareness as a significant client change event. Based on the selection and analysis of eight episodes, the author generated a model linking various therapist interactions with client awareness. Another research strategy suggested within the discovery oriented methods is Mahrer's (1988) approach based on the procedures and analytical paradigm of the grounded theory method (Glaser, 1978; Glaser & Strauss, 1967). Mahrer (1988) indicated that in a discovery oriented investigation there are at least two strategies to the endeavour: (1) to provide a closer, discovery oriented look at psychotherapeutic phenomena, and (2) to discover the relations amongst psychotherapeutic conditions, operations, and consequences. The first strategy entails selecting the target of the investigation, obtaining instances of the target, obtaining an instrument such as audiotapes or videotapes of sessions for taking a 4 6 closer look, gathering the data, and making discovery-oriented sense of the data. The second strategy refers to discovering interconnections among conditions, operations, and consequences of specific and concrete events occurring within the session. Conditions refer to how the client is doing or being in the session. For instance, the client may start the session with a deep sigh, or may be deeply silent. Operations refer to the therapist intervention immediately after the client's expression, and may consist of, for example, offering an empathic reflection, intensifying the feeling or bodily felt experience, or inviting the client to stay in the present. Consequences refer to the client's actions and interactions subsequent to the therapist intervention. As suggested by Mahrer (1988), within this strategy there are three general steps: (1) specifying the question (i.e., given this consequence, what operations and under what conditions can one achieve this consequence?), (2) obtaining the data, and (3) examining the data to obtain a discovery-oriented answer. Rennie, Phillips and Quartaro (1988), arguing for the need to move beyond theory verification and into discovery, suggested and applied the grounded theory method to the investigation of the process of psychotherapy. Specifically, the authors demonstrated the analytical steps of the grounded theory method and the generation of categories from a study on the experiences of psychotherapy as recalled by former clients. The grounded theory method was suggested as a powerful tool for the generation of theory grounded in the data and for facilitating movement into the creative, inductive, and discovery oriented research needed in psychotherapy. 47 In all of the discovery-oriented strategies, Elliott's (1984, 1989) comprehensive process analysis, Mahrer's (1988) discovery oriented methods, and Rennie, Phillips, and Quartaro's (1988) application of grounded theory, attempts are made to open up new avenues for psychotherapeutic research, to integrate research, practice, and theory, and to generate rigorous, qualitative, and scientific conceptualizations from the data. Hill (1990) argued for the necessity, validity, and usefulness of engaging in observations of the therapy process through discovery oriented methods so as to generate testable hypotheses and develop empirically derived theories on the process of psychotherapy. However, she also warned researchers of the potential dangers involved in discovery oriented research. These were identified as (1) the tendency of researchers to investigate trivial aspects of process, with little relevance to clinical practice but easily measured (the use of plural words or head nods); (2) the generation of rich and dense amounts of data which may make it difficult for researchers to discern and isolate significant aspects of the process; and (3) the possible unstated biases which may affect the results of the investigation. Given that, in the last 10 years, a significant conceptual and methodological shift was called for in the area of process research in psychotherapy and that important programmatic research was initiated in the area of individual therapy, a similar call was made in the area of marital and family therapy process research, particularly with reference to the need for methodological pluralism and diversity (Greenberg & Pinsof, 1986; Jacobson & Addis, 1993; Keeney & Ray, 1992; Moon, Dillon, & Sprenkle, 1990; Moon & Sprenkle, 1992). However, marital and family 48 therapy process research has evolved at a much slower pace. In fact, researchers (Alexander etal., 1994; Gurman etal., 1986; Pinsof, 1981, 1986, 1988, 1989) suggest that marital and family therapy process research is still in its infancy. Given that the present investigation attempts to discover and understand change episodes in marital therapy from the perspective of the new research paradigm in process research psychotherapy, the next section undertakes a review of marital therapy process research. Specifically, it reviews investigations on the process of change in marital therapy from the perspective of events-based research. The Process of Change in Marital Therapy Like individual therapy process research, investigations on the process of change in marital therapy have progressed along both quantitative and qualitative lines of enquiry. Within the quantitative mode, the traditional assessment tools utilized have been self reports of participants through questionnaires and observation of process by expert raters through the utilization of coding systems which quantify various aspects of process. Within the qualitative line of enquiry, investigators have primarily utilized task analysis (Greenberg et al., 1988) in the investigation of the change process. Quantitative Research on the Process of Change in Marital Therapy Reviews (Alexander et al.,1994; Jacobson & Addis, 1983) indicate that most of the research efforts in the process domain have examined the process of change from the perspective of Emotionally Focused Marital Therapy (EFT) (Greenberg & 49 Johnson, 1988). Yet, only three studies have examined the process of change from this clinical perspective. Johnson and Greenberg (1988), noting a complete lack of research regarding the change process in marital therapy, investigated the process of change in the "best" sessions of EFT. The authors selected a total of six couples on the basis of extreme change scores (three low change and three high change) from a pool of 29 couples originally involved in an EFT efficacy study (Johnson & Greenberg, 1985). The selection of the six couples was based on their marital satisfaction as reflected by the Dyadic Adjustment Scale (DAS) (Spanier, 1976). Then, the session in which the couple made the most progress, as identified by the therapist, and which the couple rated as the most useful session in resolving the conflict, was selected for intensive analysis. Intensive analysis comprised the application of the Experiencing Scale (ES) (Klein, Mathieu, Keisler, & Glendlin, 1969), a measure of client involvement in therapy, and the Structural Analysis of Social Behavior (SASB) (Benjamin, 1974), a measure of interpersonal dimensions in which dialogue is categorized and analyzed. The authors concluded that, in comparison with the least successful couples, the most successful couples had a higher percentage of affiliative and autonomous responses on the SASB and a deeper level of experiencing and disclosure on the ES. As well, the blamer in the relationship moved from a position of limited participation and emotional involvement to an increased level of self-exploration, deeper experiencing, and integration. Instances of softening, defined as redefining the relationship structure by connecting with emotional experiences underlying rigid interactional patterns, were only identified in 5 0 the successful couples. As far as therapeutic interventions were concerned, the authors suggested that, for therapists working from an experiential perspective, a focus on facilitating the deepening of experience and self disclosure, particularly accessing underlying needs of the blamer when the other partner was ready to respond, were especially effective. In a more recent publication, Greenberg et al. (1993) reported on three studies investigating the in-session change processes from the perspective of EFT. The first reported study by Vaughan (1986) investigated whether couples in conflict would demonstrate greater affiliation and interdependence by the end of therapy. Based on ratings of audio recordings of interactional episodes during session two and session seven on 22 couples, it was concluded that EFT facilitated autonomous and affiliative behaviors during the latter stages of therapy. Partners were more affirming, supportive, understanding, self-disclosing and self-expressive in the latter stages of therapy rather than at the beginning. The second reported study (Alden, 1989) investigated the degree of affiliation between peak (highly productive) and poor (unproductive) sessions as perceived by the couple through a postsession questionnaire. The findings from this study suggested that the peak sessions had a greater proportion of friendly statements when compared with poor sessions, which had a greater proportion of hostile statements. As well, the peak sessions showed a deeper level of experiencing and a greater proportion of self-focused positive statements (disclosing, expressing, approaching and enjoying) than other-focused positive statements (encouraging friendly autonomy and friendly influence). 51 In the third reported study, Ford (1989) investigated the role of intimate self-disclosure in the couple. In this study, the selection of the session for investigation was based on the therapist and couples's rating of session success through a postsession questionnaire. The selection of the intimate self-disclosing event was based on the researcher's observation of videotapes of the selected sessions. The findings from this study suggested that partners are more likely to respond affiliatively after the therapist facilitates intimate self-disclosure on their part and that self-disclosing of one partner facilitates self-disclosing on the other. From the clinical-theoretical perspective of behavioral marital therapy, Jacobson et al. (1993) investigated client and therapist behaviors associated with positive outcome at termination. Clients and therapists completed process ratings after each therapy session. This study reported that from the clients' point of view, the couples that gained the most from this form of therapy were those who were actively and collaboratively engaged in the therapy as well as those who complied with the homework assignments. From the therapists' point of view, therapists rated their effectiveness in terms of facilitating collaboration in the therapeutic environment. Based on their findings, the authors concluded that behavioral marital therapy's success depends on clients' involvement and compliance. Qualitative Research on the Process of Change in Marital Therapy Very little qualitative research exists within the domain of change processes in marital therapy, in spite of its current theoretically undeveloped status (Jacobson & Addis, 1993; Wynne, 1988). However, despite this scarcity, a few researchers have initiated qualitative investigations on the process of change in marital therapy in the 52 last decade. Investigations from the theoretical points of view of ExST, EFT, and Structural family therapy are notably valuable. Greenberg et al. (1988) investigated the process of change of EFT from the point of view of 25 couples who had participated in a previous outcome study (Johnson & Greenberg, 1985). The investigators in this study performed a task analysis in which the rational model was generated from a number of clinical notions derived from the Couples Project (Johnson & Greenberg, 1985) and the empirical model generated from three procedures. First, the couples were interviewed at a 4-month follow-up about incidents that stood out as helpful and how change came about for them during these incidents. Second, these incidents were sorted and categorized according to a cue for sorting. Third, these categories were computer analyzed in order to obtain latent categories. From the analysis, five empirically derived categories were generated. These categories were: (1) expression of underlying feelings leads to change in interpersonal perception; (2) expressing feelings and needs facilitates change in the interaction; (3) acquiring understanding (intellectual and/or emotional) of relationships in addition to understanding of self and partner's dynamics; (4) taking responsibility for experience; and (5) receiving validation, particularly therapist's validation of some aspect of the partner's experience facilitated change. Similar to Greenberg et al. (1988), Wark (1994) studied the process of marital change by exploring the clients' perceptions of change immediately after the therapy session rather than retrospectively. The clients' ideas regarding their psychotherapeutic change were qualitatively analyzed by discovering similarities 53 and dissimilarities of clients' ideas. Wark's (1994) findings comprised six categories for clients' positive critical incidents (positive results, routine provided by structure, alternative perspectives, non-directive style of the therapist, directive style of the therapist, and focus on positives by the therapist) and four categories for therapist's positive critical incidents (signs of readiness for change, techniques for change, client interaction in session, and change outcome). The author also identified three clients' negative critical incidents (no follow-through with assignments, therapist imposition, and no resolution of problems) and two therapist's negative critical incidents (therapist took responsibility for change and not enough data gathering). Heatherington and Friedlander (1990) applied task analysis to two sessions of Salvador Minuchin's structural family therapy. The authors generated a clinical model of analysis by observing the two sessions and discovering a salient and dramatic moment defined as clinically significant. During these two clinically significant moments the parent and child interactions were characterized as stuck in a pursue-distance pattern of interaction.The analysis of two therapy sessions of parent-child interactions revealed a shift in interpersonal relations from a marker identified as pursue-distance impasse, to a resolution characterized by becoming unstuck from rigid and dysfunctional patterns of relating. The task required to resolve the impasse was defined as establishing family collaboration. The authors termed the change event as commitment to engage on the part of the distancer. In another study, Friedlander, Heatherington, Johnson, and Skowron (1994) significantly expanded their previous investigation and generated a conceptual model of the change process in family therapy named sustained engagement. 54 Through a qualitative inductive method of analysis, these researchers discovered therapeutic episodes where family members moved from disengagement from each other to sustained engagement while solving a task. That is, the researchers developed working definitions of the marker of the event (disengagement) and the resolution of the event (engagement) in order to distinguish successful from unsuccessful events. The model of change describing movement from disengagement to sustained engagement consisted of patterns and themes absent from the unsuccessful events. The generated model consisted of five steps the family was engaged in during the resolution of the task. These steps were described as (1) recognition of personal contribution to impasse; (2) communication or emotional disclosure about the impasse; (3) acknowledgment of other's thoughts and feelings; (4) the formation of new attributions or constructions about the impasse; and (5) recognition of potential benefits to engaging, initiated by either the therapist or a family member. Recently, Christensen, Russell, Miller, and Peterson (1998) investigated the process of change in marital therapy by qualitatively analyzing the couples's perceptions of change as expressed through open-ended interviews. These researchers utilized the grounded theory method to analyze the couples's responses. Three clusters of change were identified. These clusters of change occurred in the couple's affect (feelings about themselves, the relationship or their partner), cognition (definition of the problem or the relationship) and communication (style of relating and talking). The authors reported that change within these clusters occurred gradually and no cluster predominated over others. In addition, 55 these researchers identified five psychotherapeutic contextual factors as preconditions contributing to the perceived change. These contextual factors were categorized as safety, fairness, normalization, hope and pacing. Research on the Change Process of Experiential Systemic Therapy A number of qualitative investigations on the process of change in marital therapy from the theoretical perspective of ExST have been conducted in the last 5 years. Although some of these investigations have focused on the applications of specific techniques and their impact on the process, others have explored the process of change as conceptualized in ExST. Two investigations regarding the application of techniques and their impact on the process of change have been conducted. Dubberley-Habich (1992) employed Conversational Analysis to investigate the change process of a couple engaged in a ritualistic ceremonial transaction. The other study (Wiebe,1993) examined the application of symbolic externalization via Comprehensive Discourse Analysis (CDA). Both studies generated themes describing the actions and interactions of the participants during the application of the techniques. Process research concerning the change process in ExST is a fairly recent undertaking and valuable for the present study. Newman (1995) investigated the change process of a successful case of marital therapy and attempted to expand the theoretical notion of relational novelty (change construct) from the perspective of ExST. Based on the identification of a successful case of marital therapy, the researcher selected two episodes comprising the theoretical notion of relational novelty as advanced by ExST. These episodes were then analyzed through the 56 procedures of Comprehensive Discourse Analysis. The identification of the successful case was based on three criteria: (1) documented client satisfaction with the therapy, the cessation of alcoholic drinking, and marital satisfaction at posttest and follow-up; (2) therapist's satisfaction with her work with the couple; and (3) evidence of relational novelty in a number of sessions. The selection of the two relatipnally novel episodes for analysis was based on six criteria as defined by ExST theory. It must be noted that, although eight relationally novel episodes were identified within the 15 therapy sessions, only three satisfied the defined selection criteria for further analysis. This means that the change process as reflected by this therapeutic modality encompasses processes unaccounted for in the criteria identified. Based on the discourse analysis of the two episodes, it was discovered that intimacy and reconciliation of initial distant beliefs and practices were facilitated through the utilization of intense experiential activities and the maintenance of a collaborative atmosphere. These actions encouraged the couple to engage in empathic and self-disclosing interaction, to share their vulnerabilities, and to increase their cooperation with one another. It was also found that the therapist facilitated intimacy when accepting clients' experiences and adopting clients' language during the interactions. The researcher termed the interactional process by which the therapist and clients facilitated the creation of relational novelty as syncretic change process. Sweetman (1996) investigated the resolution of a Relational Impasse event (Rl event) in two successful cases and one unsuccessful case of marital ExST via the task analysis method. The author formulated an ExST-specific theoretical 57 model and a transtheoretical empirical model of the resolution of the relational impasse event. The transtheoretical empirical model identified five steps in couple and therapist performance. The five steps in couple performance considered transtheoretically meaningful were: (1) formation of a strong therapeutic relationship; (2) disclosure of emotional reactions to the Rl event; (3) acknowledgment of the problem; (4) individual self-disclosure regarding the impasse; and (5) insight and resolution. The five steps concerning the therapist performance were identified as: (1) establishing a therapeutic relationship; (2) validating client's emotions; (3) increasing client awareness of the problem situation; (4) facilitating client experiencing; and (5) assisting client reframing of experience. The latest investigation on the process of change in ExST by Manson (1997) examined a Significant Intrapersonal Event (SIE) in a successful and an unsuccessful case of marital therapy. The significant intrapersonal event was defined as a meaningful encounter with a previously unregarded or avoided part of self during a relationally novel episode. Here, the author employed Comprehensive Process Analysis in order to discover the context, the process, and the effects of the event in the two cases. The comparative process analysis of the two cases discovered 13 differences between the successful and the unsuccessful case. These differences were identified as: (1) process-flow; (2) disequilibrium; (3) readiness; (4) symbolic experience; (5) intelligence; (6) forgiveness experience; (7) core conflict; (8) stress level; (9) self-support; (10) spiritual support; (11) supportive 58 partner; (12) support network; and (13) individuated interpersonal experience. Client readiness was identified as primary in distinguishing between the successful and the unsuccessful case. Although a limited number of investigations on the process of change in rnarital therapy have been conducted, valuable findings have been generated. These findings revealed the discovery of categories in the cognitive and emotive realm of the couple's experience in therapy. Cognitive aspects of marital change such as defining the conflict (Christensen et al. 1998), recognition of personal contribution to the impasse (Friedlander et al. 1994), acquiring understanding -(Greenberg et al. 1988), reconciliation of discrepant beliefs (Newman, 1995) and acknowledgment of the problem (Sweetman, 1996) were identified as important processes of marital change in successful cases. As well, emotive processes identified as expressing affect about self, other and relationship (Christensen et al. 1998), disclosure of emotional reactions (Sweetman, 1996), emotional and spiritual support (Manson, 1997), emotional disclosure about the impasse (Friedlander et al. 1994) and expressing underlying feelings and needs (Greenberg et al. 1988) were found to contribute to marital change. In addition, the findings emerging from these studies have produced either step-models or identification and description of categories in their conceptualization of marital change. Studies utilizing qualitative inductive method (Friedlander et al. 1994) and task analysis (Sweetman, 1996), for instance, have generated step-models in their descriptions of marital change. Others (Christensen et al. 1998; 59 Greenberg et al. 1988; Manson, 1997; Newman, 1995; Wark, 1994) have provided distinct categories describing change in marital therapy. Summary of the Review The field of individual and marital psychotherapy process research has experienced a significant shift as researchers conceived new ways of conceptualizing the phenomena under study and developed new lines of enquiry and methods congruent with its conceptualization. As a consequence, a shift toward events-based research with a focus on significant and recurrent therapeutic change events was recommended. Methodologically, a move toward knowledge generation, namely, description and explanation in order to generate understanding of the basic mechanisms underlying therapeutic change, was suggested. Although the new technology for change process research has been available for the last ten years, few investigations have pursued its utilization. This is particularly noticeable in the area of marital therapy. As evidenced by this review, research on the process of change in marital therapy is scarce and uncommon. In addition, the review indicates a lack of empirically derived conceptual models to account for the process of change in marital therapy. However, despite this scarcity, valuable initial efforts (Friedlander et al., 1994; Greenberg etal., 1988; Manson, 1997; Newman, 1995; Sweetman, 1996) have attempted to understand the mechanisms of change in marital therapy. This study further contributes to and elaborates on the previous investigations by exploring the process of change in marital therapy through a 60 discovery-oriented line of inquiry in order to generate a model accounting for the actions and interactions of the participants as evidenced in episodes of change. 61 C H A P T E R III METHODOLOGY The selection of an investigative approach demands consideration of both the nature of the phenomenon studied and what is known about it. For the purposes of the present study, a naturalistic, discovery-oriented, qualitative line of enquiry was deemed suitable. First, the nature of marital therapeutic change is complex, multifaceted, contextual and processual, thus, amenable to a qualitative approach. Second, as evidenced in the literature review, knowledge on the process of change in marital therapy is incipient, therefore appropriate for qualitative investigations. Third, the new conceptual and methodological shift for process research attests to the usefulness of discovery-oriented methodologies, particularly when much is unknown and yet to be discovered. Thus, in pursuing a qualitative, naturalistic, discovery-oriented investigation, this study explores, identifies, describes and elucidates change episodes in marital ExST. This chapter addresses the relevant and pertinent topics related to the methodology. First, the design of the current investigation is presented. Second, study participants, selection of cases, and selection of episodes of change are discussed. Third, given the nature of the study, naturalistic participant-observer, a description of the researcher's biases about psychotherapeutic change is presented. This is followed by a brief overview of ExST as the theory of change underlying the therapy. Then, an overview of grounded theory, as the method of analysis, is introduced along with its historical background and precursors. Finally, 62 the application of the investigative procedures and data analysis utilized to answer the research questions posited are presented. Design The design for the present study consisted of a multiple case embedded design (Yin, 1989) with adherence to the canons of naturalistic enquiry (Denzin & Lincoln, 1994). The case design is suitable when the questions and aim of the investigation call for intensive and in-depth exploration of the data collection and analysis over time (Gelso, 1979). In addition, the case study is appropriate when the relevant behaviors cannot be manipulated; that is, the investigator has little control over the events studied and, thus, observation is a significant source of evidence (Cook & Campbell, 1979; Hayes, 1981; Howard, 1983). A case study design is relevant when investigating events within a real-life context (Yin, 1989). A multiple-case embedded design involves more than one case and more than one unit of analysis (Yin, 1989). In a single case study design, the focus of investigation is on the individual unit or individual entity. However, multiple case design allows the research to extend and expand the findings and relationships beyond the individual case (Yin, 1989). Multiple case designs alllow for the replication of findings by exploring, observing, and analyzing case by case or, as Hilliard (1993) suggested, the generality of the findings is addressed through case by case replication. Replication may be literal or theoretical. The logic of replication assumes that cases are carefully selected so that they either predict similar results or produce diverse results but for predictable reasons (Yin, 1989). Accordingly, multiple case 63 studies may replicate findings in a manner similar to multiple experiments, either with similar results (literal replication), or contrary results (theoretical replication). To answer the first research question regarding the presence of observable, identifiable, and recurrent in-session change episodes in couples treated with ExST, three cases (couples) producing diverse results at post-test on a measure of marital satisfaction were selected for intensive and systematic observation. Specifically, the combined pre-post-test difference couples' scores on the DAS produced a high, a medium, and a minimal improver case. As such, theoretical rather than literal replication was intended in order to detect the presence of episodes of change throughout the continium of change. In addition to the three cases representing divergent results, the design also allows for the presence of units of analysis (possible change episodes) to be discovered. These units of analysis are embedded within the cases. Yin (1989) defined a multiple-case embedded design as a research scheme consisting of more than one case, with either literal or theoretical replication, and involving more than one unit of analysis embedded within the case. In sum, the questions and aim of this investigation called for a multiple-case rather than a single-case design. That is, in order to explore the presence of episodes of change along a continuum of post-test marital improvement (high, medium and minimal), the intense and systematic observation of more than one case was required. 64 Investigative Procedure The following section describes in detail the investigative procedure. This includes an outline of The Alcohol Recovery Project, particularly regarding subject and therapist inclusion in the research project that generated the data sources for the present study. Then, a description of the methods and criteria utilized to select the cases and the change episodes are presented. The procedure is detailed under three major headings. These headings are: the data sources for the present study, identification and description of case selection, and identification and description of episode selection. Participants The participants and data for the present investigation were obtained from a large programmatic investigation, The Alcohol Recovery Project (TARP) carried out in B.C. between 1989 and 1994. TARP investigated the efficacy of individual and marital ExST with male alcoholics. A total of 150 families agreed to participate in this investigation (see Appendix A: Participant Family's Consent Form). The couples treatment group involved male alcoholics and the non-alcohol misusing female partners. The couples could attend a maximum of 15 sessions of the ExST marital therapy format over a 20-week period. The average number of sessions attended was 13.3, SD = 2.40. Subject Inclusion Criteria in TARP In order for couples to be included in TARP, the following eligibility criteria had to be satisfied. 65 (1) The couple had to involve a male alcoholic living with a non-alcohol misusing female partner. The alcoholic was to have consumed alcohol within the last 3 months to be eligible. The male alcoholic had to have a score above the critical cut-off score of 5 on the Michigan Alcoholism Screening Test (MAST)(Selzer, 1971). (2) The non-alcohol misusing female partner had to have no alcohol dependency problems in the last 5 years. (3) Both partners had to be between the ages of 21 and 65 years old. (4) The couple had to be experiencing marital distress but maintaining a commitment to the preservation of the relationship. The couple's extent of marital distress had to be significant, in that, both members in the relationship had to have obtained a score below the value of 100 on the Dyadic Adjustment Scale (Spanier, 1976). (5) The couple had to be living together in a marriage or common-law relationship for at least 1 year. (6) The couple had to be parenting at least one child living at home. (7) The couple had to be willing to participate in 15 sessions of marital therapy over a 20-week period. As couples satisfied the above criteria, they were randomly assigned to one of the therapists providing ExST-Marital. A large battery of instruments was administered in order to assess outcome. The results of this investigation indicated that while some couples improved, others deteriorated at termination (Friesen et al., 1995; Grigg, 1994). 66 Therapists The therapists participating in TARP were required to have had: (1) the equivalent of at least a Master's degree in Counselling Psychology; (2) at least 3 years of experience working with substance abusive clients; and (3) the completion of specialized training and supervision in the conduct of ExST with demonstrated competency in the provision of the therapy. The therapist in the present investigation satisfied the above required criteria. The therapist in the present study held a Master's Degree in Counselling Psychology and had 6 years of experience in the drug and alcohol counselling field at the time the therapy was conducted. In addition, the therapist obtained a score of 3.4 out of a range of 1.0 to 4.0 on the Therapist Competency Form (TCF) (Appendix B). This form screened therapist's participation in TARP. A score of 3 or above indicated competency in the provision of ExST. The role of participant-observer taken by the researcher is an important feature of this investigation. Therefore, elaboration of this role ensues given its relevancy. Participant-Observer When the aim of the investigation is to explore intricate relationships and interconnections within a complex process and naturally occurring environment, the role of the researcher as a participant observer is common and appropriate in the naturalistic paradigm. A participant-observer is in a unique position to extrapolate the nuances, understand the complexity and richness of the process, and gain the depth of understanding as events unfold within the process of psychotherapy. Besides, as suggested by Kazdin (1980), it is difficult for an external observer to 67 gain the depth of understanding of intricate and complex processes. As a participant-observer, the researcher brings with him/her a wide range of experiences and awareness that maximize rather than minimize the depth of understanding required to answer the research questions posed by this investigation. Congruent with the naturalistic paradigm (Guba & Lincoln, 1994), this study was conducted from the perspective of participant-observer. As such, the assumptions and biases of the researcher as participant-observer on the topic of investigation are presented. Researcher's Assumptions on the Process of Change As indicated above, I was one of the therapists involved in TARP. Couples seek therapy for a variety of reasons. However, couples are usually deeply distressed and conflicted by the time they seek psychotherapy. I believe conflicts may be attributed to experiences of pain, betrayal, deeply rooted disappointments, and unresolved interactional patterns. Unresolved conflictual patterns permeate the relationship over time until a structure or a patterned way of being with each other is established. These conflictual patterns may take many forms; however, I believe that problems arise when a particular way of being with one another becomes rigid, static, unbendable and inflexible. Thus, I believe the troubled couples in this study related with one another in a predictable, rigid and inflexible style which encouraged disappointment, distance and grief. In attempting to help the couples resolve conflictual patterns, I believe the therapist must be fully present in coaching the couple and collaborating in the achievement of their desires and expressed therapeutic goals. As the therapeutic 68 goals and mandate are collaboratively established and agreed upon by all members of the therapeutic system, the actual working through of the conflict is initiated. As with any form of therapy, I believe the therapist must facilitate and establish a relationship based on trust and genuineness with all involved in the system and must generate an atmosphere of support and collaboration. I believe that actual change occurs when the couple works through and transforms those conflictual patterns into more satisfying and harmoniuosly interactive ones. I concur with the ExST notion that change in the couple occurs when rigid, recursive and unsatisfying interactive patterns are transformed into flexible patterns of interaction. For me, change occurs when the therapist accesses the depth of the couples's actual experiences, perceptions and sensations as they interact with one another. I believe that change is initiated the moment when one or both members of the dyad deeply experience and feel whatever experience or feeling is relevant and/or important for the self in relationship to the other as it is occurring in the present moment. The next section explains the theoretical underpinnings of Experiential Systemic Therapy. The basic conceptual premises along with its principles and phases of therapy are outlined. Experiential Systemic Therapy Experiential Systemic Therapy is an interpersonal process in which the therapeutic system members create a new story within a systemic, experiential and symbolic framework under a set of specified principles. As an integrative form of psychotherapy (Friesen et al., 1991), ExST embraces a variety of therapeutic 6 9 techniques and a wide scope of human experience (i.e., behavioral, emotional, cognitive, and visceral). ExST is systemic in its foundation and orientation and experiential in its process. In addition, ExST conceptualizes therapy as embedded within a deep symbolic framework. Systemic Dimension The systemic foundation emerged from three sources; namely, family therapy theory, general systems theory and second-order cybernetics (Friesen et al., 1991). As such, ExST assumes that living involves a complex, multidimensional, and dynamically interactive process where systems actively interact and reciprocally affect one another within a context. In addition, ExST maintains that, as persons interact, their structures become ontogenically and structurally coupled (Maturana, 1978) with others within a consensual domain and, as a consequence, the consensual domain is also ontogenically generated. This assumes that relational experiences and patterns of interaction between the experiencer and the experienced are of fundamental importance for therapy. In fact, relationships between the experiencer and the experienced (the other) include all levels or aspects of existence and the world. ExST assumes a reciprocal interdependence in which the two (the experiencer and the experienced) mutually influence one another and fit together in order to maintain the integrity of the relationship. Although some relationships may be experienced as more important and/or significant than others, the relational matrix operates and is experienced at the intrapersonal, interpersonal and contextual level. As well, the complexity of relationships can be extended to include inanimate objects, abstract 7 0 concepts and ideas. Within this systemic foundation, ExST process and nature is experiential and symbolic. Symbolic Dimension The symbolic dimension refers to the idea that therapy is a ritual of transformation of the living stories that clients bring into the session. As a therapeutic story of transformation, therapy is framed as a culturally sanctioned ritual in which all participants bring into being, experientially and symbolically, their emotions, thoughts, behaviors, issues and meaningful aspects of self. Actions and interactions are considered symbolic representations and enactments of clients' daily lives. As well, actual symbols and metaphors are considered powerful ways to access and intensify parts of self, interpersonal relationships and presenting problems. Experiential Dimension The experiential nature of this therapy model is also an important dimension of the process of change. ExST assumes that clients learn, become aware of and change by deeply experiencing thoughts, emotions, perceptions and sensations in the here and now. It assumes that profound change occurs by experiencing rather than by mere dialogue, instruction or, by just talking about "it." As a core concept in ExST, therapeutic experiencing is defined as the enhancement, elevating and intensifying of thoughts, feelings, perceptions, behaviors, patterns and interactions so as to reach new and unprecedent depths. Therapeutic experiencing increases awareness of the recursiveness of thoughts and patterns, adds new experiences, and integrates those new experiences in 71 creative ways. Thus, through therapeutic experiencing, rigidity of intrapersonal and interpersonal patterns of interaction is transformed into new patterns with a new quality. This results into new ways of doing things; new ways of experiencing and viewing the world as a deeper and unexplored potential are activated. Second-order change (Dowd & Pace, 1989) is generated as a result of activating the unknown and the unexperienced. Guiding Principles of ExST Experiential Systemic Therapy is a brief form of psychotherapy. The story of transformation, or length of therapy, may range from four to 20 sessions. Five principles are espoused as essential to its practice. First, ExST maintains a developmental framework in which clients' experiences and problems are viewed in light of the themes of the life cycle. Second, an ecological assessment is developed in order to understand the client's difficulties. This assessment includes all levels of the system in which clients are engaged, such as individual, couple, family and community context. Third, ExST adopts an active present tense therapeutic focus without negating the current influence of events from the past. A fourth principle is the collaborative stance taken by the therapist in order to provide the opportunity for client's experiencing and transformation. The therapist is considered to be a collaborator rather than an expert in the re-writing of the story of transformation. Finally, as collaboration is maintained, the therapist and client become spontaneous and creative in their interactions. Spontaneity facilitates freedom to experiment with alternative and new ways of being in the world. Guided by these 72 five principles, the therapist and the clients engage in various transactions in order to address the relational rigidity and stagnation through four therapeutic phases. Phases of Therapy The life span of the therapeutic system is viewed as a story or a play consisting of a beginning, a middle, and an end. A play starts with an introduction where the characters and the setting are introduced and the principal themes outlined. After this introduction, the stage is set for the drama to be acted and enacted until a climax is reached. This is rapidly followed by a resolution to the drama or plot in which a new narrative path is weaved, created and integrated. The end is reached as the characters are transformed by their participation in the play. Accordingly, these parts of the play or the narrative are also reflected in the therapeutic story through four phases of therapy. These four phases of therapy include: 1) Forming the therapeutic system: Establishing a context for change; 2) Perturbing patterns and sequences and expanding alternatives; 3) Integrating experiences of change: Reorientation; and 4) Disbanding the therapeutic system: Termination and acknowledgment of accomplishments. Figure 1 presents the phases of therapy as they occur within the therapeutic story. Figure 1 illustrates the four phases of therapy as they may occur over the course of therapy. These phases may overlap and aspects of each phase may be present at any given point within the overall process. 73 Phase 1 Forming Phase 2 Perturbing Phase 3 Integrating Phase 4 Disbanding Pre-therapy > > > Post-therapy Figure 1 . An overview of the therapeutic system process Selection of Cases Three couples who took part in TARP and received marital therapy from this researcher were selected for the study. The success-failure strategy (Pinsof, 1988) was utilized in determining the chosen couples. Defined as discovery-oriented, the success-failure strategy consists of rank-ordering couples on outcome measures at significant evaluation points such as midtherapy, termination and/or follow-up. Three cases, representing three distinct patterns of change at post-test, were chosen. Based on the combined pre-post-test difference couples' scores on the Dyadic Adjustment Scale (DAS) (Spanier, 1986), the couples' patterns of change were identified as high, medium and minimal improver. In addition, the pre-post-test difference scores of the three selected cases on the Alcohol Dependency Data (ADD) (Raistrick, Dunbar, & Davidson, 1983), a measure of of alcohol dependency, and the Symptom Checklist-90-Revised (SCL-90-R) (Derogatis, 1983), a measure 74 of intrapersonal distress, were examined in order to evaluate consistency of the change patterns identified through the DAS scores. In the following section, a description of the instruments utilized for the selection of cases is offered. Then, the decision criteria for selection as well as the results of the selection process is presented. Description of Instruments The three instruments utilized for couple's selection were drawn from a large battery of instruments utilized by TARP. The couples completed the battery of instruments at pre-treatment, mid-treatment, post-treatment, and follow-up. The instruments selected for the present investigation are presumed to be sensitive to change at the three levels of client functioning: alcohol dependency, intrapersonal distress, and marital adjustment (Grigg, 1994). The alcohol dependency data questionnaire. In the TARP investigation, the Alcohol Dependency Data questionnaire (ADD) (Raistrick, Dunbar, & Davidson, 1983) was used as an indicator of change in the severity of alcohol dependency. This instrument is sensitive to changes in dependency levels over time. Measures on the ADD were taken at pretest, posttest and follow-up. This instrument was designed to measure the full range of alcohol dependency including mild, moderate, and severe dependency. The ADD consists of 39 items which are rated on a 4-point Likert scale ranging from never = 0 to nearly always = 3. The maximum dependency score is 117. A score of 0 suggests no dependency, scores from 1-30 suggest mild dependency. Moderate dependency 7 5 is indicated by scores ranging from 31 to 60. Scores ranging from 61 to 117 indicate severe dependency. A 15-item shortened version was developed and compared to the 39-item version (Davidson & Raistrick, 1986). The correlation between the two versions was reported as highly significant (r = .92). Also, the split-half reliability estimates on the shortened form was high (r = .87). Investigations of the validity of the shortened form of the questionnaire (Davidson & Raistrick, 1986; Davidson, Bunting, & Raistrick, 1990) have demonstrated that dependency as measured by the instrument is a single and unidimensional phenomenon and it does measure what it purports to measure. The TARP investigation employed the 39-item version of the questionnaire. The symptom checklist-90-revised. The Symptom Checklist-90-Revised (SCL-90-R) (Derogatis, 1983) is a 90-item self-report inventory designed to measure psychological symptom patterns of disturbed clients. This instrument utilizes a 5-point Likert type scale ranging from not at all= 0 to extremely= 4. The SCL-90-R assesses nine primary symptom dimensions and three global indices of distress. The nine symptom dimensions are: (1) Somatization, (2) Obsessive-Compulsive, (3) Interpersonal Sensitivity, (4) Depression, (5) Anxiety, (6) Hostility, (7) Phobic Anxiety, (8) Paranoid Ideation, and (9) Psychoticism. The three indices of distress include: (1) Global Severity Index (GSI), (2) Positive Symptom Distress Index (PSDI), and (3) Positive Symptom Total (PST). The global indices of distress yield an overall assessment of the client's psychological dysfunction (Derogatis, 1983). 76 Measures on the SCL-90-R were taken at pretest, posttest and follow-up. Derogatis (1983) indicated that the instrument is well suited for pre and post treatment evaluations because biases after repeated administrations have been undetected. In fact, the SCL-90-R has been successfully utilized as a clinical assessment tool and treatment outcome measure in areas such as depression, sexual dysfunction, stress, substance abuse and alcoholic family investigations. The SCL-90-R's concurrent validity has been determined by contrasting the instrument scores with several scales of the MMPI (Derogatis, Rickels, & Rock, 1977) and other instruments. The reliability measures of the SCL-90-R for the 9 symptom dimensions are adequate. The internal consistency alpha levels range from .77 to .90. The test-retest correlations range from .78 to .90. The dyadic adjustment scale. The Dyadic Adjustment Scale (Spanier, 1976) is a widely used self-report inventory for measuring marital satisfaction. This is a 32-item instrument that assess four dimensions of the marital relationship. The sub-scales of the DAS include: (1) Dyadic Consensus (the degree to which the couple agrees on matters important to the relationship, 13 items), (2) Dyadic Satisfaction (degree to which the couple is satisfied with the current state of the relationship and is committed to its continuation, 10 items), (3) Affectional Expression (degree to which the couple is satisfied with the expression of affection and sexual intimacy in the marriage, 4 items), and (4) Dyadic Cohesion (degree to which the couple experiences a sense of togetherness, 7 items). In conjunction with the generation of these four sub-scale scores, the DAS also generates a total score which represents the overall marital satisfaction of the couple. The total obtainable score on the instrument ranges from 0 to 151. A total score of below 100 suggests marital dissatisfaction. Spanier (1976) reported that the instrument has an internal consistency coefficient of .96. The reliability of the sub-scales were reported as .73 for the Affectionate Expression sub-scale, .86 for the Cohesion sub-scale, .90 for the Consensus sub-scale, and .94 for the Satisfaction sub-scale. Initially, the DAS was evaluated by three judges in order to uncover the relevancy of items to dyadic relationships, the wording of the items and the extent of consistency of items with definitions of adjustment (Spanier, 1976). The weekly situation diary. The Weekly Situation Diary (see Appendix C) is a questionnaire where TARP couples rated important changes occurring during the week. The partners rated their experience of change in the areas of self, marriage, family, friendships and work on a weekly basis throughout the duration of therapy. The present study inspected the couples' Weekly Situation Diaries during the identification and selection of the change episodes in order to detect possible change occurring outside of the therapeutic environment and cross check therapeutic events. Decision Criteria for Case Selection Three cases (couples) identified as high, medium and minimal improver at post-test on the DAS were, selected. The first criterion was to select couples with whom the researcher had worked with as a therapist. This researcher delivered couples therapy to seven couples from the ExST-Marital group (N=24). The 78 second criterion was to select couples who produced diverse results at termination; that is, couples whose combined pre-post-test difference scores on the DAS showed high, medium and minimal improvement. The rationale for the selection of these three levels was to explore the presence or absence of change episodes throughout the continium of therapeutic change. Based on these criteria, three cases representing a high, medium and minimal level of improvement were selected. The high improver case, couple 2010, obtained pre-post-test difference scores on the DAS of 34 points. The medium improver case, couple 2036, revealed mild improvement, in that their combined pre-post-test difference scores was 10.8 points. Couple 2080 was deemed as minimally improved because they displayed negligible improvement at post-test. Couple 2080's combined pre-post-test difference scores was 5.15 points. Although the pre-post-test difference score on the DAS was the primary source employed in selecting the couples, data from two other standarized measures, the SCL-90-R, a measure of intrapersonal distress, and the ADDS, a measure of alcohol dependence, were examined in order to evaluate consistency in the patterns identified through the DAS scores. Table 1 shows couple 2010's obtained scores on the DAS, SCL-90-R and ADDS. As displayed on the Table, couple 2010 improved on all measures. Couple 2036, the medium improver (see Table 2), showed improvement on the intrapersonal measure. However, the husband's pre-test score on the ADDS was missing from the data-bank, therefore, 7 9 Table 1 Obtained Scores on DAS. SCL-90-R. and ADDS for Couple 2010 DAS SCL-90-R ADDS H W H W H Pre-test 66.0 65.0 64.0 80.5 27.0 Post-test 95.0 104.0 56.8 60.8 10.0 Difference Score 29.0 39.0 -7.2 -19.7 -17.0 evaluation is groundless. Nonetheless, mild improvement was evidenced in the couple's combined pre-post-test difference scores on the DAS. Couple 2080, the minimal improver case (see Table 3), displayed some intrapersonal improvement. The husband also showed improvement on his alcohol dependence post-test score. However, the couple's measure of marital satisfaction displayed a negligible level of improvement. Table 2 Obtained Scores on DAS. SCL-90-R. and ADDS for Couple 2036 DAS SCL-90-R ADDS H W H W H Pre-test 62.0 99.0 94.8 83.4 Post-test 85.0 97.6 64.4 53.3 56.0 Difference Score 23.0 -1.4 -30.4 -30.1 80 Table 3 Obtained Scores on DAS. SCL-90-R. and ADDS for Couple 2080 DAS SCL-90-R ADDS H W H W H Pre-test 89.6 53.0 84.8 79.4 56.0 Post-test 88.0 64.9 53.6 62.9 33.0 Difference Score -1.6 11.9 -31.2 -16.5 -23.0 Demographic Description of Couples Couple 2010: high improver. At the time of therapy, the couple was married and had lived together for 10 years. The wife was 36 years old and the husband was 35 years old. The wife was previously married and subsequently divorced. This was the first marriage for the husband. The couple had four children. Two children ages 7 and 9 were from their current marriage. The other two children were from her first marriage. Their ages were 14 and 16. Both husband and wife worked full-time. He worked as a machinist and she worked in the service industry. Their total family income was in the range of $40,000 to $49,000 per year. Both husband and wife were of white Anglo-Saxon origin. They had similar educational levels. The wife finished grade 12 and the husband graduated from grade 12 with some technical training as a machinist. The couple entered therapy on December, 1991 and concluded in April, 1992. They completed the 15 sessions of marital ExST with a total of 19 hours. 81 Couple 2036: mild improver. Couple 2036 was married and had lived together for the last 6 years at the time they entered therapy. They had two children, a boy and a girl, ages 4 and 2 respectively. The husband worked full-time as a labourer and the wife was a homemaker. Their family income was in the range of $ 30,000 to $ 39,000 per year. The husband had not graduated from high school. The wife had completed her Grade 12. Both were of white Anglo-Saxon origin. Couple 2036 entered therapy on April, 1992 and ended on December, 1992. Therapy sessions were interrupted due to the husband's work schedule. The couple attended a total of 11 out of 15 sessions. They were unable to complete the full treatment program; however, they completed all other protocols for inclusion in TARP. The total therapy time was 14 hours. Couple 2080: minimal improver. The couple was married and had lived together for 18 years at the time they entered therapy. They had never divorced or remarried and they had two children. They had two boys ages 9 and 10. The husband worked full-time and the wife worked part-time. Their combined family income was in the range of $40,000 to $49,000 per year. They had both graduated from high school. The husband had attained graduation from a local college. Both were of white Anglo-Saxon origin. Couple 2080 entered therapy on August, 1992 and ended on January, 1993. The couple had a total of 14 sessions of marital therapy. The wife requested three individual sessions throughout the therapy process due to difficulties in expressing herself in the presence of her husband. The total therapy time was 19 hours. 8 2 Identification and Selection of Change Episodes Given the discovery-oriented nature of this investigation, the first step was to observe in detail the therapy process of the three couples in order to uncover the presence of episodes of change. This observation comprised the following steps: 1) The 40 video-taped therapy sessions were observed by the researcher so as to acquaint herself with the data and the process of therapy. 2) The observation process consisted of the consecutive and systematic observation of couple 2010 (high improver), couple 2036 (medium improver), and couple 2080 (minimal improver). 3) With this general understanding of the overall psychotherapeutic process and events, the researcher viewed the 15 sessions of couple 2010 once more. This free-flowing observation was intended to identify preliminary and tentative episodes of change. These episodes were broadly identified based on the actions and interactions of the participants around a conflict and/or issue they were attempting to resolve. 4) Next, all the sessions were observed once more. This third viewing was sharper and more structured. The researcher took notes on the process and the content of all the therapy sessions. This observation assisted in developing a clearer focus on what emerged as definable chunks, or more specifiable and concrete events, in which the three participants were actively engaged in solving specific and concrete conflicts and/or impasses. Guided by the experiential knowledge acquired through these observations and the operational definition of a change episode articulated by Greenberg (1986), 83 criteria for the identification of change episodes were generated. These criteria were developed by the researcher and refined in consultation with the study's advisor. Criteria for Identification of Change Episodes The following criteria specify the parameters for the identification and selection of the episodes of change. 1) The presence of a relational marker involving clear, identifiable and distinct evidence of interpersonal conflict between the spouses. This problematic/conflictual relational marker was verbally identified by one and/or both members of the couple as needing resolution. The verbal statements conveyed messages which indicated misunderstanding, tension, confusion, detachment, alienation, distance, defensiveness, stuckness, and/or strong emotions. 2) Given this distinctive marker, an ongoing dialogue comprising actions and interactions engaged in by the members of the therapeutic system ensued. These actions and interactions were intented to address the conflictual emotional/relational marker. There was no deviation into other problematic relational issues; rather, the participants maintained continuity with the particular conflictual marker until resolution incurred. 3) A new in-session pattern of relating/being emerged from the interaction which clearly indicated a resolution to the conflictual marker. This new way of being and/or relating indicated a new understanding, new discovery, greater interpersonal affiliation and intimacy, and personal autonomy. 8 4 Regarding the initial conflictual marker, the couple interacted in new and more satisfactory ways with each other. Selection of Change Episodes Once the criteria were developed, the selection of the change episodes ensued. The selection consisted of the following steps: 1) All 40 therapy sessions were, again, systematically observed in detail. 2) Initial and tentative episodes of change were selected based on the selection criteria. 3) The Weekly Situation Diaries for both spouses were inspected regarding relevant therapeutic information about the daily lives of the couples. In this questionnaire, the couple described important events taking place during the week (a summary of the Weekly Situation Diaries for the three couples is available from the author upon request). 4) Information from the Weekly Situation Diaries was evaluated and contrasted with the tentative change episodes selected in order to cross-check for differences and similarities between therapeutic experiences and daily life events. 5 ) An initial selection of possible episodes of change was compiled in videotape form. 6) These tentative episodes of change were reviewed and evaluated by the researcher and the study's advisor so as to ascertain their correspondence with the selection criteria, as well as their legitimacy and credibility. 85 7) Agreement on the selected episodes was sought and obtained from the study's advisor, who is also the principal developer of ExST. The identification and selection process generated a total of ten completed episodes. Eight change episodes were selected from couple 2010 (high improver), two episodes from couple 2036 (mild improver), and no episodes from couple 2080 (minimal improver). These episodes were transcribed in order to proceed with the analysis. Grounded theory was deemed the most appropriate method of analysis to answer the questions posed by the study. In the following section, the grounded theory method is introduced. This introduction is followed by a description of the data analysis and procedures. Overview of Grounded Theory The general purpose of a grounded theory investigation is to generate theory from the data (Strauss & Corbin, 1990). Data collection and analysis are decided by theoretical sampling (Glaser, 1978; Strauss & Corbin, 1990), that is, by the concepts generated from the analysis. Data collection and analysis are determined and initiated with the first identified protocol (Glaser, 1978; Rennie, Phillips & Quartaro, 1988; Strauss & Corbin, 1990). The emphasis of the grounded theory method is on the discovery and generation of theory grounded in the data. A basic assumption is that, by grounding the emerging theory in the data, the discovered theory will be an effective and valid representation of events as they occurred at the time of the investigation (Glaser & Strauss, 1967). Strauss and Corbin (1990) noted that "a grounded theory is one 8 6 that is inductively derived from the study of the phenomenon it represents. That is, it is discovered, developed, and provisionally verified through systematic data collection and analysis of data pertaining to that phenomenon." (p.23). Hence, the essence of the grounded theory approach is on the methodical and deliberate generation of theory which conceptually accounts for the unfolding of the events under study. The role of a theory is to interpret, explain and predict phenomena as they occur in the empirical world in a coherent and logical fashion (Chenitz & Swanson, 1986). As a symbolic construction of reality (Kaplan, 1964), a theory provides a systematic explanation of an event through the generation of concepts. These concepts are linked via suggested hypotheses about the relationships amongst the generated concepts. The discovery of concepts and hypotheses relevant to the phenomenon under investigation is paramount to the generation of theory. Accordingly, Glaser and Strauss (1967) asserted that the components of a grounded theory investigation are conceptual categories along with their conceptual properties as well as hypotheses that describe relationships amongst the categories and their properties. Conceptual categories and their properties are generated from data which is also used as evidence to illustrate the emergence of the concept and properties. While a category is a conceptual element of the theory; a property is a conceptual element of the category. Hypotheses are generalized suggested relations amongst categories and their properties which throughout the course of the investigation are 8 7 verified by iteratively collecting and analyzing data until saturated (Glaser & Strauss, 1967). Historical and Theoretical Background The grounded theory method was originally developed by sociologists Anselm Strauss and Barney Glaser in the early 1960s as they collaborated in a field observational study. Their shared intellectual efforts resulted in the publication of the book The Discovery of Grounded Theory in 1967. The method was generated under an intellectual climate which favoured testing of hypotheses and theoretical verification (Charmaz, 1983; Turner, 1981). Indeed, the development of the grounded theory approach was a response to a position taken at the time that qualitative research served only as an initial, preliminary and exploratory step to subsequent investigations which could later verify findings through rigorous hypotheses testing. The assumption, at the time, was that only verification via hypothesis testing could produce rigorous and scientific findings. Furthermore, Glaser and Strauss (1970) argued that there was an over-emphasis on rigorous testing of hypotheses and a de-emphasis on whether those concepts and hypotheses were relevant for the area being investigated. The grounded theory approach emerged as a method to generate concepts and theory through the utilization of a systematic set of procedures, a clearly defined process and a defined set of criteria to evaluate its theoretical product. Grounded theory evolved from the philosophical and theoretical underpinnings of Symbolic Interactionalism (Corbin & Strauss, 1990; Strauss, 1987; Strauss & 88 Corbin, 1990). Symbolic Interactionalism was initially advanced by social psychologist Herbert Mead (1934) as a theory on the development of human behavior. Mead (1934) postulated that it is through social interaction that the person achieves a sense of self and develops a mind. In addition, Mead (1934) further asserted that it is through the role taking process and in interaction with others that the person creates meaning. The meaning generated by interacting with others is what ultimately guides action and behavior and thus, brings about consequences. Blumer (1969) further developed the particulars of Symbolic Interactionalism. From Blumer's (1969) point of view, Symbolic Interactionalism assumes three central premises. These are that "human beings act toward things on the basis of the meanings that the things have for them" (Blumer, 1969, p.2); that the "meaning of such a things is derived from, or arises out of the social interaction that one has with one's fellows" (Blumer, 1969, p. 2); and that "these meanings are handled in, and modified through, an interpretative process used by the person in dealing with the things he encounters." (Blumer, 1969, p. 2). Thus, meaning is created and recreated by interacting with others and with self. This conceptualization also assumes that behavior is a process in constant flux as interaction with self and others is dynamic and in continuous activity. Change and thereby process are two significant and essential elements built into Symbolic Interactionalism. The implications of the Symbolic Interactionalist perspective for the conduct of research are threefold. First, human behavior must be investigated within the context in which interaction with self and others actually occurs so as to understand 89 its total complexity, full range of variation and varying conditions. Second, in order to examine the totality of complex interactions and how meanings are created, the contextual setting needs to be analyzed and accounted for; otherwise, the understanding of meanings will be severely limited. Third, behavior needs to be understood from the point of view of the participants involved in the study. That is, the investigator is required to "take the role of the other" in order to understand their perceptions and learn about their world and interpretations of self in interaction (Chenitz & Swanson, 1986). This investigation fullfils these three basic tenets of the Symbolic Interactionalist perspective. From the Symbolic Interactionalist perspective, one studies behaviors through exploration and inspection (Blumer, 1969). Exploration is defined as the process of clarification of the investigation so that later interpretations and analysis are grounded in the data. Inspection, according to Blumer (1969) refers to the actual analysis of the empirical content of the study. Both exploration and inspection are utilized to examine behaviors in the naturalistic setting. Furthermore, the researcher examines behaviors at the interactional or behavioral and symbolic levels (Chenitz & Swanson, 1986). It is assumed that observation of both the behavior in the specific situation in which it occurs, at the verbal and nonverbal level, and the symbolic meaning attached to those actions by the participants are important for the analysis. In addition, there is a manifest emphasis on action and the problem situation in need of a resolution. Consequently, the methodological thrust of this perspective conceives the method in the context of problem solving situations 90 (Strauss, 1987). Finally, a relevant aspect of this perspective is that events rather than variables are believed to be the appropriate units of analysis (Strauss, 1993). An important consideration derived from the basic premises of Symbolic Interactionalism concerns the nature of the phenomenon understudy. Basically, it is presumed that the phenomenon under study is continually changing as a result of evolving conditions (Corbin & Strauss, 1990). Thus, the idea of change is embedded into the conceptualization of the grounded theory method. In fact, change, through process, is intricately linked into the analysis not only by discovering the evolving conditions of the situation but also by discovering how participants respond to those changing conditions and the consequences of their actions. This general background on the theoretical framework and historical development of grounded theory sets the context for the following section. The next section provides a specific description of the method of analysis along with its accompanying procedures and relevant concepts. Description of the Method of Analysis As a method intended for the discovery and analysis of basic social processes within the context in which they occur, the primary purpose of grounded theory is to develop conceptual theory grounded in the data. Strauss (1987) stated that the distinctive features of grounded theory are its theoretical sampling procedure, and the methodological guidelines of the comparative method. These features are intended to generate concepts that are grounded and dense. Common to all grounded theory research are basic strategies which must be followed in 91 order to generate a conceptual model. First, concepts and interrelationships amongst concepts are generated through the method of constant comparison between or within groups. Second, theory is discovered, developed, and verified through a recursive and concurrent style of data collection and analysis with the purpose of concept saturation and integration of the emerging conceptual model. Third, concepts are refined, elaborated and saturated via theoretical sampling whereby the researcher purposely samples for the emerging concepts and conceptual integration. Fourth, the systematic application of analytical methods such as the constant comparative method, theoretical sampling and simultaneous data collection and analysis gradually lead to the generation of progressively more abstract levels of analysis and integration of concepts. The Analytical Process The logic of the research process within grounded theory is conceptualized as a nonlinear activity in which several operating activities are iteratively at play (Glaser, 1978; Stern, 1980; Strauss, 1987; Turner, 1981). As the researcher collects the first pieces of data; he/she immediately initiates examination and analysis of the data by coding, categorizing, conceptualizing, and the writing down of ideas which may be subsequently utilized in the final write up of the conceptual model. Glaser (1978) succinctly outlined the essential steps of the research process by stating that: "The steps, as now formulated, are collection of research data, open coding of the data soon after, theoretical sampling, generating many memos with as much saturation as possible and emergence of core social psychological 92 problems and processes, which then become the basis for more selective theoretical sampling, coding and memoing as the analyst focuses on the core. This goes on all at once,..." (p. 16). Quartaro (1986), on the other hand, identified five aspects of the research process. These aspects are: (1) collection of data; (2) comparison of data; (3) integration of categories; (4) delimitations of the emerging theory; and (5) presentation of the theory. The first four steps basically constitute the constant comparative method which comprises the essence of the grounded theory method. Hutchinson (1986) succinctly delineated the analytical process by stating that: While coding and analyzing the data, the researcher looks for patterns. He or she compares incident with incident, incident with category, and, finally category with category or construct with construct. By this method, the analyst distinguishes similarities and differences of incidents. By comparing similar incidents, the basic properties of a category or construct are defined. Certain differences between incidents establish boundaries; relationships among categories are gradually clarified. Comparative analysis forces the researcher to expand or "tease out" the emerging category or construct by searching for its structure, ...cause, context, dimensions, consequences, and its relationship to other categories, (p. 122). Like other qualitative methods, the data for a grounded theory investigation may come from a variety of sources. Data may be collected from interviews, observations, transcripts, audiotapes, videotapes, and documents (newspapers, letters, books) (Charmaz, 1990; Strauss, 1987) or a combination of sources (Stern, 1980). Any of these sources of data can be coded in the same manner as observations and interviews (Glaser & Strauss, 1967). The data for the present analysis was collected from transcribed videotaped marital therapy sessions. The 93 ten episodes of change were entirely transcribed (complete transcripts are available from the author). During the first stage of the analysis, I collected data through open sampling so as to discover as many potentially relevant categories as possible while also focusing on the central and crucial aspects of the topic (Rennie, Phillips, & Quartaro, 1988), that is, the questions of the study. Through this process, I was open to instances offering the greatest scope in gathering the most relevant data. Strauss (1987) noted that during the initial process of data collection, the researcher may become overwhelmed by the richness and confusing nature of the data. However, as the analysis is usually initiated with the first or second fieldwork observation, the confusion is temporary as further observations will be informed by analytical questions and/or hypotheses. As the analysis progresses, instances or events are gathered on the basis of the emergent concepts. Instances, events or subjects are selected in terms of how clearly they represent the phenomenon under study (Rennie, Phillips, & Quartaro, 1988). The analysis was initiated with the first selected episode by examining statement by statement the verbal and nonverbal messages of the participants interacting with each other. This initial analytical step consisted of concurrently analyzing and questioning the events through three mediums of information. These media were listening to the audio-tape of the episode in order to capture nuances in tone of voice without body language, listening and watching to actions and interactions in video-tape form, and the reading and close examinination of the transcripts. The salient actions and interactions were analyzed and named 94 accordingly. The statements were examined and compared by maximizing and minimizing the differences and similarities present in the actions and interactions of the participants. As well, questions such as what was this relevant to, and what was actually going on, were constantly asked as the analysis continued. This breaking down and opening up of the data generated a total of 185 pages of typed material including the memos for the first episode. Overwhelmed with the substantial amount of information generated, and confused as to where to go next, I decided to analyse the next three episodes following the same format, that of opening up the data and generating provisional names for significant and salient actions and interaction of the participants. The opening up of the data generated a total of 338 pages of typed materials for the first four episodes. The high density and richness of the generated material, as well as the tediousness of the task, forced me to move onto the next step in the analysis; that is, to begin to cluster provisional names according to their obvious fit. Initial concepts were clustered under another, broader provisional concept. As the clustering of provisional concepts for the first four episodes continued, a general pattern and internal flow to the episodes began to emerge. However, because of the extensive number of concepts and the density of the data, a conceptual story of each episode was developed. The memos generated during the analysis became very useful during this process. Creating a conceptual story for each episode greatly clarified and assisted in linking concepts regarding the unfolding of events. 95 The conceptual story for each of the four episodes also assisted in the analysis of the following six episodes. Namely, the analysis of the six episodes was based on both the concepts already generated from the previous analysis, and the emergence of new concepts. The analysis consisted of comparing and contrasting concepts as well as sampling for repeating concepts. During the analysis of the seventh episode, concepts and themes began to repeat themselves; however, all episodes were fully analyzed. The repetition of concepts forced me, once more, to integrate further the concepts and categories. Conceptual Integration Through continued close examination of the emerging concepts, some became more central or salient in relation to others. Then, I started to integrate the concepts by focusing on questions such as: how does it all fit and what brings it all together? Similar to the clustering of concepts from the first analysis, here I collapsed concepts while searching for an emergent category that would explain and hold concepts together. Once I was able to identify the central category which seemed to hold the story of the episodes together, I then integrated all other concepts around the one main category by attempting to make theoretical sense and linking concepts as they fit together. Criteria for Evaluating a Grounded Theory Investigation Traditionally, there has been a tendency for researchers to evaluate their practices with criteria derived from the positivistic paradigm. From this perspective, 96 concepts such as objectivity, validity, generalizability and reliability are the foundation for evaluation. However, the manner in which qualitative researchers evaluate their procedures, practices and research findings does not adhere to these criteria as they are viewed as being ontologically inappropriate (Eisner & Peshkin, 1990; Krefting, 1990; Guba, 1990; Grumet, 1990; Wolcott, 1990). Consequently, some researchers (Eisenhart & Howe, 1992; Wolcott, 1990) have developed ways to ensure the validity of qualitative findings. Guba (1981) proposed a model for evaluating both qualitative and quantitative research based on the concept of trustworthiness. Accordingly, trustworthiness in all research must be established according to criteria based on neutrality, truth value, applicability and consistency. Within these criteria, apropos qualitative investigations, Guba (1981) generated terms comparable to the quantitative tradition. These terms are confirmability (objectivity), credibility (internal validity), transferability (generalizability), and dependability (reliability). In general, theories are appraised according to the criteria of extensiveness of explanation, parsimony, internal consistency, usefulness, and empirical validity. Although important, these criteria are less pertinent in grounded theory than in theory generated through other methods (Morse & Field, 1995). Instead, in grounded theory the degree of fit of the emergent theory with the data is more relevant and appropriate (Glaser, 1978). In fact, Glaser and Strauss (1967) and Glaser (1978) developed specific criteria for theories generated through the grounded theory approach. These criteria are referred to as fit, relevance, work and modifiability. This study followed closely the suggested evaluative criteria as the 97 analysis was performed. The last chapter of this dissertation will evaluate the findings of the study through the criteria identified. In the following two chapters, the results of the investigation are presented. The presentation of the results is divided into two chapters given the density of the findings. The next chapter, chapter four, presents the results of the observational, qualitative analysis of the three couples. This includes a brief description of the process of therapy process of the three selected cases and an introduction and description of the selected episodes of change. Then, in the following chapter, the results of the grounded theory analysis are presented. A conceptual model of marital therapy change, along with illustrations depicting its categories and subcategories is thoroughly presented. 98 CHAPTER IV RESULTS: O V E R A L L THERAPY CONTEXT This chapter provides an overview of the 40 therapy sessions of the three marital ExST couples. The provision of this contextual background endeavors to situate the findings resulting from the qualitative analysis of the ten selected change episodes. Also, this overall therapy context is deemed necessary because it identifies the circumstances surrounding the change episodes and it locates the clinical background against which the ultimate model of change emerged. In addition, this chapter describes the selected change episodes. Brief Overall Context of the Therapy Process In order to answer the first research question regarding the identification of observable, identifiable and recurrent in-session change episodes, it was necessary to observe and systematically examine the process of therapy of the three selected couples. A complete description of the therapy sessions (280 pages) of the three couples is available from the researcher. In the following pages, a description of the therapy sessions is offered in the form of an outline. This psychotherapeutic outline consists of the following elements: (1) participants' identification of areas of conflict; (2) desired state; (3) meaning of desired state; (4) symbolic representation of desired state; and (5) salient psychotherapeutic events. In addition, the selected change episodes are identified within the outline. 99 Outline of the Psychotherapeutic Process for the Three Couples Couple 2010: High Improver Participants' identification of areas of conflict Wife: Tension over husband's alcohol misuse. Lack of trust and intimacy. Unable to share and communicate with each other. Unable to identify and share feelings. Husband: Distant, he no longer loves or likes his wife. Anger, resentments toward his wife. Conflicts over alcohol. Doesn't trust or express feelings to anyone. Therapist: Blocks to intimacy: pain, frustrations, anger, resentments, alcohol, hurt, mistrust. Desired state Intimacy and closeness. Meaning of desired state Wife: Tenderness through words. Husband: Tenderness through touch. Symbolic representation of desired state Wife: Three roses representing friendship, knowledge, and love and a teddy bear representing warmth. Husband: His wedding band representing closeness. Couple: A cushion of happiness. Salient psychotherapeutic events Session 1: 1. Externalization of current state of relationship. 2. Externalization of desired state. 3 . Removal of blocks to closeness. 4. Identification of symbol of happiness (cushion). 100 Session 2: 1. Exploration of symbols of closeness. 2. Exploration of patterns of interaction: Wife: push-pull Husband: withdraw-withdraw 3. Identification of wife's first husband and husband's anger as block to closeness. 4. Identification of alcoholism as block to closeness. 5. Identification of wife's childhood sexual abuse as block to closeness. Session 3: 1. Blocks (anger, betrayal, abuse,abandonment) are evoked. 2. Push-pull and withdraw-withdraw patterns enacted. 3. Significant session for both: experienced togetherness. Episode # 1 Working with distancing pattern. Session 4: 1. Limited dialogue: wife praised husband, husband unable to praise wife. 2. Wife admitted and shared experiences of sexual abuse and impact on marriage. 3. Conflict explored: husband blaming, wife retreating in fear and shame. Session 5: 1. Exploration of their wounds. 2. Generation of symbolic names for their ghosts: wife: the "bastard" husband: the "bitch" Episode # 2 Bringing ghosts out into the open. Session 6: 1. Exploration and working through: anger. 2. Husband angry with wife: sexual abuse. 3. Wife angry with husband: lack of compassion. 4. Husband disengaged from therapy process. Episode # 3 Session 7: Episode # 4 Session 8: Engaging and committing to involvement in therapy. 1. Evoking and enacting anger. Working through feeling/experiences of anger. 1. Evaluating therapy progress: coming closer, developing togetherness and connection. 101 Session 9: Session 10: Episode # 5 Session 11: Session 12: Episode # 6 Session 13: Episode # 7 Session 14: Episode # 8 Session 15: 2. Re-enacting their distance with blocks to intimacy externalized. 3. Blocks still present, no longer in between the couple, rather cushion of happiness in between them. 4. Exploration of husband's and wife's relationship and impact of alcohol in the marriage. 1. Working through couple's relationship to alcohol. 1. Working on husband's relationship to his ghost. 2. Externalizing alcohol, the "bitch" and working through connections in relationship to his wife. Releasing husband's ghost. 1. Exploring husband's relationships and perceptions of women. 2. Enacting husband's distance to his wife and alcohol. 3. Exploring their dance of push-pull in the marriage. 1. Couple closer to each other: blocks to intimacy loosing their power. 2. Couple interacting with each other. 3. Discovering ways to connect as therapy terminating. Releasing wife's ghost. 1. Openness with each other: secrets are out. 2. Experiencing intimacy. Actual removal of blocks to intimacy and closeness. 1. Sharing of symbols representing letting go. wife: photograph of first wedding husband: "bitch" 2. Exploration of meaning of letting go of symbols. 3. Searching for ways to celebrate termination of therapy. Burning ritual: letting go of symbols. 1. Exploring ways to stay emotionally connected through daily living. 2. Reflecting on achievements made in therapy. 3. Appreciating members of therapeutic system. 102 4. Finding concrete ways to link good and new experiences in their future lives together (cushion of happiness). Couple 2036: Mild Improver Participants' identification of areas of conflict Wife: Feeling forced to engage in unwanted sexual acts. Removed and distant from husband due to his abusive and manipulative behaviours. Lack of affection and compassion from husband. Husband: Childhood sexual abusive experiences and trauma affecting him and his marriage. Experiencing intense flashbacks about sexual abuse as a child. Issues related to the expression of his sexuality in the marriage. Therapist: Issues related to childhood trauma and sexual abuse. Conflicts around expression of intimacy, compassion, caring and respect within the marriage. Distancing and abusive behaviours expressed by partners. Desired state Wife: To open lines of communication. To discover respect, understanding and openness in the relationship. Husband: To find self-acceptance and acceptance of others. Meaning of desired state Unexplored during therapy Symbolic representation of desired state Wife: A wedding photograph. Husband: Unable to define. Salient psychotherapeutic events Session 1: 1. Exploration of problematic issue for the couple. 103 2. Exploration of desired state. Session 2: Episode # 9 Session 3: 1. Exploration of husband's childhood sexual abuse issues. 2. Exploration of wife's relationship to her husband: pushed away by him. 3. Discovering and accepting different ways of expressing pain. 4. Limited and restrictive couple interaction. Working through couples distance. 1. Exploration of drinking behaviour and its impact on the marriage. 2. Couple unable to maintain interaction/communication. 3. Exploring husband's lack of trust and lack of acceptance of his wife. Session 4: Session 5: 1. Distance revisited: discrepant interest and views on their lives. 2. Intense emoting by wife as husband continues hurtful distancing behaviors. 3. Working with husband's difficulties in trusting and accepting his wife. 4. Significant issue for husband: inability to trust anyone. 1. Time lapsed between session 4 and 5 was of 6 weeks. 2. Discovering ways to express affection in non-sexual ways. 3. Exploration of impact of sexual abuse: divided self. Session 6: 1. Working on wife's fear of husband's anger. 2. Exploring meaning of wife's symbol (wedding photograph). 3. Working with husband's push-pull relating pattern in marriage and in therapy sessions. Session 7: 1. Time lapsed between sessions: 4 weeks. 2. Working with couple's distance from each other: wife's need for affection and husband's need for sex. Session 8: 1. Working with husband's push-pull pattern with therapist. 2. Husband's beginning to notice his feelings now. 3. Husband discovering he has many issues to work on. 104 Episode #10 Session 9: Session 10: Session 11: Working with husband's childhood trauma. 1. Exploration of impact of alcohol related behaviors in the marriage. 2. Revisited their therapeutic goals; three more sessions available. 3. Couple discouraged due to limited number of sessions. 1. Unable to engage in interaction with each other. 2. Continued conflict around expressions of affection and lust. 3. Wife unable to express feelings to husband. 1. Couple's last session. 2. Expressed concern about many unfinished issues individually and within the relationship. Couple 2080: Minimal Improver Participants' identification of areas of conflict Wife: In therapy only to support husband's sobriety. Fully apart and distant from husband. Unwilling to engage with husband as she had made her decision to leave the marriage prior to coming for therapy. Marriage has ended for her. Complete lack of love or respect for her husband. Husband: His family and wife are more important now that he is sober. Wants his wife's love and respect back. Desperately holding onto wife. Wishes to have another chance and show her in therapy that he is a changed man. Therapist: Wife unwilling to engage/work on couple's issues. Marriage has more or less ended. Couple completely distant and disengaged from each other. Desired state Wife: Lacks hope/desire as marriage has ended for her. Husband: To keep his family intact. To show and convince his wife that he is a new man without alcohol. 105 To have his wife beside him. Meaning of desired state Unexplored in therapy. Symbolic representation of desired state Unexplored in therapy. Salient psychotherapeutic events Session 1: 1. Exploration of therapeutic goals. 2. Enactment of distance and blocks to coming together. 3. Emotionally the wife has already left the marriage. Session 2: 1. Wife reaffirming her decision: desire to leave the marriage. 2. Exploration of therapeutic goals: Wife: out of the marriage and husband: to gain love and respect from his wife. 3. Re-enacted conflictual dance: Husband pulling his wife and wife going away. 4. Wife in therapy out of threats and force coming from her husband. 5. Husband pleading with her to come back to him. Session 3: 1. Couple engaged in role reversal; facilitating understanding for husband about wife's decision to end marriage. 2. Couple unable to engage in dialogue around their conflict. 3. Wife reaffirming her unwillingness to come closer to her husband. 4. Husband pulling her in closer to him through threats. Session 4: 1. Exploring husband's relationship to alcohol. 2. Wife refusing to engage in process around husband's issues. 3. Therapist suggested individual sessions: wife agreed but husband reticent. Session 5: 1. Session with husband. 2. Determined to have wife back at any cost. 3. Wife unwilling to relate to him at all. 4. Encouraging focus on himself. 106 Session 6: Session 7: Session 8: Session 9: Session 10: 1. Session with wife 2. She no longer loves him and is unwilling to be with him. 3. Wants out of the marriage as soon as possible but waiting until he is more stable and accepting of her decision. She expresses fears of his retaliations. 1. Conflict continues: pushing wife to make plans for a future life together. 2. Husband unwilling to listen to wife's lack of commitment. 3. Couple delaying the final ending. 1. Husband desperately trying to win wife back. 2. Couple delaying decision to separate. 1. Individual session with husband. 2. Role reversal to facilitate understanding of wife's decision to end marriage. 1. Couple in wait and see mode. 2. Role reversal: husband understands somewhat wife's unwillingness to be with him. Session 11: 1. Individual session with wife. 2. Externalizing her conflict: needs of the children to have a father and her needs to love someone else. 3. Confirmed her decision to end the marriage. Session 12: 2. Wife in direct dialogue with her husband regarding her wish to separate from him. Husband retaliates by using the children as weapons and decides to end therapy. Session 13: Session 14: Session 15: 1. Individual session with husband, wife was ill. 2. Insisting on keeping his wife at all costs. 3. Requests a referral to a counsellor that would keep his wife in the marriage. 1. Couple distant and postponing decision to end the marriage until after Christmas. 1. Postponing her decision to end marriage due to fears of retaliation until after Christmas. 2. Wife requesting one more session after the New Year. 107 As displayed in this outline, the therapy process of the three couples showed important differences and some similarities. The similarities were evident in the couples' conflict dynamics. For instance, the three couples reported and expressed considerable distance, lack of intimacy, and conflict over expressions of intimacy and contact. Another similarity in the couples' therapeutic process concerned the identification of a desired state. However, although the three couples identified a desired state, only the highly improved couple (2010) generated a conjoint desired state. The desired goals of couple 2036 (mild improver) and couple 2080 (minimal improver) were separately perceived and individually generated by the partners. In fact, the wife of couple 2080 was unable to develop a desired state for her marriage. Rather, she clearly expressed from the beginning of therapy her desire to end the union. The noted differences were observed in the couples' therapy process and the couples' response and engagement in therapy. Concerning differences in the therapeutic process, the meaning of the desired state was unexplored with couples 2036 (mild improver) and 2080 (minimal improver), but clearly delineated by couple 2010 (high improver). Also, the generation of a symbolic representation of the desired state was explored and enacted only with couples 2010 and 2036. The couples' responsiveness and engagement in the therapy process revealed many differences. Couple 2010 was fully committed to therapy, attended all sessions and followed through with the entire therapy program. Couple 2036, on the other hand, missed many sessions and was usually 108 unprepared and late for appointments. In couple 2080, the partners were emotionally distant from each other and largely uninvolved in the therapy process. In fact, this couple was in the process of separating when they began therapy. In addition, although the three couples were emotionally distant and organizationally disconnected from each other at the beginning of therapy, the style of engagement and interaction during the therapy process was also distinct. Thus, the engagement style of the partners in couple 2010 was reflective and attentive to each others' interactions as the therapy progressed. In contrast, couple 2036's style of engagement was chaotic and disorganized. Although the partners worked together on a variety of issues, their interactions were usually confusing to each other and reflected a state of pseudo-intimacy. Couple 2080 was fully disengaged and the partners were entrenched in their distancing interactions and uncommitted to each other. This brief outline of the therapy process provides the context for the episodes of change. In the following section, the ten change episodes are presented. Introduction to the Change Episodes Based on the extensive and systematic observations of the therapy sessions of the three cases (couples), ten change episodes met the a priori generated selection criteria delineated in chapter three. Of these, eight episodes emerged from couple 2010 (high improver), two episodes from couple 2036 (mild improver) and no episodes from couple 2080 (minimal improver) (see Table 4). 109 Within the overall process of the therapy sessions, the episodes showed two distinctive characteristics: (1) recurrence of process as specific chunks within the process of therapy and (2) completeness. The reoccurrence of the ten episodes emerging from couples 2010 and 2036 was manifested in the repetition of process rather than content. That is, the process of the episode was characterized by (1) a specific conflictual-relational marker identified by the couple as in need of a resolution; (2) ongoing actions and interactions on the part of the therapist and the couple intended to address the identified conflict; and (3) a final resolution to the conflict. This process repeated itself throughout the ten episodes selected. The content of the issues addressed during these episodes varied, however. Another characteristic of the episodes selected concerned their completeness. Episode completion refers to achieving a resolution, or bringing to an end the entire piece of work once a conflictual-relational marker had been identified by the couple. Incomplete episodes were present in all three couples' psychotherapeutic process. In these episodes, no resolution to the initial conflictual marker was present. The process of couple 2010 (high improver) for instance, displayed only three incomplete episodes. The process of Couple 2036 (mild improver) on the other hand, revealed 14 incomplete episodes. Couple 2080's process displayed 42 incomplete episodes. 110 Table 4 Emergence of Change Episodes in Sessions Session # Couple 2010 Couple 2036 Couple 2080 1 2 Episode # 9 3 Episode # 1 4 5 Episode # 2 6 Episode # 3 7 Episode # 4 8 Episode # 10 9 10 Episode # 5 11 12 Episode # 6 13 Episode # 7 14 Episode # 8 15 Incomplete Episodes 3 14 42 Although all change episodes fit the a priori generated criteria for episode selection, differences in process were evident. The eight change episodes from couple 2010 (high improver), for instance, depicted a complete process of therapy with a beginning, a middle, and an end. As such, they represented what might be termed the stages of therapy, particularly as defined by ExST. The two change episodes from couple 2036 (mild improver) reflected a stage of initial therapeutic work. This couple's work centered on the husband's intrapersonal issues which were considered to be extremely relevant by both members of the couple. Couple 2080 (minimal improver) showed no episodes meeting the Ill episode selection criteria. The couple was determined not to continue the marriage. The partners' interests, goals, and motives in seeking therapy were disparate. The husband's motive was to bring his wife back to the marriage, while the wife's motive was to develop strength to leave the marriage. Despite these differences, the ten episodes of change revealed a coherent internal pattern with noticeable similarities and differences. In the following section, a description of the episodes of change is presented. This section describes the individual internal structure of each episode along with its time span and the conditions under which the episode evolved. Description of the Change Episodes Observation and analysis of the change episodes revealed diverse contextual conditions prior to their emergence. That is, within the therapy sessions, the episodes evolved under different circumstances. The context to the episode depended on the stage of therapy, particularly in terms of the couples' desired goals. As such, the context of some episodes reflected the initial stage of therapy while for others it reflected the middle or the ending of therapy. Also, the internal structure of the individual episodes, as reflected by the categories and subcategories, was slightly dissimilar. In addition, the time span and location of the episodes within the sessions was also different. As such, a brief description of the conditions prior to the beginning of the change episode along with the generated categories is presented below. 112 Episode 1 This episode was selected from the third session of couple 2010. The episode lasted 29 minutes, and it appeared 27 minutes into the session. The internal structure of this episode revealed four distinctive categories which occurred over time. These categories were named (1) couple distancing, (2) spouses acknowledging/owning their own part in the distancing, (3) tentative, restrictive, limited contact between spouses, and (4) engaging with each other through acceptance and support. Prior to the beginning of this episode, the couple explored their distancing pattern. Although the wife was actively involved in the interview, the husband was removed, distant, detached and non-expressive. He displayed little affect and used brief monosyllabic statements. The wife's anger, pain and frustration and the husband's loneliness and refuge in drinking were explored. Contrary to the wife's insistence that problems in the marriage were due to her husband's distancing actions, including his drinking, the husband denied any problems. This episode began under these conditions. Episode 2 This episode emerged in the fifth session of couple 2010. The episode appeared 12 minutes into the session and lasted 34 minutes. The internal structure of the episode revealed four categories. These categories were: (1) partners acknowledging and opening up to their inner pain, (2) partners opening up to self and to each other under conditions of constrictive and limited contact, 113 (3) working through issues and releasing the wife's ghost, and (4) partners intimately engaging with each other. The events prior to the initiation of this episode revealed tension and distancing behaviors by the couple. During the previous session, the wife had shared traumatic experiences of childhood sexual abuse. She had tentatively recognized the possible impact of those experiences on herself and her marriage. The husband had also acknowledged these experiences as the most significant block to generating intimacy and closeness in their marriage. However, in comparison to his wife, the husband's assumption was that his own painful experiences had not impinged as negatively on the marriage as hers. Furthermore, the husband blamed his wife for the problems in the marriage by reflecting on the many obstacles she had brought into their relationship. Given that the husband had not shared painful or difficult issues related to himself, the therapist invited him to do so. As a result, the husband reluctantly disclosed the existence of early childhood emotional abuse, neglect and loneliness. He also shared his experiences of living with some wounds which had been inflicted in his childhood. However, he quickly pointed out that the wounds had been put away. His assumption was that pain was to be forgotten and put away. The episode started at a point in the session in which the husband was distant, subtly angry and frustrated as he minimized and denied significant emotional pain, while the wife displayed fear of her husband's feelings and distanced herself from the therapy process. 114 Episode 3 This episode emerged during session number six which occurred near the middle phase of therapy of couple # 2010. The time duration of the episode was 12 minutes and 42 seconds. The episode occurred 25 minutes into the session. The analysis of the episode revealed three distinctive categories. These categories were conceptualized as (1) husband owning his part in the relational distance, (2) partners in brief, restrictive contact with each other, and (3) couple relaxing: husband trusting/wife relieved about the husband's new openness in the therapy process. This episode began with the husband demonstrating serious reservation and reluctance to take part in the therapy process. He was emotionally uninvolved with the process of therapy. He also expressed lack of trust of others. He had made a decision early in his life to stay away from other people because of the deep hurt and betrayal suffered as a result of past relationships. As the therapist worked hard to engage the husband in the process of therapy, the wife listened attentively to him. The husband's monotonous, detached, and monosyllabic style of response did not change easily despite the therapist's continuous empathic, supportive, and respectful reflections. The therapist conveyed the message to the couple that the current problems in their marriage were equally shared by both members of the dyad. Given this situation, the therapist's focus centered on the husband's needs in the present moment and his lack of engagement in the process of therapy. 115 Episode 4 This episode emerged from the seventh session of couple 2010. The episode appeared 8 minutes into the session and lasted 52 minutes. The analysis of the episode produced four distinguishing categories. These categories were termed (1) couple contacting: pleading for understanding in fearful-distant interpersonal contact, (2) couple acknowledging the negative impact of sexual abusive experiences in the marriage, (3) couple unlocking, expressing, and feeling anger, and (4) couple expressing understanding, compassion, and acceptance. At the beginning of this episode, the therapist encouraged the couple to decide on the focus of the session. The mood between the partners was one of tension, frustration, and distancing. Further, the tone of their voices revealed frustration and impatience. Also, the wife described instances in which they had been angry and very frustrated with each other. Anger was unresolved and easily evoked in their lives. Any minor interrruption from either spouse would provoke intense outbursts of anger which would escalate and maintain the distancing pattern in the relationship. During the session, the wife acknowledged and disclosed her awareness of and concern with unexpressed anger in the relationship. This anger resulted in a significant block to their closeness as a couple. She further indicated anger toward the "bitch" (woman who had deeply betrayed the husband's trust) and the "bastard" (man who had sexually abused the wife) for the pain and suffering they had endured individually and as a couple. While the wife eagerly identified anger as a significant block to their 116 intimacy and, therefore, the need to address it in therapy, the husband minimized and denied its power and thus was reluctant to attend to his anger. He further identified anger as being his wife's issue but not necessarily his. Episode 5 This episode occurred in the tenth session of couple 2010. The episode appeared 7 minutes into the session and lasted 16 minutes and 27 seconds. The analysis of the episode generated two categories. The first category was named exposing and releasing a secret bond with a ghost from the past and the second was termed brief sharing of perceptions and feelings. Prior to the emergence of this episode, the therapist invited the couple to decide on the obstacles (represented through actual objects in the therapy room) to their marriage that they wished to work on during the session. They decided that since the husband had brought in his letter to the "bitch" (the woman that had created intense pain and anguish for him) they would focus on that obstacle. He shared the depth of love and tenderness he felt toward this woman and the cruelty and harshness with which she treated him while they were together. This was his first relationship with a female. He was 27 years old at the time. The consequences of that relationship left him unable to trust and love others. He had written a letter to this female which he brought into the session for the therapist to read outside of the session. The letter was placed on the chair representing the "bitch" (his chosen word for the object representing a significant block to intimacy with his wife). This chair was situated to his right hand side. He was sitting and facing his wife directly. The cushion of happiness (symbol of their 117 desired state, closeness) was placed on the floor between the partners. The therapist was fully present for him, addressing him in a calm and relaxed manner. The husband had not expected to read the letter himself or have it read aloud at all. In other words, he was not expecting to bring the secrets of that relationship out into the open and share those secrets with his wife. Eventually, the husband read the letter aloud. Episode 6 This episode occurred 28 minutes into session twelve of couple 2010. Its time lapse was 24 minutes and 57 seconds. The analysis of the episode generated three categories labeled (1) partners calmly engaging with each other, (2) wife releasing her block to intimacy, and (3) partners engaging each other compassionately. Prior to the beginning of this episode, the wife reflected on the many strings that were attached to her and the negative impact and influence these strings had on their marriage. The strings were alcohol, her ex-husband, the "bastard" and the "bitch." Also, she reflected on her explosive outbursts of anger and her lack of awareness as to which string was being pulled during these explosive episodes. Further, she pondered on the string linked to her husband, that is, his relationship with the "bitch" regarding his lack of trust. This particular string had prevented him from coming closer to her. The episode began as the partners were interacting and sharing their feelings of hurt about the lack of trust in each other. 118 Compared to the previous ones, this episode was initiated under a different condition. Here, the husband was fully present, engaged and authentic with his wife and the therapist. Also, the wife shared and expressed freely her feelings and experiences to her husband. More specifically, she expressed her sadness and pain about her husband's lack of trust in her. The therapist stepped back and encouraged the couple to dialogue with each other at their own pace. Episode 7 This episode emerged from the thirteenth session of couple 2010. Its duration was 17 minutes and it began 38 minutes into the session. The analysis of its internal structure revealed the emergence of two categories: (1) removing the couples's blocks to closeness, and (2) the couple engaging with each other in freedom, genuineness, and intimacy. The physical seating arrangement of the members of the therapeutic system accurately reflected the atmosphere prior to the emergence of the episode. Everyone was sitting around a circle in the middle of the therapy room. The husband and wife were facing each other. On the floor, a cushion (couple's symbol of togetherness and happiness) was placed equidistantly to each other. The "bastard's chair" (representing the man who sexually abused the wife) was placed to the wife's left-side. The "bottle" (symbol of alcohol) was placed to the husband's left-side. The wife's ex-husband's chair, another block to the couple's closeness, was placed between the "bottle" and the "bastard". The "bitch's chair" (representing the woman that betrayed the husband) was placed a bit further back to the husband's right hand-side. The therapist was sitting 119 equidistant from the wife and the husband. All obstacles to the couple's sense of intimacy and togetherness were evoked and physically externalized at the beginning of the episode. The couple was in a state of tension and anticipation about the heightened presence of the many blocks to their togetherness. Episode 8 Episode # 8 occurred in session fourteen of couple 2010. Its time span was 21 minutes and it occurred 42 minutes into the session. The analysis of the actions and interactions generated two interrelated categories conceptualized as (1) letting go: the husband letting go of the "bitch" and the wife letting go of the "bastard", and (2) acquiring a renewed sense of self with a new perspective. Prior to the emergence of this episode, the husband revealed doubt and skepticism about the therapy process while the wife revealed anticipation. During the previous session, the therapist suggested to the couple that they reflect on and bring into the session an object symbolic of the experiences associated with the blocks they wished to let go of. The wife brought in a photograph of her wedding to her first husband. In this photograph, she was in her wedding gown standing between her ex-husband and the "bastard" (the man who sexually abused her). The "bastard" was giving a toast to the bride. The husband brought in a large piece of paper with the word "bitch" written on it. The purpose of the invitation was to encourage the couple to engage in a letting go ceremony. Although the wife was ready and prepared to engage in such a ceremony, the husband was doubtful and sceptical. Following some story-telling about his 120 relationship with the "bitch" and the suffering he had experienced with her, the therapist wondered about his readiness to let go of some of the experiences associated with her. The husband was frustrated, uptight and tense despite his engagement and full collaboration with the therapy process. The tension stemmed from doubt and some unwillingness to let go of something that was deeply interwoven into the fabric of his being. The wife listened attentively to her husband's inner struggles. She was no longer fearful of his frustrations and tensions. The therapist was fully present for the husband. Her stance was supportive and attentive. Her tone was soothing and gentle. Episode 9 This episode appeared in the second session of couple 2036. The episode lasted 16 minutes and occurred 9 minutes into the session. The analysis of the psychotherapeutic actions and interactions generated two categories. These categories were conceptualized as (1) couple distancing: wife pulling away in pain and husband pulling away in fear, and (2) couple engaging through verbal expressions of support and acceptance. Prior to the beginning of this episode, the husband and wife were blaming and criticizing each other about their lack of communication and support. The couple had discrepant views on whether and how they communicated and supported each other. Lack of connection and communication was the result of distancing actions manifested by both partners. The wife recounted numerous occasions during the week in which her husband was unable to share openly and support her. As she related these events, the husband distanced himself 121 even more by adopting a sulky and silent pose. This episode began as the wife, in a somewhat distant and detached manner, reflected on her husband's lack of care, compassion, and support for her and their immediate family. By now, the husband was unresponsive and inattentive to her story about her wish to be cared for, supported and loved by him. Episode 10 Episode # 10 emerged in session eight of couple 2036. This episode occurred 11 minutes into the session and lasted 34 minutes and 2 seconds. Analysis of the action and interactions of the members of the therapeutic system revealed three categories: (1) couple agreeing to a mutual therapeutic mandate, (2) couple working through demons, and (3) couple coming closer to each other through appreciation and understanding. Prior to the emergence of the episode, the husband expressed frustration, tension and anticipation regarding the unfolding of events in the session. The wife, on the other hand, appeared in a state of wonderment and support toward her husband. The husband had earlier been engaged in a push-pull dance with the therapist regarding the exploration of traumatic experiences from the past. He was confused and frustrated because he expected her to provide a cure for his emotional wounds while he was also afraid to explore and delve into those issues. In addition, he also expected her to provide answers to questions he had concerning possible sexual abusive experiences to which the therapist seemed unwilling to respond to. In a gentle and caring way, the therapist challenged and encouraged him to stay focused on his need to find the answers through the process he was engaged in. The wife 122 was attentive and supportive toward him but also in a state of wonderment about the confusion her husband was experiencing. This description of the ten selected episodes of change was intended as a general account of the episodes. The episodes occurred at various points within the session and their time spans varied. Episodes number one to eight revealed a regular flow of the therapeutic process, with a beginning, middle, and end. Episodes nine and ten revealed only an initial stage of the therapy. However, despite these differences, the actions and interactions of the members of the therapeutic system, as revealed in the ten episodes of change, showed a coherent structure and noticeable similarities. The following chapter presents the results from the grounded theory analysis of the ten change episodes. 123 CHAPTER V RESULTS: C O N C E P T U A L MODEL OF C H A N G E This chapter presents the findings of the qualitative, grounded theory analysis of ten change episodes selected from two marital ExST cases. The results are presented in three major sections. First, the conceptual model of change generated from the analysis is introduced. Second, the core category, along with its explaining categories and subcategories, comprising the model of change, is presented. Third, each category and subcategory is defined and exemplified with a corresponding illustration. While another selection of illustrations is provided in Appendix D, an extensive set of examples is also available from the researcher. Conceptual Model of Change The discovery-oriented observational analysis of the 40 marital ExST sessions revealed the presence often episodes of change. The grounded theory analysis of these episodes addressed the three interrelated research questions posed by this investigation; namely, the provision of a conceptual description of the internal structure of the change episodes as depicted by the clients' and therapist's actions and interactions. The analysis of the actions and interactions of the members of the therapeutic system, in the episodes of change, was articulated in a conceptual model of change entitled synergetic shifting (see Figure 2). 124 cn CD °> f— CD c C >, racti eely = tr essi mac racti eely Q. O essi mac racti eely 0) CL essi mac O Q. Int " 3 < (/) x .E UJ co u • <D D i _ 0) c CO CD T3 O TO 3 •4-1 Q 0 O £ O O c\i o 3 O) CO o • •MB CD g>i CD S.I CO H—H 0) Q . COU ting TJ o o c o (A o 0) ict t : <*-(0 tz Q . o W o fl) 75 c c o o TO JS c 0) 'E $ © O 4-1 tn c o CO 1_ <D Q. o 75 c o To c (0 CO 125 The concept of synergetic shifting, further defined below, best explained the internal organizational structure of change and described the salient actions and interactions of the clients and therapist in facilitating change across time. Synergetic shirting's foundation consisted of four client categories, 14 client subcategories, and three therapist categories. Synergetic Shifting The 1989 Edition of the Webster's Encyclopedic Unabridged Dictionary defines synergetic as the working together of two or more parts in order to enhance an effect. The concept shifting is defined as movement from one position to another. As revealed in the change episodes, synergetic shifting encompasses both aspects of the change process. As such, synergetic shifting refers to the working together of two or more parts in order to generate a more harmonious or desired effect. That is, the partners moved away from distancing, rigid, restrictive, and inflexible patterns of interaction and toward those expressing emotional and cognitive flexibility, and caring compassion. Thus, synergetic shifting refers to an interactional process in which the partners, with the assistance of the therapist, moved away from rigid, distancing, and alienating relational patterns toward interpersonal flexibility, caring, compassion and affiliation by working through relational blocks hindering the partners' engagement and intimate connection. Synergetic shifting's conceptualization consists of three components. These components are (1) movement overtime; (2) togetherness in action; and 126 (3) the participation of two or more parts or individuals in the process. Movement over time refers to the actions and interactions of the participants occurring through a time span. Togetherness in action pertains to conjoined action; namely, the couple with the assistance of the therapist collaboratively working toward the achievement of a desired state, a more gratifying effect. The participation of two or more parts or individuals refers to the relational nature of the working together. Movement along a continuum of time was apparent in the client categories and subcategories describing synergetic shifting. The internal structure of the change episodes revealed movement over time along four client categories. These were conceptualized as Phase One: owning one's part in the relational conflict; Phase Two: couple contacting: constricted; Phase Three: couple working through blocks to intimacy; and Phase Four: couple engaging compassionately. In addition, movement along a time span was also revealed within each of the phases. For instance, the phase "owning one's part in the relational conflict" occurs over a time span of actions and interactions categorized as distancing, reflecting, expressing, and acknowledging . Although the categories and subcategories explaining the internal structure of the change episodes reflected movement and action over time, some categories were not revealed in all the episodes of change. The following section identifies the occurrence of categories within the individual change episodes. 127 Occurrence of Categories within the Change Episodes The analysis of the ten change episodes revealed that some categories were present in all of the episodes while others were absent in some of the episodes. As depicted in Table 5, the categories "couple engaging compassionately" and "couple working through blocks to intimacy" emerged in all ten episodes. The category "owning one's part in the relational conflict" emerged in episodes one, two, three, and five of couple 2010 and episodes nine and ten of couple 2036, that is, in six of the ten episodes. The category, "couple contacting: constricted, limited," was revealed in seven of the ten episodes. This suggests that the categories are reflective of the stages of therapeutic shifting within the episodes. For instance, the category "owning one's part in the relational conflict" was revealed in episodes corresponding to sessions occurring earlier on in therapy. This pattern suggests that, on the one hand, the members' of the system were working on individual issues impinging on the functioning of the couple but, on the other hand, it may have been indicative of an initial stage of therapy, preparing the ground for focusing on deeper couples issues. As the intrapersonal issues were addressed, the partners shifted into actual contacting with each other, despite their tentativeness and constriction. This was reflected by the second category entitled couple contacting: constricted, limited. It seems as if, once the partners were able to shift their individual positions by working and owning their part in the marital conflict, they moved into their relationship by contacting each other in an awkward and limited 128 way. As the partners moved closer to each other, they actually worked on the obstacles hindering their contact and engaged intimately with each other. Table 5 Occurrence of Categories within the Change Episodes Core Category: Synergetic Shift ing Categories Owning one's part in relational conflict Couple contacting: constricted, limited Working through blocks to intimacy Compassionate engaging Episode # 1, (session # 3) X X X X Episode # 2, (session # 5) X X X X Episode # 3, (session # 6) X X X X Episode # 4, (session # 7) X X X Episode # 5, (session #10) X X X X Episode # 6, (session #12) X X Episode # 7, (session #13) X X Episode # 8, (session #14) X X Episode # 9, (session # 2) X X X X Episode #10, (session # 8) X X X X The analysis also revealed that the presence of categories during the latter stages of therapy varied accordingly. For instance, the absence of phases one (owning one's part in the relational conflict) and two (couple contacting: 129 limited and constricted) in episodes corresponding to sessions twelve, thirteen and fourteen of couple 2010 may reflect a parallel process occurring between change as represented in therapy in general and change as represented in the change episodes. In spite of these general differences, as the categories and subcategories were analyzed, linked and collapsed, the internal structure of the change episodes revealed itself as coherent, organized and similar. An important part of the internal structure of the episodes of change consisted of the actions and interactions engaged in by the therapist in order to effect shifting to a desired state for the couples. The process of synergetic shifting was facilitated by all members of the therapeutic system. That is to say, the actions and interactions of the partners, as well as the therapist, facilitated movement away from distancing stances toward intimacy. The therapist's actions and interactions were categorized according to three distinct operations. These operations were conceptualized as shifting, transitional and supporting categories. The naming of the therapist operations was based on their function and effectiveness in facilitating change. Hence, a shifting category was defined as an essential or crucial operation in the facilitation of change or movement for the couple. In other words, shifting categories were the most potent in moving the client/couple to a new state of being or awareness. A supporting category was defined as an operation supporting the implementation and facilitating the conditions for the implementation of a shifting operation. A transitional operation 130 was defined as an operation facilitating a transition from one phase to another within the episode. That is, as a new condition was created within a particular phase of the episode by the couple, either through a sense of completion or a new awareness, the therapist initiated a transition into a closely related aspect of the couples' therapeutic process. The transitional categories functioned as bridges between two client categories. The following section defines, explains and illustrates the categories explaining synergetic shifting, as they emerged from the analysis of the actions and interactions of the participants. Within each category, both the context for the emergence of the category and its associated subcategories are described in detail. Phase One: Owning One's Part in the Relational Conflict Within the overall organizational structure of the change episodes, owning one's part in the relational conflict emerged as the first category. Owning one's part in the relational conflict referred to the working through of individual/personal issues that had been out of the client's awareness. Individual issues such as rejection, unlovableness, trauma and abandonment were viewed as impeding closeness and intimacy by the partners. The partners were in a state of distance from each other because of lack of awareness about their part in the relational conflict. In addition, there was considerable blaming and accusing of the other with little reflection on personal responsibility as to the condition of the marriage. This category had three components: (1) an initial state of distance from the self and blaming of the other, (2) the working through or discovery of an intrapersonal 131 issue impinging on the relationship and (3) a subsequent new state of owning one's individual part in the conflictual condition of the marriage. Contextual Conditions Related to the Emergence of Phase One The condition prior to the emergence of the category owning his/her part in the relational conflict consisted of the partners being in a state of distance, disengagement and entrenched in their own individual emotional, cognitive and behavioral positions. This distancing pattern was evident at the intrapersonal and interpersonal levels. For instance, prior to the initiation of Episode # 1 , the members of the therapeutic system were exploring the entrenched and conflictual distancing pattern experienced by the couple. Although the wife was fully engaged in discourse with the therapist, the husband was removed, distant, detached and non-expressive. He displayed significant unwillingness to engage, showed lack of affect, and used brief and monosyllabic statements. The wife's expressed pain and anger toward her husband because of his distancing behaviors, as well as his distancing behaviors through his closeness to alcohol, were evoked and heightened. As such, the husband was physically removed from the centre of the therapy room, where the wife and the therapist were sitting. He was actually removed far into a corner of the room, sitting right beside a large bottle (symbol of alcohol). At the same time, he was verbally denying any conflictual connection between his alcohol misuse and his marriage. The husband's distancing stance was manifested at the verbal and nonverbal levels. During Episode # 2, intrapersonal distancing and entrenched emotional, cognitive and behavioral disengagement were also evident and formed the 132 background for the emergence of the category owning one's part in the relational conflict. In a previous session, the wife had briefly acknowledged the significant impact that her childhood sexual abuse trauma had on herself and her marriage. As well, the husband had also spoken about the powerful impact of those experiences in the marriage. In fact, he had identified his wife's sexual abuse experiences as the biggest blocks to generating closeness and intimacy in the marriage. Furthermore, his assumption was that, in comparison to his wife's trauma, his own personal trauma did not impinge negatively on his marriage. Given that the husband had not brought up personally painful or difficult experiences, but had placed the blame for the distancing blocks on his wife, the therapist invited him to share some of his issues. He reluctantly disclosed experiences of intense emotional abuse and neglect as a child, loneliness as a teenager, and wounds from the past. However, he also stressed that those wounds were forgotten. Moreover, he reflected on his belief that emotional pain was to be put away through denial and minimization. Given the extent of the denial and the distancing behaviors (reluctancy, blaming the other), the therapist evoked and invited him to bring out those wounds (client's own word). Another instance where owning one's part in the relational conflict was evident occurred during Episode # 3. The background to the emergence of this category was one in which the husband revealed his inability to trust others. He spoke of feeling complete lack of trust irrespective of situations or persons. Because of deep and significant hurt and intense disappointment suffered in past relationships, he had made a decision to keep to himself and disengage from 133 others, including his wife. The therapist had sensed throughout the therapy process the husband's distancing stance and actions. His monosyllabic and detached stance persisted despite the therapist's empathic, supportive, and respectful reflections. Given the husband's lack of engagment and distancing interactions in the therapy process, the therapist addressed this issue by bringing it into awareness and focus. The fourth instance in the emergence of "owning one's part in the relational conflict", as a category, occurred during Episode # 5, session 10. The condition preceeding the unveiling of this category consisted of tension, fear, and reluctance on the part of the husband. Although initially the husband had agreed to read a letter he had written to a woman from the past, he suddenly became unwilling, reluctant and tense about actually disclosing the contents of the letter. The contents of this letter represented an important block to the couple's closeness. For the husband, the letter represented a significant relationship with a woman whom he still loved. For the wife, the letter represented a block to their connection with each other because of her husband's unwillingness to share his life experiences with her. She was unaware of the contents of the letter. The fifth instance where the category owning one's part in the relational conflict emerged was during Episode # 9, session 2 of couple 2036. Prior to the beginning of the episode, the husband and wife shared their divergent perceptions regarding each other's communication styles. The couple had discrepant views on whether and how they communicated. They criticized and blamed the other for their lack of connection and emotional contact. As the wife 134 talked about the numerous occassions both in the past and in the present concerning her husband's distancing actions, he gradually removed himself from the events at that moment. This episode began under a condition in which the wife in a somewhat distant and detached stance reflected on her husband's lack of care, compassion, and support for her and their immediate family. The husband was unresponsive and unattentive to her story regarding her need to feel cared for and supported by him. Indeed, his nonverbal stance revealed a desire to actually depart from the therapy room. The condition prior to the emergence of "owning one's part in the relational conflict" during Episode #10, session 8 consisted of distancing actions on the part of the husband. In the two months prior to this session, the husband had become aware of being sexually abused by a family member when he was a young child. This new realization had generated intense confusion, anger, and a need to distance himself from everyone around him. He had been pushing his wife away and was uncomfortable being close to people. Prior to becoming aware of being sexually abused, he had misused alcohol for several years. Now, that he was no longer abusing alcohol, one of the reasons he distanced himself from others was because of the emotional and psychological confusion surrrounding his sexual abuse experiences. The husband was unable to relate to and connect with others, including his wife, as he felt "crazy" at times. Given the extent of confusion and disorientation on the part of the husband, the wife encouraged and supported her husband to work on the abusive experiences that were holding him back. 1 3 5 In the next section, the subcategories explaining the category owning one's part in the relational conflict, along with illustrative examples, are presented. Another set of illustrations is offered in Appendix D. Further examples are available from the researcher. The personal names in the illustrations have been altered. Explaining Subcategories; Phase One The subcategories explaining and supporting the category "owning one's part in the relational conflict" were conceptualized as follows: (1) distancing: anger/fear, denying, resisting, minimizing, blaming, and flipping; (2) reflecting: doubting, wondering on actions/experiences related to self or others; (3) expressing: sharing, disclosing, feeling, experiencing on actions, experiences, feelings related to self and others; and (4) acknowledging: realizing, opening up, and owning. Distancing Distancing as an action, feeling, and experience involved the moving away and separating from one another. Distancing was manifested at the intrapersonal and interpersonal levels by both partners. At the interpersonal level, during Episode # 1, the husband's distancing expressions were manifested by minimal monosyllabic responding to the therapist's attempts to involve him in the therapy process. The therapist actively attempted to engage with the husband who appeared very distant and actually unwilling to interact despite her attentive, present, supportive and empathic stance. In addition, he displayed 136 significant lack of affect and emotional intonation in response to the therapist's interventions. The following excerpt illustrates his distancing actions. T: You know that now, as you said to me, "every time I come back to Joan, I come back a little, I come back to her, but a little farther,...a little farther." H: Humm, humm ( distant, detached but still listening) T: "and, next time I go away, I am going to come back a little farther from her." H: Huumm, humm (distant, aloof) Reflecting Reflecting was the term generated to account for the actions and interactions of the partners as they shifted from distancing into wondering, pondering and reflecting on their actions regarding the conflicts in the marriage. Reflecting referred to the act of meditating or pondering on experiences, actions, feelings or thoughts concerning the self in relationship. This subcategory entailed a shift in the client's thought or perception regarding the interpersonal conflict of the couple. Through a process of pondering, doubting, wondering and inquiring about particular personal conflictual experiences impinging on the marital relationship, the partners shifted in their positions from one of distance to one of wonder and reflection. In the following excerpt from Episode # 3, the husband expressed doubts about his own role in therapy. Although he had blamed his wife for most of the problems in the marriage, now he doubted and wondered about his part in the conflict. A shift in regard to his blaming from wife to therapist as well as a shift from denying and minimizing to doubting had occurred. H: yeah! I view her as having the bigger problem. T: the bigger problem, and today, do you view that the same? 137 H: well I don't know!....the more you... you are... are...say...exploring, the more doubts I have about myself. T: and that feels a little bit uncomfortable. H: Yeah!! I don't like that!., hugggh basically, I am happy about the way I am, and who I am. And then, you come along and start giving me doubts!! As the partners reflected about their role or part in the relational conflict and the impact that their own individual issues had on the marriage, a gradual shift occurred. During many occasions, the process of working through of the individual issues (abuse, abandonment, betrayal, lack of trust) took the form of silent reflection and seemed to involve a cognitive rather than emotive process. Expressing Expressing experiences, feelings and thoughts related to self and/or significant others in the couples' lives emerged as the next subcategory within the category owning one's part in the relational conflict. Expressing refers to processes such as revealing, sharing, feeling and experiencing feelings, experiences and bodily sensations associated with conflictual aspects of self and/or the other. These conflictual aspects were often outside of the client's or the partner's awareness. As the members of the dyad discovered and worked through their own individual issues, they progressed through the processes encompassed under the subcategory, expressing. These processes assisted the couple in shifting from one position to another in their distancing stance in that the client became more genuine, self-assured, and slightly more aware of inner processes, as disavowed material became owned. 138 Expressing is illustrated in the following excerpt from Episode # 10. Here, the client vividly expresses emotions and experiences associated with sexually abusive events from his past. H: oh I can't because I haven't seen any pictures. So, I don't know what is true... so if I (silence 15 seconds)... ahmm I get the feeling that (silence, 20 seconds) I am getting scared that (nervous laugh). T: a whole bunch of emotions went through you. H: Yeah! T: as you said, "I am getting scared" what were some of those just before you said you were feeling scared? H Silence (30 sec) H: ahggg. H: silence (20 seconds) T: what are you feeling right now? H: oh when I go to say something ...hum something stops me. T: something holds you back. H: I don't know it... it's like like I think of the word, but just as I go to say it, it blanks out of me. T: it goes. H: yeah! I don't know. I just.... I get the feeling hughhh.... hughhhh I am being confused. Expressing was manifested by the vivid, genuine, real and honest display of emotions, experiences, and sensations associated with individual issues which the clients deemed relevant and important in their relationship. These issues limited and obstructed the development of an authentic and trusting relationship with each other. When the partners were able to express deeply felt emotions and sensations, they gradually shifted to a place of acknowledging their own individual issues. The next subcategory within the category owning one's part in the relational conflict was named acknowledging. 139 Acknowledging Acknowledging and gaining a greater awareness of self and others was the last emerging subcategory in the progressive flow of events within the category owning one's part in the relational conflict of the couple. This subcategory referred to the realization and recognition of a new awareness, or the actual discovery of something new about the husband's or the wife's conflictual part affecting the couples' closeness in the marriage. This new awareness took different forms. In some instances it emerged as an acknowledgment or realization, whereas in others it evolved as a new felt flexibility about the self or others. Acknowledging entailed a personal openness and flexibility on the part of the husband and the wife regarding the issues being addressed. During Episode # 1, for instance, the wife had been exclusively focused on her husband's distancing, without consideration or awareness of her own distancing actions in the relationship. The recognition of her own distancing behavior was manifested in the following excerpt. W: Because if I ask him back again, I know he is going to find a way of hurting me again. So, I feel vulnerable and like I never saw it like that before. But you are right. It was reaching out with one hand, and wounding him with the other. Because I want to have this closeness, and want to have the intimacy, and I want to have all these things. But at the same time, I am so afraid of being hurt again that Acknowledging involved a process of recognition and discovery of a new awareness of the impact that intrapersonal issues had on the marriage. This new realization was usually accompanied by the expression of emotions about the 140 issue at hand. In this way, the partners acknowledged but also owned their part in the relational conflict. Owning one's part in the relational conflict entailed the recognition and awareness of intrapersonal processes of the partners as negatively impinging on the development of the couples' intimacy. This phase of synergetic shifting consisted of four subcategories. These subcategories were termed distancing, reflecting, expressing and acknowledging of significant intrapersonal issues negatively affecting the couples's interpersonal connection. A central component of owning one's part in the conflictual relationship and of the overall process of change involved the actions and interactions of the therapist. The following section addresses the therapist actions and interactions identified in the analysis. Specifically, significant and salient therapist actions and interactions emerging within the category owning one's part in the relational conflict are presented and exemplified. These categories were organized under three broad categories entitled shifting, supporting, and transitional categories. Therapist's Operations: Phase One Three distinct and salient therapist actions and interactions within the category "owning one's part in the relational conflict" emerged from the analysis of the episodes. These actions and interactions were organized according to their function and effectiveness into three categories: supporting, shifting, and transitional. 141 Supporting Categories Supporting categories referred to the therapist's actions and interactions intended to maintain a therapeutic working relationship, to enhance the collaborative atmosphere and to foster acceptance, encouragement, safety and trust in the clients and the therapy process. Supporting categories also assisted in the implementation of shifting and transitional categories. Some of the therapist's supporting actions and interactions unveiled within this category were accepting, labeling, empathic responding, validating and supporting client's experiences, feelings, perceptions and actions. Accepting client's experiences and actions. By accepting the client's experiences and feelings, the therapist conveyed a message of willingness to receive what the client had to offer. This willingness of the therapist to accommodate the client and to consider the client's offerings as true and believable was not only shown verbally but also through non-verbal behaviors. For instance, the therapist displayed attentive sensitivity to both partners. As well, the therapist's tone of voice communicated acceptance of the client as a person and his/her experience by employing a gentle, warm and soothing tone. Accepting the client's experiences and feelings was evident in all of the episodes and occurred repeatedly throughout the category "owning one's part in the relational conflict." During Episode # 2, as the husband was working through his reluctance to take responsibility for his part in the process of therapy and the problems in the marriage, the therapist fully accepted his unwillingness to assume personal 142 responsibility. In the following illustration, the husband, to some extent, acknowledged his own part in the marital conflict when the therapist communicated her acceptance of his stance. T: So, you came so that something can happen, and she can change, and you wouldn't feel so confused in relating to her. H: Yeah! I view her as having the bigger problem. Empathizing and validating client's experiences. The clients' experiences, feelings, and actions were also validated, valued and supported by the therapist. The manner in which she engaged in these actions was through basic empathy, advanced empathy, validating and normalizing. Similar to the previous category of accepting, there were two common characteristics in to the implementation of these operations. First, the therapist focused on the present moment of the action, perception, experience, or feeling of the clients by using the present tense, or by employing the word "now" in her statements. Second, the therapist utilized a calm, respectful and attentive stance and a soft, soothing tone of voice which conveyed warmth, acceptance and support to the clients. During Episode # 3 for instance, the therapist empathized with the husband's fears regarding her interest in his emotional and personal life. In this excerpt, he was able to acknowledge that the therapist was disrupting his emotional and psychological rigidity. T: It is a frightening experience, it's scary. H: You are rocking the boat! 143 Although the supporting operations maintained the therapeutic environment and encouraged the clients to work through issues, these operations also facilitated the clients' shifting process. However, the shifting operations were salient in the actual process of synergetic shifting. Shifting Operations The therapist's actions and interactions which contributed to a shift in the clients' emotional, cognitive or behavioral realm of experience were categorized under shifting operations. Under the category "owning one's part in the relational conflict," there were a number of interventions which seemed to have facilitated the clients' movement. The naming of these interventions reflects closely the actions and interactions of the therapist as evident in the data. The shifting operations included reifying experiences, linking the couple, encouraging self-focus and self-connection, utilizing client's metaphors and language, and challenging client's actions. It is noteworthy that all of these actions and interactions were embedded in a present moment therapeutic stance. In addition to these specific actions and interactions, a salient theme evident in the therapist's actions was her perseverance and trust. Therapist perseverance does not necessarily reflect an intervention; rather, it refers to a particular stance taken by the therapist under certain conditions where the client was distancing from continued engagement in the therapeutic process. 144 Reifying experiences. Reifying experiences refers to making real, concrete and specific an amorphous, shapeless, and sometimes abstract experience of the client. Reifying seemed to have significantly facilitated shifting from one place to another or from one experience to another. Reifying took many forms in that sometimes the therapist reified a feeling or an experience, while at other times an action or thought was reified. In Episode # 2, when the husband was adamant about his lack of emotional pain, the therapist assisted the husband's shifting by making his emotional wound more real and concrete. Without an awareness of the extent of his emotional pain, the therapist facilitated the husband's acknowledgment and release of this pain by exploring the possible size to his emotional pain, searching for a location of the pain within his own body, exploring possible locations in the body, and linking the size of the wound to a particular location in the body. In addition, she employed his metaphor when speaking of emotional pain. T: The biggest wound that you have in your heart., or maybe in your stomach. I don't know. H: Well, the one that would affect Joan the most would be the..no girlfriend that I had before her... T: Gina... wounded you, wounded you, and Gina created a big crack in that heart that is wounded now. And the big crack came from a powerful feeling of rejection, (H: humm ) and almost abandonment, and you trusted Gina and Gina let you go. H: I shouldn't have trusted her! She wasn't trustworthy she was cold.... 145 Linking the couple. Linking the couple refers to attempts made by the therapist to connect or to create links between the partners. Linking the couple was implemented through the language utilized by the therapist as well as by actual encouragement to link under different conditions. The therapist encouraged the partners to connect when they were either emotionally open and close to each other, or when they were distant, tense, and aloof. The distance between the partners was reduced as links and connections were encouraged. During Episode # 9 for instance, the therapist linked the couple as the partners were engaged in their distancing pattern. The following excerpt illustrates linking the couple as the partners are engaged in a push- pull pattern of interaction. H: I just find that if I shut my feelings off there is less pain. Because if I deal with my feelings there is more pain. That is why I guess I shut my feelings off. T: so, right now, "I am protecting myself (therapist pulls back in her chair and holds her arms around her chest) So, when Carol goes to you like that (comes closer to husband and opens both arms to him) maybe you can do that and see what it feels like. I hear you saying "I am like this" (therapist pulls back and covers the front part of her body with her arms as if protecting herself)."I am protecting myself, I am looking after me." And Carol is like this to you (therapist moves closer to husband, and opens up both arms to him, as if embracing). That is what I hear you saying Carol. I hear you saying "I want to share, I want Walter to share with me, and I to share things with Walter." W:Yeah!! Encouraging self-focus and self-connection. Encouraging self-focus and self-connection refers to inviting the clients to turn inward in their search for solutions, new answers and new discoveries to their dilemmas. As well, this category refers to encouraging the partners to 146 connect with the feelings and experiences which have been disowned, denied or out of their awareness. During Episode # 1, for instance, as the therapist worked with the wife's experiences regarding her husband's distant and detached stance, the wife became angry. The therapist then encouraged her to self-focus, that is, to focus on her feelings and experiences in the present moment. T: What is it that you are feeling right now? What is your experience right now? W: I feel very vulnerable. Utilizing client's metaphors and language. Employing the client's language and his/her metaphors was another salient operation facilitating the shifting process. As the therapist used the client's language, he/she felt more completely heard, accepted and valued by the therapist. Feeling heard and fully accepted encouraged movement of the client to a deeper level of experience. An example of utilizing the client's language and metaphors was revealed during Episode # 5. In this episode, the therapist integrated and expanded the client's metaphor by making the metaphoric language more vivid and clear and by linking the husband's metaphor to his wife and the therapist (the process of therapy), while at the same time, validating his pain and discomfort implicit in the metaphor. This operation seemed to have facilitated the client's movement from "stuckness" to doubt about his actions. 147 H: Just as embarrassing; just as painful (deep breathing). I mean dragging it up and living through it again and then you are sharing it with other people as well. It is just like an invasion of privacy. For me, it's a private matter; something that I keep to myself, and to share is like going to the bathroom in a corner or something that is the same sort of T: So that is really exposing yourself to your wife right now. Really exposing your self to her by reading this letter to Gina. Or is it exposing yourself to me too? H: Yeah!! you and her or anybody you know....l don't know if I could read that to anybody I could read it to Gina. Challenging actions and interactions. Challenging the client's actions and interactions also seemed to have facilitated shifting or movement in the couples' process. Shifting from one postion to another occurred through challenging the client in various different ways. Challenging took the form of gentle, caring but firm statements about a particular action or interaction that the client was engaged in right at the moment of the client's action. For instance, an illustration of therapist challenging interactions occurred during Episode # 9 when the wife minimized her husband's distancing actions toward her. The therapist challenged her to explore the manner in which she framed her husband's lack of care for her. W: Oh well... That's it! I mean, I remember the week being really bad but like I have a hard time. I just remember telling him that he seemed uncaring. And if someone else is sick or something like one of his friends, he is right there. But he doesn't seem to do that at home. T: He doesn't seem to do that.... or he doesn't. W:l feel the hurt.... (She breaks down in tears; she is covers her face with her hands so that her husband doesn't see her tears and pain) 148 Therapist perseverance. Therapist perseverance was a salient theme emerging in the majority of the episodes. Therapist perseverance refers to the therapist manifested trust in the process and the client's potential for change. This was particularly evident in episodes # 2, # 3, # 5, # 9, and #10. The therapist displayed a sense of certainty that the client would pull himself/herself through the morass of inner conflict and out of the experience of psychological "stuckness". The therapist had a confident sense of persistence and trust in the process. For instance, in Episode # 5, therapist perseverance was particularly evident. In this episode, the client was in a state of paralysis due to his fears of experiencing feelings of pain and betraying a deep secret by reading a letter he had brought into the session. Although the client was adamant about not reading his letter, the therapist persisted in her invitation to disclose the contents of the letter. A number of antecedent events preceded the therapist persistence. First, he had identified a previous relationship with a woman that blocked his coming closer to his wife. Second, this relationship was blocking his ability to love and trust others, including his wife. Third, he had written a letter addressed to the woman which was now symbolized as a block. Fourth, he had brought the letter into the session and asked the therapist to read it privately. Fifth, the couple had decided to work with that letter during this session. Finally, he had previously indicated the need to read the letter. Given this background, the therapist persevered in her invitation to read the letter. She trusted the husband's process 149 by staying focused on the task at hand and deterring from possible deviations into other related issues. H: She is not here though, and you are! T: She is here with her soul. H: Yeah! but you are also in the room. T: You bring her into your therapy with you. You brought her in today you said because you wanted to work with her. H: This is a private thing!! If I were to read it to her, it would be just me and her!! there wouldn't be anybody else nobody else in the room. It would be embarrassing to read it with other people in the room. An important and necessary condition for therapist perseverance was the maintenance of a collaborative atmosphere and a positive working relationship. Maintaining a collaborative and supportive atmosphere encouraged the clients to stay present with their experiences and engaged in their process. Also, as clients felt supported and validated, their trust in the therapy process and therapist increased. A parallel process of mutual trust and collaboration between the therapist and the clients was particularly crucial for therapist perseverance. These six therapist shifting categories, namely reifying experiences, linking the couple, encouraging self-focus and self-connection, utilizing client's metaphors and language, challenging actions and interactions and therapist perseverance were the most salient and significant in facilitating synergetic shifting for the couples within the intrapersonal realm of therapeutic shifting. Although supporting and shifting operations were clearly evident and salient, transitional operations were not revealed during the client category "owning one's part in the relational conflict." Rather, transitional operations facilitated transitions from one client category to another in the flow of events within the 150 episodes. As such, transitional categories are described and illustrated in the next section. In the following section, the second category emerging within the flow of events of synergetic shifting is presented. This category termed "couple contacting: restricted and limited," along with its context, subcategories and examples, is discussed. Phase Two: Couple Contacting: Restricted, Limited Analysis of the internal structure of the change episodes revealed a second client category named couple contacting: restricted and limited. This category supported and explained the actions and interactions of the members of the therapeutic system in the second phase of the core category synergetic shifting. The unfolding of events within the episodes revealed movement from owning one's part in the relational conflict to couple contacting in a constricted and limited way. In other words, the couple initiated contact with one onother, even though the contact was conflictual and difficult. Contacting referred to verbal exchanges between the partners under limited and constricted conditions. The interchange between the partners lacked a sense of mutuality or reciprocity. The couple's contact was characterized by a sense of holding in and self limiting by the use of restrictive, tight, and rigid interactions. Indeed, the partners were unable to maintain a satisfying dialogue with one another. An important distinction between the category "couple contacting: restricted, limited" and the category "owning his/her part in the 151 relational conflict" was that in the latter the partners's focus was on their individual issues. In this category, the central theme was one of taking the initial steps of establishing meaningful verbal contact with one another. Couple contacting: constricted and limited, was revealed in Episodes # 1, # 2, # 3, # 4, #5, # 9 and #10. The subcategories explaining and supporting this category were: (1) distancing: flipping/fear/anger, (2) conflictual messaging: accusing/distancing, and (3) brief, restricted and limited contact. Contextual Conditions Related to the Emergence of Phase Two The category couple contacting: restricted and limited appeared under conditions where one or both partners had come to a new realization that their intrapersonal issues impinged negatively on their marriage. These intrapersonal issues blocked intimacy and inter-connectedness. Attempts at connecting with each other were initiated either by the therapist or by one of the partners. However, these attempts were restricted, limited and short-lived. Thus, the contact had limited success. During Episode # 1 for instance, as the wife realized her own distancing, pushing and pulling actions in the marriage, the therapist encouraged dialogue between the partners. A new condition had been generated, in therapy, by the wife's discovery of her own part in the dance of distance. She was emotionally open to receiving insight, and could therefore, acknowledge her part in the conflict. At this juncture, the therapist encouraged the wife to dialogue with her husband, who was still very distant and removed from her, both physically and emotionally. In fact, the husband was still physically removed and sitting in a 152 corner of the therapy room. He was attentively listening to his wife but reticent to come closer to her emotionally and physically. The circumstances preceeding the emergence of couple contacting during Episode # 2 occurred as the couple was in a state of fear, nervousness and agitation. The husband had just disclosed and acknowledged painful experiences of betrayal and abandonment by a former lover. He acknowledged the woundedness resulting from this relationship and denied any other form of emotional pain or difficulties. The therapist invited the wife to reflect on what she had heard her husband say. The wife, however, became fearful of her husband's retaliations. The circumstances under which this category emerged could be described as those of fear and distance by both husband and wife. The category "couple contacting: constricted and limited" also emerged in Episode # 3. The circumstances under which this category appeared were the wife's distancing behaviors motivated by fear and the husband's responding offensively. After the husband acknowledged his own part in the relational conflict by indicating that it took two people to have a marital problem, the wife spontaneously initiated contact with him. The husband, however, immediately became distant, tense, and frustrated. The wife, in turn, retreated in fear. In Episode # 4, the condition prior to the emergence of this category revealed distance of the partners in an atmosphere of fear and frustration. The therapist invited the couple to decide on the focus of the session. Conflict arose immediately as the couple had different views. The wife's intention was to work with feelings and expressions of anger. The husband, however, was reluctant to 153 focus on their anger as he considered this to be unnecessary. At the same time, he was unwilling to focus on other issues. The therapist did not interfere in their deliberations but rather encouraged them to continue with the dialogue in attempting to resolve their differing viewpoints. The condition prior to the emergence of constricted and limited couple contacting during Episode # 5 was slightly different. Since the husband was adamant in his refusal to read the letter out loud and disclose its contents in public (his wife and the therapist), the wife became encouraging and supportive despite his high level of frustration. As the therapist sensed a powerful wall of resistance coming from the husband, she appealed to the wife's knowledge and understanding of her husband. At this juncture, the wife came forward with support and understanding rather than retreating in fear and paralysis. During Episode # 9, couple contacting in a very limited and restricted manner occurred under a condition in which the wife was in tears but unwilling to verbally express her pain and the husband was desperately embarrased and in a state of panic. Their limited contact with each other arose spontaneously from the husband's desperate attempts to understand his wife's pain. Limited and restricted couple contacting during Episode #10 evolved after the husband had done a significant piece of intrapersonal work. As this occurred, the therapist encouraged the husband to engage in dialogue with his wife regarding her experience of witnessing his therapeutic work. The husband, however, refused to engage with his wife. Rather, he preferred to continue with 154 his original pattern of running away from his wife when experiencing discomfort and embarrassment. That is, he preferred to maintain his distance from her. As is evident from the circumstances leading to the emergence of the category, "couple contacting: restricted and limited," the partners were in a state of distance, tense and usually experiencing deep emotions such as fear, frustration and embarrasement when attempting contact with one another. Despite the powerful emotions blocking their contact, the couple maintained brief and restricted contact with each other. In the next section, the subcategories explaining the category couple contacting: restricted and limited are described and illustrated with examples from the transcripts. These subcategories were termed: (1) distancing: flipping/fear/anger, (2) conflictual messaging: accusing/distancing, and (3) brief, restricted, tentative contact. Explaining Subcategories: Phase Two Distancing: Flipping/fear/anger This subcategory referred to the initial step taken by the couple to make contact with each other. Here, the therapist encouraged direct dialogue between the partners. However, the partners experienced extremely difficulty maintaining contact due to the large distance separating them and the intensity of their feelings. The intensity of the fear experienced by the wives and the anger experienced by the husbands contributed significantly to their distancing behaviors. For both couples, the wives had similar fearful responses to dialogue with their husbands. Their fear seemed to be intended either to protect themselves from their husbands' responses or to protect their husbands from 155 their own emotional reactions. The husbands, on the other hand, maintained their distancing stance through emotional expressions of frustration, anger, embarrassment, and confusion. The husbands perceived the emotional expressions of their own and their wives as negative, shameful, and inappropriate. Couple dialoguing in a distant and fearful stance occurred during Episode # 4 when the wife expressed her need to work on issues related to the expression of anger in the marriage and the husband withdrew from the dialogue by minimally responding to her. However, the couple was able to maintain a brief dialogue despite the fear and anger displayed by the partners. The expression of fear and anger as they were in limited contact with each other was like this: W: I think to initiate the closeness and intimacy, I think we need to look at the anger because it seems to get in the way. H: Hummmm hummm W: Don't look at me like that! H: Like what?! W: Burning blue eyes, I put you on the spot. H: Last session, you were angry at me because I wasn't angry at Paul... how can I be angry if I don't even know him? That is being prejudiced. It's been bothering me all week. How could you be angry at me for not being angry at someone that I don't even know? He never did anything to me... W: I can't understand how you can't be angry at him. And not just him but any other guy or woman who hurts a child that way, or hurts a child period, whether it be physical or sexual. H: I know it is wrong. I don't approve it in any way shape or form. W: But don't you feel any anger toward people who did that? H: No! W: I don't understand that. 156 Conflictual Messaging: Accusing/Distancing Conflictual messaging refers to the couple in contact with each other through an accusing and distancing stance. The distancing took the form of accusing and blaming the other while in dialogue, either with each other or with the therapist. An example of accusing/distancing from Episode # 4 illustrates this subcategory. Here, the husband's accusing and distancing stance was characterized by lack of empathy, rationalization, lack of compassion, and denial of anger and frustration. The distance in fear stance taken by the wife consisted of expressions of anxiety, depersonalization and other painful experiences associated with defending herself and justifying her pain and suffering. In the following excerpt, the husband in an unsupportive and uncaring manner blamed and accused his wife for failing to resolve the trauma she endured while being sexually abused and the impact this trauma had on their lives. This accusative stance is depicted in the following statement. H: Well!! humm this guy did these things to you that really hurt you and you are screaming! mad at him for doing that. So it's like if he pokes you in the eye you'll be mad at him. He did something worse than poke you in the eye. W: But in sense he poked a stick in your eye because he hurt me and he comes between me and my feelings that I can't let you get closer and I can't express what I feel H: That makes me a little angry yeah but that is equally shared between him and you....my anger at him for doing that to you, to make you that way. And you for not being able to get over that you see. T: "So you've been feeling angry at me for a long time, it sounds like you've been blaming me for not getting over these experiences." (speaking as wife) H: Yeah! a little bit, yeah... for not being able to work it through, and get over it, for hiding it. 157 Brief. Restricted Contact Brief and restricted contact with each other referred to dialogue in which the partners were withholding and limiting themselves in the contact with one another. A tight interpersonal stance was still maintained by the members of the couple. The dialogue was constricted and of very brief duration. The partners were tentative and uncertain as to whether to trust each other or come closer and be vulnerable and open to each other. Brief, tentative, and limited dialogue is exemplified in Episode # 3. Here, as the husband acknowledged and owned his part in the marital problem, the wife spontaneously initiated contact with him. This contact was short lived, however, because the husband responded in a short and impatient tone of voice. The wife retreated in fear once more. W: When you said... that you came because of me and the way, I can't remember the words you chose but the way it sounded was that it made me feel like you thought of yourself as not as important. You thought of my problems as greater and more important to be solved than yours. H: Humm hummm W: Therefore you were less important. H: no! It's not less important I am still me! W: That is just how it came across..... that is how I heard it. I can't,... I wish I can remember the words but I can't. That's how I remember how you said it I was thinking. H: I don't think that is what I meant!! Couple contacting involved a limited, restricted, and tense dialogue between the partners. This dialogue was brief, tentative and rapidly deteriorated as the couple was unable to maintain and expand on it. Rather, it abruptly ended 158 because of the partners'rigidity and holding in of their emotions. The therapist encouraged and facilitated the partners' contact given their intrapersonal openness. The therapist viewed intrapersonal openness as a window of opportunity to encourage interpersonal connection. The next section describes the salient therapist operations within the category "couple contacting: restricted and limited." Therapist Operations: Phase Two The therapist actions emerging from the client category "couple contacting: restricted, and limited" were similar to the therapist operations identified in the previous category. As such, supporting operations were evident throughout the phase of couple contacting. Movement from a distant and restrictive to a more open and somewhat trusting position was facilitated by the therapist shifting operations. Transitional operations, however, were salient in moving from one category to the next as the therapist encouraged a shift from an intrapersonal to an interpersonal focus. In the following section, transitional operations will be discussed followed by shifting operations. Transitional Operations Transitional operations refer to the therapist actions and interactions intended to facilitate movement from one client category to the next within the internal progression of the core category synergetic shifting. Transitional operations were evident when the partners were in a state of readiness to move into the next phase. When the clients displayed openness and contact with their inner world, movement toward interpersonal connection was encouraged. This 159 transitonal operation was termed bridging the couple and was implemented within a here and now framework in an atmosphere of support and collaboration with the partners. In the following section, the transitional category bridging the couple is presented along with examples. Bridging the couple. Bridging the couple refers to reducing the distance between the partners by encouraging or inviting connection with each other. The therapist invited verbal exchanges and disclosures from a place of inner openness by either of the partners. For instance, during Episode # 10 when the husband had just ended a significant piece of inner work lasting around 30 minutes and the wife had witnessed and taken part in his process through her calm presence, the therapist encouraged the husband to empathically listen to his wife's experience. T: Maybe you want to ask Carol as I am aware that she has been witnessing your experience, which seems like a new experience in which you wanted to run but you had the courage to be here. I am wondering how did that feel for you? H: It felt ok. But right now I want to leave. I want to go and smoke a cigarette I can take a Tylenol because I have a bad headache. T: Maybe you would like to find out Carol about how her experience was here. H: No because I would like to just quit. It is over I want time to settle down now. T: So maybe you can just quit for now and begin to settle down. And how would you feel like if I were to ask Carol about her experience? Would that be alright for you? Bridging the couple appeared to have facilitated contact between the partners despite their distancing and unwillingness to engage with each other. Bridging the couple was particularly effective when one of the partners was more integrated, open to self and possessing a willingness to be vulnerable. This inner openness seemed to have facilitated interpersonal connectedness. 160 The transitional operations facilitated moving through to the client category couple contacting: restricted and limited. Within this category, various supporting and shifting operations were revealed.The next section discusses the supporting and shifting operations emerging within the category couple contacting: restricted and limited. Supporting Operations There were a number of supporting operations emerging within this category. Supporting operations were similar to the ones revealed in the previous category and were instrumental in supporting, maintaining and enhancing the therapeutic relationship. These operations included empathic responding, paraphrasing, validating, and normalizing client's experiences and feelings. Given the similarity of these operations within the two categories, they will not be illustrated here. However, it is noteworthy that, compared with the previous client category, the supporting operations were less frequent in their occurrence within this client category. Rather, the shifting operations were revealed as more frequent and salient. The following section discusses the shifting operations as they emerged in the category "couple contacting: restricted and limited." Shifting Operations Similar to the shifting operations emerging during the previous category, the shifting operations for this category were characterized by their potency in shifting the partners from their rigid and inflexible pattern of interaction to a more resilient and flexible one. The shifting operations in this category were somewhat 161 different from the ones in the previous category, nevertheless, their function served a similar purpose, that is, shifting the couples' pattern of interaction. The shifting operations within the category were named (1) encouraging direct interaction, (2) modelling interactions, (3) linking the couple, and (4) challenging the partners' actions and interactions. In the following section, these operations will be defined and illustrated. Encouraging direct interaction. Encouraging direct interaction refers to the therapist's actions to facilitate direct interaction and communication between the partners when one partner was in a state of openness and self-connectedness and the other was nonverbally present and attentive but distant. Encouraging direct interaction challenged the clients to dialogue despite their reticence and ambivalence. Encouraging the couple to interact with one another during Episode # 9 was evident when the husband expressed discomfort with his wife's tears and the wife seemed to hold back self-expression in order to protect her husband. The therapist invited her to come forward and interact with her husband rather than stay away from him. H: Because her crying makes me feel like a shit! (laughing nervously) T: It makes you feel like shit. W: You see! That is why I don't want to...that is why, we talked to and I T: You can say it to him. W: No... I had told him this before because we were talking and. T: Can you say that to him right now? W: What (nervous laugh) Encouraging the couple to interact, particularly when they were in a state of interpersonal distance facilitated initial coming together for the partners. This 162 therapist operation challenged the clients to dialogue despite their restrictive, reticent, and apprehensive interaction. Modelling interaction. As the partners took initial steps to dialogue, their statements were usually short, brief and lacked expansion. The therapist modelled interaction for the couple in various ways. For instance, during Episode # 1, the therapist modelled expression by expanding on an implied message. The therapist expanded the wife's message which expressed a deeper sense of her experience, that is, her lack of trust for her husband. W: I am afraid. T: "I am afraid that you will hurt me." W: Yeah!! I am afraid that you will hurt me, I am afraid that I can't trust you! Linking the couple. Linking the couple was also identified as a salient shifting therapist operation. During Episode # 5, the therapist linked the couple by appealing to the wife's knowledge of her husband and encouraged her support in the difficult task of publicly revealing the contents of his letter. T: What do you thing makes Peter feel so uncomfortable reading this letter, here right now with you, Gina and the bottle? W: (deep sigh) probably fear of us not accepting his feelings or looking down on his feelings. As not being manly... or ...just not giving him credit for his own feelings. T: That would make him feel uncomfortable, reading the letter himself. W: Well he says it out loud, you know he is saying it out loud ..and he doesn't say things (she laughs) So, to say it out loud! 163 Linking the couple was used to assist the partners to express experiences related to the relationship in order to reduce their distance and initiate dialogue between them. Challenging actions and interactions. Challenging client's actions and interactions was another salient shifting category within the client category "couple contacting: restricted and limited." In this category, challenging the couples' actions and interactions was revealed in a manner similar to the earlier one. An example of challenging the client's interactions was evident in Episode # 3. Here, as the wife spontaneously came closer to her husband by paraphrasing what she had understood about his experience in that moment, the husband replied to her in a harsh, frustrating, and aggressive tone. He sounded bothered by her comment. The therapist challenged him as he distanced from his wife through his limited response to her courageous action to come closer to him at that moment. W: That is just how it came across. That is how I heard it I can't. I wish I can remember the words but I can't! That's how I remember how you said it. I was thinking. H: I don't think that is what I meant! T: What did you mean? H: Just that .s s that in order to solve the problem, hers is the bigger problem. Challenging the client's actions and interactions in order to facilitate contact between the partners, and thus increase closeness meant facing the distancing behavior of the client immediately as it occurred. The therapist's tone of voice and posture was caring, gentle, and decisive when challenging. As the clients 164 experienced the challenge, they showed psychological movement and expanded their positions regarding their partner and the statements they were making to each other. The four therapist categories identified and illustrated above were observed as the most powerful and salient in facilitating the synergetic shifting process within the couple contacting phase. Couple contacting involved a shift from no contact to limited contact between the partners. As the couple initiated limited contact, they were faced with powerful and significant blocks. The following major section addresses the third category, "couple working through blocks to intimacy" which emerged from the analysis. Phase Three: Couple Working Through Blocks to Intimacy Working through the couples' blocks to intimacy refers to the actual sharing, disclosing, and telling of tales of abuse, betrayal, abandonment, and rejection that the couple viewed and experienced as blocks hindering the development of intimacy. However, this category not only involved the telling or sharing of these tales but also the revealing and realizing of the impact that these experiences had on their marriage. In addition, working through these tales also refers to the unlocking of deep experiences of abuse and the transformation of these stories into new stories of forgiveness and acceptance. By working through these blocks, the couple removed and released the obstacles which hindered their togetherness. This category was present in all ten episodes of change (see Table 3). The internal structure of the category was similar in all ten episodes in that, the 165 emerging themes as reflected in the subcategories were similar across episodes. However, the conditions under which the category emerged were slightly different in some episodes. In the following section, a description is given of the conditions preceeding the emergence of this category. That is followed by the identification, along with illustrations of the emerging subcategories. Contextual Conditions Related to the Emergence of Phase Three The conditions under which the category working through blocks to intimacy emerged varied among the episodes. Contrary to the first and second categories, where the condition prior to their emergence was characterized as distancing, tense, ambivalent and strained, at both the intrapersonal and interpersonal levels of experience, the conditions for this category reflected openness and trust displayed between the partners. During this phase, the partners exhibited a sense of trust and partnership in their endeavors. They displayed limited distancing actions; rather, they focused on working together and supporting each other in working through their individual and shared relationship blocks. Prior to the emergence of working through blocks to intimacy during Episode # 1, for instance, the relationship was characterized as more open and relaxed. The wife disclosed her need to have her husband closer to her emotionally and the husband, although physically still distant from her (sitting in a distant corner of the therapy room), nonverbally displayed an open and relaxed stance toward his wife.This more relaxed position allowed both partners to 166 disclose and release self imposed assumptions, expectations, and beliefs they had about each other. In Episode # 2, the category working through blocks to intimacy was revealed under two different conditions. The couple expressed tension and stress, but also a willingness to engage and disclose very painful experiences perceived to be blocking their togetherness. Here, the wife brought up a painful and traumatic experience of long-term sexual abuse. However, prior to this, the husband revealed some sexual experiences and practices he had engaged in as a child which his wife believed had affected him. The husband, however, had disregarded these experiences by indicating that, "My attitude towards my sexuality and what happened is a lot different than hers...". Thus, although he disclosed these experiences during the episode, his sharing was hesitant because of his intense discomfort and belief regarding the lack of impact of these events on himself and his relationship to his wife. During Episode # 3, this category was evident once the therapist had done a significant piece of work with the husband regarding his distancing behaviors and lack of involvement during therapy. As a result of this work, the husband was more open, acknowledging and trusting of the therapist and the process of therapy while the wife was in a state of eagerness and relief as she witnessed her husband opening up. Given the openness of the husband, the wife shared more freely regarding her frustration in attempting to engage her husband in dialogue as well as frustration concerning her own restricted pattern 167 of interaction. She showed amazement at this openness by indicating that, "I have learned more about Peter in the last 2 weeks than I have in 10 years". The category couple working through blocks to intimacy was revealed under a condition of tension and apprehension during Episode # 4. The couple was tense and uptight because the husband blamed his wife for failing to deal with her issues regarding the sexual abuse. However, contrary to previous instances of intense blaming on the husband's part, on this occasion the wife did not retreat in fear. Rather, with the support and encouragement of the therapist, she was able to respond and maintain dialogue with him while at the same time she reflected on the many steps she had taken to deal with her sexual abuse issues. During Episode # 5, this category emerged when the husband actually began to read a letter he had written to a lover from a previous relationship. By reading and disclosing the contents of the letter, the husband took a significant risk in exposing secrets regarding a past relationship. Initially, as he read his letter he was reluctant, unwilling, and upset. However, as he continued reading, his tone of voice became softer, more mellow, and gentler. His wife was fully present and supportive as she listened attentively to her husband's new revelations. The couple was working through one of the husband's ghosts blocking their intimacy. This category was again evident in Episode # 6 as the partners were openly and comfortably interacting with one another. The couple actually worked through their sense of lack of trust when the wife, in a comfortable and confident 168 manner, shared her feelings of sadness and disappointment due to the secrets her husband had kept away from her regarding a past relationship. The husband was also comfortable and relaxed as he shared openly his feelings and thoughts regarding his decision to keep the contents of that relationship away from his wife. During Episode # 7, this category was revealed under cirmunstances of stress and tension at the beginning of the episode. Contrary to the circumstances surrounding other categories, the sources of tension and distress emerged from the physical organization and arrangement of the partners and the identified blocks to the couples' intimacy. Thus, a circle was formed by all members of the therapeutic system. The members of the circle were: (1) the husband and wife facing each other; (2) a cushion (their symbol of happiness in the relationship) placed on the floor at equal distance from the partners; (3) the "bastard" (man who sexually abused the wife) represented by a chair and placed to her left side; (4) the "bottle" (symbolizing alcohol) placed on the husband's left side; (5) the wife's ex-husband placed in between the bottle and the chair of the bastard; (6) the "bitch" (the woman that betrayed the husband) placed a bit further back on the husband's right side; and (7) the therapist completed the circle by sitting in between the husband and the wife. The therapist sat a bit closer to the wife. All of the identified obstacles to closeness and intimacy were physically present. During Episode # 8, this category was revealed under conditions of support and openess between the partners. The wife was engaged and ready to 169 let go of the experiences connected with the man that had sexually abused her. Furthermore, she trusted and believed in the benefits of a ceremonial "letting go activity" during the session. The husband, on the other hand, although he had brought into the session a symbol representing the letting go of his relationship with the lover who had betrayed him, he was skeptical about the possibility of being able to let go of such an experience given its closeness and deep connection to him. Thus, while both had specific symbols of their trauma, representing experiences that they needed to let go of, they had contrasting beliefs about the benefits of engaging in a letting-go ceremony. During Episode # 9, this category was revealed under circumstances of distance and pain. The wife had finally opened the gate of tears; she was no longer able to control her tears and pain. The husband, on the other hand, was distant and umcomfortable with his wife's pain. In addition, the husband maintained a safe distance from his wife. The couple shared their experiences of their distancing actions and worked through their distancing block in an awkward and precarious way. The category "working through blocks to intimacy" also emerged during episode # 1 0 , session 8 of couple 2036. The condition under which this category emerged was one in which the husband was present and engaged in the process of therapy but was also nervous and agitated as he spoke in metaphoric terms about his inner experience at that moment. The wife was attentively listening to her husband; however, her physical posture showed fear, disbelief and wonder. The husband had just ended a significant piece of intrapersonal 170 work when the therapist encouraged the couple to connect with each other. As the husband was vulnerable and self-connected, he distanced himself from his wife. He was unwilling to communicate with his wife despite her supportive and warm presence. The therapist encouraged him to engage in a new pattern of interaction by staying present and connected rather than distancing. Explaining Subcategories: Phase Three The subcategories explaining and supporting the category couple working through blocks to intimacy were conceptualized as follows: (1) disclosing, sharing tales of abuse, neglect and betrayal, (2) unlocking blocks/ghosts/demons, (3) transforming stories and metaphors, and (4) letting go of blocks. The following section explains and describes the identified subcategories in detail. In addition, illustrations exemplifying the subcategories are provided. Disclosing, Sharing Tales of Abuse. Betrayal This subcategory refers to the couples's telling, disclosing, and sharing stories which the partners were either slightly aware, noncognizant or unaware. These stories spoke of horrible, painful, and traumatic experiences associated with extensive sexual abuse, abandonment, neglect, betrayal, and rejection as children or adults, suffered by both partners. As well, these stories spoke of the current state in which the couple found itself regarding their present conflictual issues. A clear illustration of sharing and telling stories of neglect was evident during Episode # 9. The couple spontaneously started to tell about their experiences regarding their distancing block as the therapist validated the wife's 171 feelings and hopes to have her husband emotionally closer to her. The following excerpt illustrates the couple engaged in telling stories of neglect and interpersonal distance. W: Oh yeah! he said. So when we were talking about what happened to him when he was young, I think it was the next day after our session, and sometime ago and I said something about and.... I said "why are you pushing me away?" I believed you from the beginning. I never went through denial by not believing you and I tried to stay by you, and you said "you don't matter" because you are an outsider not one of my family. So I don't know I am not to be closer to his life somehow And his Mom probably he hasn't called her lately but she just seems to be pushing him away and worrying about herself. And he continues to let her in. She continues to push him away but he continues., that pisses me off! T: So emotionally... H: I was looking because I have always fought for acceptance. You know my parents and that.. But I am learning now that my Dad is codependent on me trying to live his life over again through me by putting me in sports and everything... the only way I got acceptance is when I did the things he wanted. When I tried to do the things I wanted there was no acceptance, so all my life I have been searching for acceptance. And after I guess, I had this flashback about I found out about the abuse I felt that if they knew what happened you know, and how it screwed me up, then maybe I'll be accepted. But then since then, I learned it doesn't matter what I do; I will never get that acceptance it is just the way it is. So I cut off communication with my family basically trying to get on with ...but it is not easy. T: Yeah and again I hear "for a while I wanted the acceptance of my parents of my Dad, and I was kind of getting closer to them rather than to you Carol and because I have always wanted my parents acceptance, so I was going like this (therapist leans closer to the two chairs that are located to her left side) looking at my parent and then my parents went to me like this like they don't want to and where am I in relationship to my wife and my parents right now?" H: Neither The stories disclosed and shared by the couples consisted of three aspects. First, the stories were told with a deep felt sense of engagement by the partners. Second, these stories concerned untold, secret, or forbidden tales of abuse, pain and betrayal. Third, in tears and deep sorrow, valuable new learnings about 172 each other were attained. The next subcategory was named unlocking blocks/ghosts/demons. Unlocking Blocks/Ghosts/Demons Unlocking blocks, ghosts, and demons refers to the opening up of tightly and firmly locked experiences and thoughts hidden within the self. Unlocking significant experiences which were blocking the partners togetherness involved a joint endeavor with the couple working together. This took the form of mild support from one partner as the other was either unlocking a particularly painful or extremely confusing, shaming, or embarrassing experience. During Episode # 5, for instance, one of the ghosts in the couple's life was a past relationship the husband had prior to meeting his wife. He loved and trusted this woman. However, he felt used, betrayed and abandoned by her. He had been unable to trust or love another woman after this relationship. In fact, he indicated that he still loved this other woman and found it difficult to love and trust his wife because of this past relationship. This was a significant ghost in their marriage. As the therapist invited the wife to comment on her husband's disclosure, she reflected on the newness of the information provided by him. She sounded somewhat distant and unimpressed. T: There is still underlying feelings of love. H: Humm humm T: And betrayal. Did you know about this powerful relationship that your husband had? W: Well.. I knew he had a girlfriend named Gina. He hadn't really expressed how involved he was with her. Like he never expressed to me that he loved her and... and., he never told me he tried to commit suicide because the relationship ended, hummm.... and I didn't realized it was so soon between the end of that relationship and the beginning of ours. 173 This subcategory entailed the uncovering and opening up of tightly locked experiences which were blocking the couple coming closer. In some instances, the blocks were intense feelings such as shame, fear, anger and love while, other instances, the blocks were identified as intense experiences such as abuse, betrayal and pain. Irrespective of the block, the process of unlocking meant trusting, releasing, and opening up to oneself and the other. It also meant the development of a new flexibility and calmness as the blocks were being uncovered and unlocked. Transforming Stories/Metaphors Transforming stories and metaphors was the third subcategory and involved the changing of the nature or form of the client's story or metaphor from self-destructive relational metaphors to those that were need-satisfying and intimacy-building. The transformation of the clients' metaphors occurred spontaneously at an experiential level as they engaged in deep feeling, experiencing, and expressing of the story. The shift in the story was verbalized as it occurred. During Episode # 2, for instance, when the wife was fully engaged in disclosing her story and experiencing feelings associated with the trauma and shame of being sexually abused for many years, the transformation of her tale occurred spontaneously. T: You are feeling your shame right now and that hurts ....When you feel your shame what image comes to you of this shame that you have inside....... what image comes to you? W: Humss hmsss ...something broken!! T: something broken .. a broken glass a broken .... 174 W: Vase or something. T: Vase. W: Vase! T: A vase, a broken vase. W: I don't know? T: That is what comes to you right now. W: (In deep tears) something? Something that was really pretty and it's just broken and T: And that something that is pretty. W: It's my little girl!! T: It's your little girl. W: And she is broken, and no matter how much glue I put on it, it doesn't get fixed, and I try! and I try! and I try! and I try! T: so right now... what do you feel like saying to this little girl? W: Right now? T: Right now ..as you are in touch with this little girl what do you feel like saying to her? W: That you are only a little girl, I have done it all the time, you are only a little girl it wasn't your fault. Letting Go of Blocks The fourth subcategory was named letting go of blocks to intimacy and refers to the actual removing and releasing of experiences that were blocking or inhibiting the likelihood of the partners coming together in a more mutually satisfying and gratifying way. An example of this subcategory emerged during Episode # 7. In fact, the overall theme of this episode was about removing the obstacles to intimacy in their relationship. At the beginning of the episode, the couple was in a state of tension and apprehension with all of their obstacles physically present and located near the partners. The partners then removed the objects that symbolically represented obstacles to intimacy from the therapy room. The following excerpt reveals the process the couple was engaged in. 175 T: You have externalized these obstacles we know who they are, what they have done, we know how they have traumatized you and how they have kept you apart and I don't know what would happen if we were to remove them. And I feel like I want to explore a new sense of being for the two of you, a new sense of being without these obstacles. And I know that this is the one (pointing at the chair of the bastard) that keeps you apart from Peter this one here. W: It holds me back yeah! T: And Peter, what keeps you apart is this guy over here (bastard), that guy over there (wife's first husband), and this woman (the bitch) over there so to try something new I want to invite you to remove this from your space as you are here today, and just leave what you want to leave, just with you what would it be like with this little cushion, the cushion of happiness for the two of you. W: Ok. (Couple starts to remove their obstacles) T: That is Peter's. W: Oh yes sorry. H: I have to remove my own! T: Yes Gina, and the bottle, the bottle. H: the bottle is out there. W: He put it out! Is that one that you want to get rid of that too? H: Yeah we have to get rid of that, it comes between us. Letting go of blocks which the couple viewed as limiting and impeding intimacy between each other involved a process by which the partners discovered and expressed specific aspects of an experience they wished to let go of. This was followed by reflections and considerations regarding the suitability of a "letting go activity" and their perceptions and feelings about it. Finally, the activity was enacted and the partners were invited to reflect on the impact of letting go of the "ghosts" of the past for their present lives in relationship to each other. The subcategory letting go along with the subcategories disclosing, sharing tales of abuse, unlocking blocks to intimacy and transforming stories and 176 metaphors provided an elaboration of the category couple working through blocks to intimacy. In the following, pertinent therapist operations are discussed. Therapist Operations: Phase Three The therapist operations emerging from this client category were similar to the operations revealed in the other two client categories. Similar to those two categories, the therapist operations for this category were organized under the terms of supportive, shifting, and transitional operations. As previously indicated, these operations were identified based on their salience and significance in facilitating synergetic shifting for the couple. In comparing the emergence of the operations within this category and the previous two client categories, the difference was in terms of frequency rather than type. Overall, the therapist operations maintained similar function and quality but occurred considerably less often in this category. This decline in the number of therapist operations seemed to reflect greater openness in the couple to work together without the aid of the therapist. As the couple became more involved with each other, the therapist took a less active role in the therapeutic process. Further comparison of therapist operations within this client category to earlier therapist operations revealed a notable difference regarding the uneven occurrence of supporting and transitional operations. The supporting and transitional operations were considerably less frequent. In fact, only one transitional operation was evident during this category. However, the shifting operations were strongly evident within this category. 177 Supporting Operations Supporting operations were intended to maintain, enhance and foster a collaborative and supportive working relationship among the members of the therapeutic system. The emerging supporting operations were paraphrasing, empathizing, validating, accepting, and normalizing clients' experiences, feelings, and actions. As the therapist employed these operations, she maintained a present-oriented focus by utilizing the word "now," the phrase "at this moment" or by using the present-tense during her statements. Thus, the clients were constantly challenged and encouraged to maintain and stay in the present of their experiences, feelings and actions. An example of accepting the client's experience in the present moment within this category occurred during Episode # 8 and is presented below. Acceptance of the client's experience occurred during the initial moments of engaging in a ceremony of letting go of the couples' blocks to intimacy. The therapist demonstrated full acceptance of the couples' skepticism and doubts regarding their engagement in a letting go ceremony. This acceptance was particularly noticeable when the husband expressed strong skepticism about the helpfulness of engaging in such a ceremony. In the following illustration, acceptance was manifested by expressing and validating the underlying fears and apprehensions of the client and predicting a moment of readiness in the near future. The excerpt also manifests the therapist's validation of the husband's relationship to a ghost from the past, respect for his sense of time and 178 encouragement of the couple to engage in a ceremony at their own pace and within their own level of readiness. T : So right now, as I am aware that time is running very quickly, I want if you are not feeling ready to let go of anything about Gina that is all right. I know there will be a time when you feel ready, and you need to protect yourself and I almost feel like Gina is helping you to protect yourself, and almost as if that is your experience. It's important that you do this at your own pace. H : Hummm humm T : And if you feel like you want to keep these experiences in terms of your relationship with Gina that it's all right. And I want to invite you to have a ceremony right now. A little ceremony of letting go of these experiences that each one of you has and for you to share what it is that you are letting go of. And I wonder what it is that you would like to do in this particular ceremony of letting go? Transitional Operations The transitional operation emerging within the category couple working through blocks to intimacy was named evoking a new state of being. This referred to eliciting through imagination and artistry, a vivid realization of a new state of being in the relationship with each other. This transitional operation was clearly demonstrated during Episode # 7. During this episode, the therapist initiated a transition in the couples' relationship by first eliciting the power and relevance of the relational blocks, and then heightening the presence and potency of these blocks by naming them and pointing out to the couple the actual physical spaces taken by these blocks. Finally, the therapist invoked newness by reflecting on the actual possibility of removing the blocks from their lives and injecting a sense of discovery in the experience. The therapist's intention was to offer the couple a vision of newness, involving intimate contact, in their relationship. 179 T: You have externalized these obstacles we know who they are, what they have done, we know how they have traumatized you and how they have kept you apart. And I don't know what would happen if we were to remove them. And I feel like I want to explore a new sense of being for the two of you. A new sense of being without these obstacles and I know that this is the one (pointing at the chair of the bastard) that keeps you apart from Peter this one here. W: It holds me back yeah. T: and Peter what keeps you apart is this guy over here (bastard), that guy over there (wife's first husband), and this woman (the bitch) over there. So to try something new, I want to invite you to remove this from your space as you are here today and just leave what you want to leave just with you. What would it be like with this little cushion, the cushion of happiness for the two of you. This transitional operation was helpful for the couple because it offered them an opportunity to experience newness with each other. The newness stemmed from the actual removal of the obstacles and the experience of intimate connection without the obstacles. This transitional operation facilitated movement from one phase to another within the episode but also assisted the couple in shifting from a condition of being blocked to another one of being unblocked, opened and vulnerable to one another. Shifting Operations Salient and significant therapist actions in facilitating synergetic shifting within this client category were categorized under five distinct operations. Similar to the previous client categories, these therapist categories were named linking the couple, reifying client's experiences, challenging clients, encouraging interaction and utilizing the client's language and metaphors. Linking the couple. The therapist operation linking the couple, in this client category, closely resembled other instances in the previous client categories in which the therapist 180 joined and created links between the partners in order to foster inter-connection. For example, the therapist linked the couple by focusing on the partners' needs to come closer to each other by connecting deep expressions of emotion of one partner with new actions enacted by the other and by focusing on the couples' commonalities of experience. An example of this therapist operation was evident during Episode # 8 when the husband ended his burning ceremony and reflected on the possible impact of this ritual on his experience of the ghost of the past (his previous relationship).The therapist linked the couple by inviting the husband's reflections on the impact of this ritual on his relationship with his wife. T: How do you think that that would affect your relationship with Joan now that you have more control? H: hmmm I would say there might be a little bit more sharing and intimacy. T: A little more sharing. H: Hummm hummm T: It is important to acknowledge that Gina is still between the two of you though. You haven't let her go completely. She is still a very powerful force in your relationship. Do you want to ask him any questions? Or how do you think your husband is feeling right now? What do you think is going on for him? W: Oh a whole mess of things. The links were encouraged while the partners were in a deep emotional state or when the partners had engaged in new patterns of interaction. Encouraging interaction. Encouraging interaction was also evident within this category, although there was only one instance where this operation emerged as salient. During Episode # 2, the therapist encouraged the wife to interact with her vulnerable, 181 tender part as she became impatient and short with it. The therapist's intention was to generate compassion and understanding toward that new part of self. W: And she is broken and no matter how much glue I put on it, it doesn't get fixed and I try, and I try, and I try, and I try. T: So right now... what do you feel like saying to this little girl? W: Right now? T: Right now ..as you are in touch with this little girl, what do you feel like saying to her? W: That you are only a little girl, I have done it all the time, you are only a little girl it wasn't your fault. Reifying client's experiences. Similar to the other two client categories, reifying client's experiences referred to the creation by the therapist of real, concrete and specific clients' experiences that were abstract and amorphous but significant to the process of healing. Within this client category, reifying the client's experiences occurred during Episode # 2, for example, when the therapist encouraged the partners to generate specific names which symbolized their relationship to the perpretators of the past trauma. T: Yes and if you had a name for that chair that symbolizes for you right now this man. What name comes to you for that chair? W: What name does come to mind? T: Yeah. W: you bastard!! (she laughs) T: So, this is the ghost. There are ghosts in this relationship that you have with each other. The ghosts what I call the ghosts of the abusers in your lives both of your lives that don't let you evolve with each other. That keeps you apart. Keeps you separated. Keeps you unhappy. And keeps you running the whole day in one thing or another and keeps you running to the bottle. The ghosts that are in this relationship are very powerful. The ghost of the abusers. The ghost of the bastard. The ghost of the... What are you going to call your chair? The wound I don't know. What name do you feel like giving that....? H: And ammmmmmmaamam I don't know a name for my abuserrrrr.. the bitch! 182 Challenging clients. Challenging the client's perceptions and actions regarding his/her partner was another salient therapist shifting operation manifested within this client category. Challenging consisted of a gentle but focused therapist verbal statement regarding the actions or perception one partner had concerning the actions, feelings or thoughts of the other. An example of challenging the partners occurred during Episode # 4 in which the therapist challenged the husband regarding his assumptions about change. As the husband blamed the wife for her lack of change regarding her sexually abusive experiences, the therapist challenged the husband and encouraged him to share his approach to healing wounds from the past. In response, he shared his method of healing as one of denial and minimization. T: Maybe you can help her. Maybe you can share with Joan how is it that you let go of some of your painful experiences. H: Humgm basically just to say that it doesn't matter, that is in the past, you can't do anything about it, what happened happened. Challenging client's perceptions and actions regarding their partner was a significant therapist shifting operation when framed in a supportive, gentle but focused tone. The therapist challenged the clients when they discounted, minimized and were punitive to each other's experiences, actions and feelings. Utlizing client's language and metaphor. Utilizing the client's language and metaphors during therapeutic discourse also facilitated the partners' therapeutic process of shifting. When the therapist 183 employed the couple's language, the couple appeared to feel validated and heard. Also, by using the client's language, the therapist joined with the couple and normalized the client's experiences as expressed through their metaphoric language. Utilizing the client's language and metaphors occurred on a number of occasions during Episode # 4, for instance. As the couple was working through the blocks of blame and anger, the wife pointed out to her husband that the unresolved issues she carried regarding the sexual abuse were not only impacting her individually but also her relationship with him. The metaphor she used to describe that experience was "hitting me in the eye." The therapist employed the wife's metaphor as she pondered on the idea that perhaps he was also "hit in the eye." H: That he is causing all these problems. T: That he hits Joan in the eye and also he hits you in the eye. H: Yeah! through that. Through hitting her, he is hitting me back in the eye. I just recently made that connection in the past week. Utilizing the client's metaphorical language in order to validate, accept, support and encourage connection was revealed as significant in facilating the shift from distance to closeness as the couple worked through their blocks to intimacy. Utilizing the clients' language, particularly their metaphorical language was helpful in that it relieved tensions, apprehensions and distrust as the couple worked through difficult and painful experiences. Phase Four: Couple Engaging Compassionately The analysis of the internal structure of the ten change episodes revealed a final category named "couple engaging compassionately." As the partners 184 synergetically shifted from distance and conflict to connection and intimacy, they reached a state of engagement with one another characterized by understanding, compassion, and support. The partners moved through three discrete and concrete subcategories. These were named interacting freely, accepting and supporting each other, and physical expressions of intimacy. These subcategories showed a progressive flow of events within the episodes of change. Couple engaging compassionately refers to the free, warm, respectful, caring, supportive and mutual engagement of the partners with each other. The partners were no longer distant and/or tentative in their connection, rather, they interacted freely, accepted and supported each other and spontaneously expressed their love and compassion. This category was present in all episodes of change (see Table 3). In addition, the internal structure of the category was similar in all ten episodes. That is, all episodes revealed intimate connection of the partners either through acceptance, support, compassion and/or understanding. In addition, the circumstances under which this category emerged were similar, as the couple had worked through significant obstacles in their relationship. The following section elaborates on the circumstances under which the category couple engaging compassionately was revealed. Contextual Condit ions Related to the Emergence of Phase Four In order to more adequately situate this category and its subcategories in the process of synergetic shifting, the contextual conditions preceeding its emergence are presented. Prior to the emergence of this category, the partners 185 were in a state of new intrapersonal and interpersonal discovery. They were in the process of developing a deep emotional connection with each other. This engagement arose spontaneously or out of the therapist's invitation. For example, this category was revealed during Episode # 1 in a couples' context of closeness, support and understanding. Softening of the husband had occurred as a result of being able to listen and hear more clearly the confusing messages given by his wife regarding her wish for closeness and her need for distance as well as her fears and apprehension in coming emotionally closer to him. He was also able to hear more clearly her direct and honest statement and wish to communicate with him when not intoxicated but sober and clean. The husband was also able to share with his wife his need to be heard, supported and accepted. When the partners were able to hear and accept each other, they naturally shifted into a relationship of openness and acceptance. During Episode # 2 this category was facilitated by the use of a therapist transitional operation. A new condition of warmth and openness had been created in the moment of the interactions. The wife had wept while telling and transforming her story of sexual abuse without hearing her husband's comments and perceptions. The husband had witnessed and emotionally participated in the wife's therapeutic process through his presence and close attention to her story. Subsequently, the therapist invited the husband to reflect on his wife's story and share his feelings with her. While engaged in this process, the husband was fully present and attentive to her. 186 The category couple engaging compassionately was also revealed in Episode # 3. In this episode, the couple reflected on the present state of their relationship.The wife was able to see humor in the manner in which she had been trying to engage with her husband, while the husband was fully engaged and emotionally connected to his wife. In fact, a significant shift occurred as the wife saw her way of relating with her husband in an amusing and comical way. During Episode # 4 this category became evident while the partners were deeply connected to their feelings of anger and fear. The partners had just ended an extensive and powerful process in which the husband, on the one hand, was able to fully express and connect with deeply denied and disavowed feelings of anger. The wife, on the other hand, had just witnessed her husband's therapeutic work and felt encouraged to do the same. However, her fear and emotional paralysis resulting from her husband's expression of anger restricted her in accessing her own feelings of anger. Given that both husband and wife were deeply connected to their own inner experience and the experience of their partner, the therapist initiated a transition from a place of emotional connection to one of direct expression of encouragement and support. During Episode # 5 this category was revealed under calm, confusing, and relieving circumstances. The husband had earlier revealed secrets about a past relationship which had significantly affected his relationship to his wife. The husband appeared relieved and calm after this revelation. For the wife however, the discovery of these secrets about her husband was overwhelming and 187 confusing. Despite these circumstances, the wife was able to express compassion for her husband's experience of loss and betrayal. This category was also evident during Episode # 6. Once the wife finished reading her letter written to the "bastard," she felt overwhelmed with intense sadness, hurt, disappointment and shame. She wept deeply and was speechless. The husband, on the other hand, was also speechless and overwhelmed with the new information and awareness about his wife. His nonverbal behavior was warm, open and supportive toward his wife. Under these circumstances, the therapist linked the couple by exploring the wife's hopes for the relationship from her husband. During Episode # 7, this category was evident as the couple faced each other physically without the obstacles impeding intimate contact. The couple removed all their blocks conceived as ghosts from the past but kept the symbol which represented happiness in the marriage. The couple placed the cushion, symbol of happiness, at an equal distance from each other as they sat face to face. The couple was relaxed but uneasy. They felt awkward in this state of intimacy, as they did not know what to say to each other. The removal of the blocks seemed to have generated a temporary sense of emptiness between them. At this point, the therapist noticed and reflected back to them her observations about the husband's new nonverbal behaviors. He was actually playing with the cushion. The therapist also facilitated a transition as she invited the couple to reflect on their feelings and experiences while in contact with each other without their respective ghosts. 188 This category also emerged during Episode # 8. Both husband and wife had just ended a burning ceremony where they had let go of powerful obstacles to their affiliation as a couple. The husband experienced a sense of empowerment as he verbally reflected on his new realization that he could actually control the impact of past trauma on his life. The wife felt a sense of relief when she was able to let go of some of her shame and frustrations associated with her traumas and difficulties. The partners were in a personal state of calmness and ease and the tension in the relationship was gone. During Episode # 9, this category was revealed when the therapist initiated a transition. The husband was able to acknowledge his shortcomings regarding his expressions of support and understanding toward his wife and was able to actually come closer to her by spontaneously expressing affection. The wife, on the other hand, was unable to stop her tears. The therapist facilitated the couple coming closer to each other by normalizing and validating the couple's experience at that moment. She normalized the wife's pain and tears, validated the husband's lack of knowledge and awareness of how to be supportive and understanding and validated awareness of their perceived shortcomings. During Episode # 10 this category was revealed while the couple was in a state of tentative closeness. The husband appeared emotionally exhausted but present while the wife was attentive, present and shared her experiences freely. This category emerged out of the spontaneous reflections of the wife regarding her actions and intentions to support her husband as he worked through intense and painful emotional issues. 189 As is evident from the above discussion, the category couple engaging compassionately along with its explaining and supporting subcategories was developed within the therapeutic process of the episodes. The following section addresses and illustrates the salient and significant subcategories which emerged in the category. Explaining Subcategories: Phase Four The subcategories explaining and supporting the category couple engaging compassionately were conceptualized as follows: (1) interacting freely, (2) accepting and supporting, and (3) physical expressions of intimacy. What follows is an explanation along with detailed illustrations exemplifying the identified subcategories. Interacting Freely The subcategory "interacting freely" refers to the carefree, easy-flowing and relaxed interactions engaged in by the partners. These interactions occurred between the partners or were present in the relationship with the therapist as reflections of a new state of being. The partners were no longer holding back from each other. Free and easy interactions between the partners occurred during Episode # 6 when the wife wept deeply and her husband was fully present. As the wife finished reading her letter to the "bastard," she displayed intense emotional pain by weeping and sobbing. Her husband was fully present and attentive but unable to act or respond to her pain. The therapist facilitated therapeutic shifting in the interactive patterns of the couple. The partners interacted in a calm, easy, and 190 supportive manner with each other and the husband was supportive, understanding, and empathic with his wife. T: What would you like from Peter right now Silence She is crying. W: Just that he understands. T: You want his understanding? W: Yup! huggggm humm, humm. H: I still love you. It doesn't make any difference. I understand more now why it has affected you so much because you not only went through once. You went through and you went back for more and back and back and back! And not just as a little girl but as a woman as well. W: Because the little girl never grew up. H: Yeah you respected the little girl from what he had done to you ...I didn't know what happened I figured you know it happened when you were a little girl and that was it! huuug. That is what I understood but..a... now I understand a lots more but as I said, it doesn't make any difference. I still love you. I love you for you, the person that I met at Andrew's until now you know. W: And that person was there to get some pot and get through an abortion. H: And get through an abortion yeah.. We all make choices. Things happen but I love you for you. W: I am still trying to put the person that you think I am and that person back together again you know. Accepting, Supporting The subcategory "accepting and supporting each other" pertained to the actual expressions of support, understanding, validation and acceptance conveyed by the partners. These expressions were evident when the partners were either in a state of personal vulnerability or when one of the partners had engaged in a significant piece of therapeutic work. During Episode # 10, for instance, as the husband had ended a significant piece of therapeutic work related to searching and connecting with "demons" inside himself, the therapist explored the wife's experience given her role as a silent witness to her husband's process. Accepting and supporting of each other was revealed in a loving, 191 gentle, and soothing tone as the wife described her own actions to support her husband in the moment. The following excerpt demonstrates the wife's support and acceptance of her husband's experience. W: I just looked at the floor so he would think that I was not paying attention and then he would. T: And you were successful, so that was your way of supporting Walter today. W: Yeah I just H: I appreciate that! W: Because I know he feels self-conscious if too many people are looking at him. T: Walter said I appreciate that to you now. How did that make you feel? W: How did that make me feel? T: Yes. W: Good! I don't know the word for it really. The subcategory "accepting and supporting each other" entailed a deep sense of understanding, love, appreciation, and compassion. The partners were able to express support and acceptance once a significant and emotionally powerful piece of therapeutic work had ended. Nonverbally and verbally the partners expressed compassion and love toward each other. Physical Expressions of Intimacy Another form in which the couple engaged compassionately with each other was through actual expressions of physical intimacy. These expressions of intimacy conveyed a respectful, gentle, considerate and loving message. The couple engaged with each other with fondness and thoughtfulness during moments of deep vulnerability and emotional openness. This subcategory was evident during Episode # 9, for instance, as the husband expressed physically his support and understanding of his wife by indicating his wish to hold her hand. This was an expression of remarkable 192 shifting on the husband's part as he was unaccustomed to expressing love publicly and nonsexually. His intimate expression of love was genuine, tender, and caring. T: Yeah right off the top of your head in relationship to Carol, I am aware that it feels embarrassing and I am glad that you shared that feeling of embarrassment. "I don't know what to do Carol." "With your tears." And I hear you saying to me Carol, you don't know what to do with your tears also. And I am saying to you, and we are celebrating your tears, and it feels strange but I feel like you are celebrating pain right now, celebrating,.acknowledging pain in a different way than what we celebrated and acknowledged last week in our first session. And so again I wonder. What would you like to do? H: Hold her hand so she knows I don't care. T: Hold her hand so she knows you don't care. H: Yeah! so about her crying or not. (He holds her hand) T: So I noticed that Walter is appreciating you right now. H: Nice spilling your guts. W: I am an emotional person anyways I cry lots. The subcategory "physical expression of intimacy" reflected actual manifestations of love, compassion and understanding in a novel and tender manner by the couple. This usually occurred once the partners had engaged in a significant piece of therapeutic work and were emotionally connected. The physical expressions of love were genuine, real and appropriate to the unfolding of events within the episodes. Therapist Operations: Phase Four The therapist actions evident in this category consisted of supporting and transitional operations. Contrary to the previous client categories where the therapist was actively involved and engaged in facilitating the shifting process, during this category, the therapist operations were minimal. In fact, during some 193 episodes the therapist intervened only through minimal prompting. The partners engaged intimately with one another and required limited assistance from the therapist. As such, shifting operations were absent from this category. Transitional operations, however, were salient in facilitating movement from the category "couple working through blocks to intimacy" to the category "couple engaging compassionately with each other." Supporting Operations The number of supporting operations employed by the therapist during this category were relatively small in comparison to the previous client categories. The therapist utilized prompting, empathy, validation and support of the client's experiences, feeling, and actions infrequently. Also, the type and quality of these operations closely resembled the supporting operations utilized during the client categories mentioned above. Consequently, illustrations exemplifying these operations are omitted here. Instead, the transitional operations are discussed and illustrated given their salience within this category. Transitional Operations Transitional operations consisted of therapist actions intended to facilitate movement from one client category to the next. Within the context of the present category, the transitional operations facilitated synergetic shifting from the category "couple working through blocks to intimacy" to the category "couple engaging compassionately." Transitional operations were employed by the therapist when the couple was in a state of readiness to move into the next phase within the episode. That is, the couple had ended a significant piece of 194 therapeutic work and needed to move toward new patterns of relational interaction. This state of readiness was manifested by a personal openness and vulnerability along with a new understanding of the dynamics of the problem. The transitional operations that the therapist employed were termed (1) bridging the couple and (2) encouraging spontaneous expressions of support. Bridging the couple. The therapist operation bridging the couple was revealed in a number of episodes within the client category couple engaging compassionately. Bridging the couple refers to creating solid links of intimacy between the partners. The therapist focused on forming connections between the partners by focusing on new actions, experiences, feelings or states of the partners. This was accomplished as she invited the partners to be more affiliative and spontaneous in their actions and interactions with each other. During Episode # 7, the transition from the previous category took the form of the therapist bridging the couple's dynamics by noticing and reflecting on the husband's new nonverbal behaviors. As the husband spontaneously played with the couples' symbol of happiness in a relaxed and comfortable manner, the therapist reflected on his new action and the absence of the obstacles to their intimacy. The therapist focused their attention on his playfulness and their sense of togetherness without their obstacles. T: Yeah well, I noticed when I was closing the door you went right in there, to hug the cushion of happiness with your feet. H: Humm humm. T: It is symbolic of something. I wonder as you are with one another right now. What does it feel like to be with one another without the ghosts? 195 Encouraging spontaneous expressions of support. Another transitional operation manifested within the category couple engaging compassionately was termed encouraging spontaneous expressions of support. This therapist category consisted of interactions intended to facilitate spontaneous expressions of support, understanding, and love between the partners. These expressions referred to actions rather than verbal exchanges of support. During Episode # 2 for instance, as the partners were deeply engaged verbally, the therapist invited them to take some action based on their feelings experienced at that moment. T: What do you feel like doing right now, right this minute? H: I can give her a hug if that would help. T: Do you feel like giving her a hug right now? H: Sure yeah. T: Ok, maybe you can ask her if she wants a hug from you. Within the same episode, given the extensive and genuine expression of love, understanding and support displayed by the husband, the therapist also encouraged the wife to take action by offering support to her husband. T: I wonder whether you feel like giving Peter a hug. The therapist's category encouraging spontaneous expressions of support was evident only during Episode # 2. Nevertheless, it was an important operation in that the therapist encouraged the expression of action within the context of newness experienced and manifested by the couple. The therapist's operations emerging from the client category "couple engaging compassionately" were less frequent in comparison to the other client 196 categories. The partners were in a new state of openness, engagement, and trust. They no longer required the therapist as a facilitator of their process. Rather, they were able to freely and spontaneously engage with each other as deep compassion, understanding and support were incorporated into their interactions. Summary This chapter presented the results of the qualitative observational analysis of the ten episodes of change. The grounded theory analysis provided a conceptual description of the internal structure of the episodes, and thus, answered the major research questions outlined in chapter one. In the following chapter, the findings generated by this investigation are discussed. 197 CHAPTER VI DISCUSSION This chapter discusses the major findings of this investigation. First, conclusions related to the research questions are explored. Second, theoretical and practical implications of the study's results are addressed. Third, links between this investigation's findings and the current knowledge base regarding the change process in marital therapy are discussed. This is followed by a discussion of methodological issues and limitations of the study. Finally, recommendations for future research are suggested. Findings Related to the Research Questions This naturalistic multiple-case-embedded study explored four research questions related to the process of change of three couples treated for alcohol misuse with Experiential Systemic Therapy (ExST). The first research question sought to discover the presence of observable, identifiable and recurrent in-session change episodes in the three couples treated with ExST. The next three questions sought to describe, understand and explain the therapeutic dynamics in the change episodes. These three interrelated questions were intended to produce a description and explanation of the observable and identifiable change episodes, a conceptual model outlining the clients' process of change and a model representing the manner in which change occurred. The grounded theory method of analysis "answered" these three interrelated questions. 198 Overview of the Findings Related to the Research Questions This study found the process research perspective suggested by Rice and Greenberg (1984) useful for the investigation of the process of change in marital ExST. Specifically, the methodological, discovery-oriented perspective and the conceptual focus on change process research facilitated discernment and understanding of how change occurs in ExST marital therapy. As such, this study explored, discovered and identified observable in-session change episodes from three couples treated with ExST. The discovery-oriented, observational analysis of 40 marital ExST sessions yielded ten episodes of change. The selected change episodes consisted of a conflictual marital condition, an ongoing dialogue among the participants which addressed the conflict, and a satisfactory resolution to the conflict. As well, the selected episodes were clearly identifiable in that they were demarcated as separate and distinct chunks embedded within the overall context of the therapy process. Also, the recurrent nature of the episodes was demonstrated by their repetition. In other words, the conflictual condition, the addressing of the conflict by the participants, and the attainment of a resolution were sequentially replicated in all selected episodes. Episode Completion Although the three cases received similar treatment from the same therapist, the analysis showed differences in terms of the therapy process. One important difference referred to the presence of complete and incomplete episodes of change. A complete episode fully satisfied the criteria for episode selection outlined 199 in chapter three. Incomplete episodes showed a clear conflictual marker and an ongoing dialogue among the participants intended to address and resolve the marker. However, no resolution was achieved. Rather, the clients deviated into other tangential and conflictual issues. A similar finding was reported in Wark's (1994) study of the process of marital therapy change. Wark (1994) identified a category entitled "no resolution to problems" as a critical negative incident from the perspective of the couples. In this investigation, Couple 2080, the minimal improver case, displayed an innumerable number of incomplete episodes and no complete episodes. Couple 2036, the medium improver case showed 14 incomplete episodes and only two complete episodes. Couple 2010, the high improver case, on the other hand, showed only three incomplete and eight complete episodes. A possible client factor that may explain some of these divergent findings concerns the clients' readiness to engage in therapy. Wark (1994) identified clients' readiness for change as a critical incident in effecting change for couples. In this study, the three couples seemed to have been at different stages of readiness or preparedness to engage in psychotherapy. Although the three couples displayed considerable distancing, detachment and alienation from each other at the beginning of therapy, their level of commitment and willingness to delve into and work through their conflicts varied across the cases. Couple # 2010, for instance, showed a high level of readiness to embark on the difficult task of working through issues. The couple was prompt and ready to start its sessions, the spouses completed homework assignments to the best of their ability, and they attended all the sessions. Couple # 2080, on the other hand, displayed limited readiness to 200 work on the presenting problems, homework assignments were not completed, and they regularly canceled sessions due to other commitments. The partners maintained system equilibrium from the beginning to the end of therapy (wife's decision to separate from her husband and husband's determination to keep his wife in the marriage). The therapeutic work of couple # 2036 revealed considerable attention to the husband's urgent need to focus on trauma resulting from experiences of sexual abuse and failed to provide equal attention to the wife's needs. The couple was severely entrenched in its belief that the major source of their marital conflicts was the husband's unresolved sexual abuse issues. In addition, the couple missed five sessions and failed to follow through with assignments. Couples' differences were also noted in their level of knowledge of the therapy process. Couple # 2010, for instance, had some knowledge and awareness of the activities and process of therapy in general. Couples # 2080 and # 2036, on the other hand, lacked a basic knowledge of therapy and seemed unsophisticated regarding how to interact or engage in a therapeutic context. This was particularly evident with the husbands of couples # 2036 and # 2080. As an example, couple 2080's husband insisted that the therapist was in a position to verbally force his wife to return to the marriage. His therapy attendance appeared related to his expectation that the therapist would satisfy this request. Likewise, the husband of couple 2036 demanded from the therapist an instant "cure" to the trauma and suffering arising from childhood sexual abusive experiences. Thus, both clients expected and insisted that the therapist take the role of expert rather than 201 collaborator in the therapy process. This demand was contrary to the practice of ExST and the ethics of the therapist. Proximal Versus Large "O" Outcome An important finding of this investigation was the discovery of a significant number of change episodes in the high improver case, while the minimal improver case revealed no episodes. These selected episodes of change represented immediate or proximal outcomes. Greenberg (1986) made a distinction between proximal or immediate outcome and large "O" or final outcome. Proximal outcomes refer to in-session and immediate change resulting from specific interventions and overall interactions of the participants that appear directly related to session content. Large "O" or final outcomes refer to ultimate change evaluated at the end of therapy or at follow-up. Final outcome may be related to the culmination of immediate and intermediate changes over the course of therapy. Following this line of reasoning, the number of immediate change episodes emerging from the analysis contributed to the final outcome. However, this interesting observation was not of central concern to this investigation. This study focused on an understanding of how change occurs in marital ExST by exploring the presence of observable immediate outcomes in the form of change episodes and by describing and explaining how change occurred during those episodes. The grounded theory analysis often change episodes, eight from the high improver case and two from the medium improver case, "answered" the next three interrelated research questions, namely, (1) the provision of a description of how change occurred in the change episodes; (2) the identification of the client actions 202 and interactions that facilitated change; and (3) the identification of the therapist operations that facilitated change for the couples. The core of this research endeavor resulted in the generation of a model of change entitled synergetic shifting. The following section discusses the theoretical and practical implications of the research findings for marital ExST. Implications of the Study The conceptual model describing how the couples, with the assistance of the therapist, changed have implications for the theory and clinical practice of ExST. This section discusses the process by which synergetic shifting occurred and the operations facilitating and contributing to its realization with particular consideration to how the current findings expand, support and challenge the notions of change advanced by marital ExST. Theoretical Implications for ExST The conceptual model of marital change that resulted from the analysis of the ten episodes of change of marital ExST significantly expanded the theoretical notions of change as theorized by the developers of ExST. Indeed, the findings of the study provide an actual framework of how change occurs in marital ExST. In addition, the resulting model linked the therapist's interventions to the couples' change process as change naturally occurred in marital therapy. As an integrative form of psychotherapy, ExST draws from the Interpersonal Theory of H. S. Sullivan (1953), Object Relations Theory of J. Bowlby (1988) and structure determinism (Maturana, 1978). As such, ExST's understanding of human experience is based on a relational paradigm and therefore, psychotherapeutic 203 change is also viewed relationally. The term coined by ExST to explain psychotherapeutic change is relational novelty (Friesen et al., 1989). Accordingly, relational novelty refers to the experiencing of new and alternative ways of being in relationship by altering rigid and recursive patterns of behavior as expressed through emotional, cognitive, behavioral and physiological processes. Embedded in these intrapersonal and interpersonal interactive patterns are themes like rejection, abandonment, unworthiness and unlovableness when relationships are in conflict. ExST theorized that by experiencing deeply new alternative patterns of relationship growing out of the convergence of the physical, emotional, cognitive and behavioral aspects of experience, the rigid and recursive intrapersonal and interpersonal patterns are transformed and clients become liberated from these rigid ways of being. This investigation generated the concept "synergetic shifting" to describe and explain the manner in which change actually occurred in marital ExST. Briefly, synergetic shifting referred to an interactional process where the partners, with the assistance of the therapist, moved away from a relationally rigid, distancing, and alienating stance toward interpersonal flexibility, caring, compassion, and affiliation by working through blocks hindering the partners engagement and intimate connection. In addition, the conceptual model delineated the process by which the partners moved from distance and rigidity toward harmony and flexibility. As such, the partners shifted through four action-oriented phases. These phases were named (1) owning one's part in the relational conflict (distancing, reflecting, expressing, acknowledging); (2) couple contacting: restricted (distancing in contact, 204 accusing, blaming, contacting); (3) couple working through blocks to intimacy (disclosing, unlocking, transforming, letting go of blocks); and (4) couple engaging compassionately (interacting, accepting, expressing intimacy). The process of change identified here expanded the concept "relational novelty" by actually describing what occurs as the partners moved from distance to intimacy. The model generated by this analysis expanded the conceptual notions of change through the identification of properties such as process, progression and action orientation. First, therapeutic change emerged as a dynamic, fluid and evolving process rather than as an instantaneous, ephemeral and brief event. Conceptualized as a process, synergetic shifting also refers to actions and interactions occurring over time, or as a temporal becoming in relationship. This process entailed movement over time through four distinct phases of actions and interactions of the couples. Each of these phases evolved through time with a distinct set of actions and interactions on the part of the clients and the therapist. This suggests that therapeutic change may be a spiral process consisting of distinct layers, or phases each interconnected through the actions and interactions of both the clients and the therapist. On the other hand, it may be that the manner in which the episodes of change were operationally defined (a conflictual relational marker, the ongoing client and therapist actions and interactions, and the resulting resolution to the original conflict) may have confirmed the resulting discoveries. Namely, episodes of change were defined as a process and the resulting model also evolved as a process. 205 Another contribution to ExST's conceptualization of change concerns the focus of change within the episodes. In effecting change, the actions and interactions of the participants progressed from an intrapersonal/ individual to an interpersonal/relational focus. That is, the first phase in the model consisted of an individual/intrapersonal process of "owning one's part in the relational conflict" in which the partners separately identified, worked and owned intrapersonal issues that negatively impinged on the relationship. Once the partners were able to own their part in the conflict, a shift toward the relational/ interpersonal realm occurred through a "coupling" working through and coming together of the partners. The partners focused directly on the couples' issues. This was manifested in the phases identified as: "couple" contacting: restricted, "couple" working through and "couple" engaging. The findings from the present study support the theoretical notion of relational novelty in several ways. The points of concordance center on the newness experienced by the couple as they shifted their interaction pattern from a position of rigidity in their distancing and alienating stance to a place of harmony, affiliation and togetherness. The partners' convergence of cognitions, emotions and behaviors shifted intrapersonally and interpersonally as they worked through blocks such as abuse, abandonment, rejection and unlovableness which inhibited intimacy and connection. As the partners worked through these blocks by disclosing and sharing untold stories of abuse, neglect and betrayal, opening up tightly locked experiences of abandonment and abuse, transforming these experiences, and letting go, deep experiencing occurred through the convergence of genuinely felt 206 emotions, bodily sensations, thoughts and actions. The sharing, unlocking, transforming and letting go of blocks to intimacy significantly facilitated the partners intimate engagement. As such, two important notions of the concept of change in ExST were supported by the present study's findings, namely, the importance of experiencing (convergence of emotions, thoughts, behaviors and sensations) in facilitating change, and the importance of working through intrapersonal themes such as abandonment, neglect, abuse, and betrayal which limited the partners flexibility and intimate connection. Although the present study supports the idea that change occurs through the experiencing of novel ways of being around conflictual relational themes, this study also found that other change processes were equally important. For instance, cognitive shifting appeared to have been the central focus during the first phase of change where the partners individually owned their part in the relational conflict. In fact, the predominant shift for husbands and wives consisted of a new realization, a new awareness, an insight or new knowledge about behaviors, feelings, patterns and/or experiences related to the self. Another unaddressed issue regarding marital change from the perspective of ExST concerned the couples' contact and communication. It was revealed during this analysis that in order for couples to delve into deeply uncharted experiences and work through relational themes blocking intimacy, direct contact and communication between the partners was necessary. In fact, the couples were extremely far apart from each other, displayed significant lack of trust and were unable to maintain interaction during the early part of each episode. The therapist 207 was required to take an active role in modeling, challenging and facilitating basic communication between the partners so that self-disclosure and openness gradually encouraged trust. Couples' communication and intrapersonal cognitive shifts are important aspects of the change process in marital therapy and may need to be evaluated as possible aspects of the conceptualization of change in ExST. Synergetic shifting encompassed not only the partners' actions and interactions but also the therapist's operations. These therapist's operations (supportive, shifting and transitional) were paramount in facilitating synergetic shifting. These operations are discussed next. Clinical Implications The couples' shifting away from distance, alienation and rigid relational ways toward closeness, harmony and intimacy appeared to have been facilitated through therapist's operations referred to as supporting, shifting and transitional. The supportive and shifting operations lend support to the clinical tenets and practice of ExST. The discovery of transitional operations, as important therapeutic operations, may contribute to the clinical practice of marital ExST. According to ExST, relational novelty is facilitated through the intensification or deepening of client experiences. Intensification and enhancement of feelings, thoughts, perceptions, behaviors and relational patterns increases awareness of recursivity and rigidity, adds new experiences to the client's awareness, and provides and opportunity for personal integration (Friesen et al., 1989). Intensification of experience is achieved through the use of metaphorical and pictorial language, the repetition of words or actions, the identification of underlying 208 emotions, the use of symbols, and the generation and maintenance of a collaborative therapeutic relationship (Friesen et al., 1989). These activities speak of therapist actions and interactions required to facilitate intensification of experiences and foster the generation of relational novelty. As indicated earlier, the findings from this study suggest that the therapist's actions and interactions encompassed under the supporting and shifting operations closely resembled the clinical tenets of ExST. The findings from this study support the idea that the identification and enhancement of underlying emotions and experiences, thoughts and relational patterns may encourage the generation of newness and facilitate shifts for clients. However, this study also discovered that in order to deeply intensify clients' experiences, the supporting operations may be important in preparing the ground for intensification. Supporting operations maintained the therapeutic working relationship, enhanced a collaborative therapeutic atmosphere and fostered acceptance, hope, encouragement, safety and trust. The most salient supporting operations were identified as empathy, normalization, validation and acceptance of clients experiences and feelings. According to ExST, one of the foundations to its treatment approach is the notion of collaboration. Collaboration refers to a joint venture in which the therapist is an integral part of the therapeutic system rather than a distant observer. In addition, the therapist is aware that clients behave and relate according to their experiences. As such, "a posture of respect for what clients bring to the therapy is maintained, no matter what the clients present." (Friesen et al., 1989, p. 72). Furthermore, ExST postulates that in order to maintain a collaborative stance so 209 that the therapeutic system functions and the therapeutic goals are achieved, the establishment of safety, commitment, hope and trust through validation, normalization, acceptance, and empathy is essential and integral to the therapeutic process. The findings from this study clearly support the notions of collaboration, safety, support and trust. Also, the findings suggest that without a collaborative and supportive atmosphere, the implementation of shifting operations necessary for deepening of experiences may not have been realized. In fact, salient shifting operations defined as actions and interactions intended to facilitate a significant shift in the client's emotional, cognitive and behavioral realm of experience were also congruent with the ExST's notion of therapeutic intensification of experience. Shifting operations such as reifying clients' experiences, linking the couple, utilizing client's language and metaphors, and challenging clients' actions facilitated the intensification of clients' experiences. The findings from this study suggest that the identification of underlying emotions such as fear, sadness and emotional pain were useful for clients' connection with blocked parts of self and the deepening and owning of disavowed and powerful experiences of emptiness, betrayal, emotional abuse, sexual abuse, abandonment, rejection and neglect. The intensification of clients' experiences was also realized through the utilization of clients' language and metaphors. Within this context, clients' metaphorical language refers to the communication of something that represented for something else. The clients felt accepted, were challenged, shifted their positions and reached new and deeper levels of intrapersonal and interpersonal 210 connection when the therapist judiciously utilized their metaphors and language. For instance, spontaneously generated client metaphors such as wounds, scars, poking in the eye, demons, ghosts, bastard, bitch were purposely utilized by the therapist because of the powerful, significant and intrinsic meaning the metaphor held for the clients. Utilizing the client's language and metaphors appeared to have not only intensified the experience but also as the clients lived and re-experienced the event through the metaphor, a new quality or frame seemed to have been added to that experience. Utilizing the clients' metaphorical language occurred naturally, spontaneously and was non-invasive. During the intensification of powerful experiences, the therapist heard, validated, expanded, involved the other partner, played with possibilities of association and marked the metaphor (Sims & Whynot; 1997). This process was different from inviting the clients, through probing or questions, to generate their own metaphors regarding problems, conflicts or different contextual situations (Combs & Freedman, 1990). Client's intensification of experience appeared to have also been manifested through the generation and use of client's symbols. Symbols are discrete things that crystallize and facilitate powerful associations (Combs and Freedman, 1990). The employment and creation of symbols such as drawings, wedding photographs, pictures, chairs, bottles, wedding ring, flowers, teddy bears and cushions may be invaluable in accepting, normalizing and enlightening the clients' process. Working with symbols seems to add significant richness of meaning and to assist in the expansion of experience regarding the clients' conflicts. As well, the use of clients' 211 symbols facilitated clients' movement into a deeper level of experience by releasing rigidity and shifting perceptions about the self and the partner. This study also found support for the ExST notion of a "here and now" focus. In fact, throughout the episodes, the therapist maintained a present focus by either employing the words "now,"" at this moment" or "right now" or by using a present-tense structure which encouraged the partners to stay focused on the present of their actions and interactions. Staying in the present proved useful for the intensification of feelings and experiences in that it seemed to have encouraged the clients to stay focused in the moment of the experience and the current context of the therapy. It also appeared to have detracted the clients from shifting into story telling or "talking about" experiences from the past. Transitional Operations This study also may also contribute to an understanding of how change occurs in ExST by discovering a distinct type of therapist's operation named transitional. Throughout the actions and interactions of the clients, the therapist monitored the state of client readiness to move to a deeper and more meaningful level of interaction. For instance, once the partners moved to a new level of understanding, as reflected in the shifting displayed from phase one "owning one's part in the relational conflict" to phase two "couple engaging in a restricted and limited manner," the therapist encouraged and facilitated a transition from no contact to contact. Likewise, as the therapist detected a state of emotional openness, tenderness and support between the phase three "couple working through blocks to intimacy" and phase four "couple engaging compassionately", she 212 encouraged the partners to express that support directly to one another. Thus, it may be helpful for therapists working from the ExST perspective to be alert to states of readiness manifested either by the generation of a new perspective or new understanding, or by the generation of a new sense of emotional openness as these transitional operations (bridging the couple, encouraging direct interaction) may facilitate movement and connection for the partners. Links between Clients' and Therapist's Actions and Interactions An important contribution of this study to marital ExST is an understanding of the possible links generated between the couples' and the therapist's actions and interactions. Indeed, discovering how the therapist's and clients' actions and interactions intertwined as the couple shifted from distance and alienation to togetherness and affiliation may be a valuable finding. For instance, it was noted that the therapist's operations may vary according to the phase of the change process. During the phase "owning one's part in the relational conflict," for example, the prevalent therapist shifting operations were: utilizing client's language and metaphors, linking the couple, encouraging-self focus and self-connection, and reifying clients' experiences. Likewise, in the third phase, "working through blocks to intimacy," similar operations were revealed as prominent. The nature of the therapist shifting operations appeared to be similar during both phases in that, both categories concerned an actual working through of the couples' conflictual issues and blocks hindering their desired goals. However, a noted difference seemed apparent in the intrapersonal focus of the working through during "owning one's part in the relational conflict" and the interpersonal nature of the working through 213 during the "working through blocks to intimacy." Thus, although the focus of the two phases noted above centered on either an intrapersonal or interpersonal "working through," the therapist's shifting operations utilized seemed similar. Also, the therapist shifting operations emerging from the second phase "couple contacting: restricted and limited" seemed to closely correspond to the client events occurring during that phase. As the partners attempted contact and interaction with each other but used a distancing, accusing, blaming and limiting stance, the therapist modeled, challenged and encouraged interactions. Frequency of Therapist's Operations This study found that the frequency of the various therapist's operations varied throughout the episodes in accordance with the clients' psychotherapeutic process. However, the supporting operations (empathy, normalizing, validating, encouraging, naming, and supporting clients' experiences) which appeared to have fostered a collaborative and working relationship seemed more or less evenly distributed in every phase of synergetic shifting. Nevertheless, a small difference was revealed during the first and last phases. During the first phase, "owning one's part in the relational conflict," the supporting categories occurred more frequently. A plausible explanation is that the first phase of the episodes demanded constant support and validation as the partners were engaged in the initial phase of the therapeutic process and were faced with intense conflictual relational issues. During the last phase, "couple engaging compassionately," on the other hand, the supporting categories occurred slightly less frequently due to the couples' 214 willingness to rely on each other's support. The therapist facilitation seemed no longer necessary. Integration of Findings to the Literature on Marital Change This section integrates the findings from this study with the current knowledge base in the research literature of marital therapy process research as outlined in the review of the literature. Commonalties and differences between this study's findings and the literature on the change process in marital therapy are integrated. Basically, the aim, focus and findings of this study addressed how change occurs in marital therapy. As such, the following section undertakes a synthesis of the points at which these findings and the current literature on marital therapy converge. Shifting Several researchers have recently referred to the process of change in marital and family therapy as shifts occurring among members of the family or marital dyad. Shifts from conflictual relational patterns to intimacy and engagement (Heatherington & Friedlander, 1990; Friedlander et al., 1994), shifts from distance to hope (Coulehan et al., 1998), and shifts in various domains of experience (Christensen, 1998) have been identified. This study underscores the importance of and supports the nature of marital change as shifting from rigid, distancing and alienating relational patterns to interpersonal flexibility, compassion and intimacy. The change process in clinically significant moments of parent-child interactions from a Structural Family Therapy perspective (Heatherington & Friedlander, 1990) revealed a shift from a pursue-distant interactional pattern to a 215 commitment to engage on the part of the distancer. Likewise, the present study noted that when the partners were in an initial state of distance, alienation and rigidity, they gradually shifted into tentative and limited contact with each other. A similar pattern was reported by Friedlander et al. (1994) in a successful case of Structural Family Therapy. In this study, family members moved from disengagement to sustained engagement while resolving a relational task. Shifting in successful sessions of Constructivist Family Therapy was also observed by Coulehan et al. (1998). These authors noted that, as family members expressed their individual needs, their affective responses shifted and hope was acknowledged. Conceptualizing change as a shifting process from distance and alienation to intimacy, hope and harmony is congruent with recent findings from the theoretical perspectives of Structural, Constructivist and Experiential Systemic Therapy. In addition, this study's finding regarding the conceptualization of marital shifting in various domains (emotion, cognition and behavior) of experience is congruent with Christensen et al.'s (1998) conclusions regarding the process of change in marital therapy. Christensen et al., (1998) identified three clusters of change based on clients' perceptions. The authors concluded that shifts occur in couples' affect, cognition and communication style. In fact, the present study demonstrated that clients shifted their feelings and thoughts during the first phase of synergetic shifting, i.e., "owning one's part in the relational conflict." As well, the most potent and significant shift occurred during the phase in which the couples worked through blocks hindering their intimate connection by accessing and shifting 216 the emotional, cognitive and behavioral realms of the experiences. This investigation also showed that clients shifted in their communication pattern from no contact to limited contact during the second phase of this study's model, "couple contacting: restricted and limited." A shift in communicative style also occurred during the last phase of synergetic shifting as the partners actually interacted in a calm, supportive, relaxed and compassionate manner. The conceptualization of marital change as a shifting process from a distant and alienating stance toward intimate and compassionate engagement consisting of shifts in the cognitive, emotional, and behavioral domains of experience reported in this study, is congruent with recent research conclusions on the process of change in marital and family therapy. Indeed, various researchers (Coulehan etal., 1998; Friedlander et al., 1994; Greenberg et al., 1988; Wark, 1994) have reported change within these domains of experience in marital change process research. The following section identifies the manner in which marital change in these three domains of experience has evolved. Emotional Domain Change within the emotional domain of experience was evident throughout the process of synergetic shifting. For instance, during "owning one's part in the relational conflict," the partners experienced, expressed, revealed, shared and felt profound feelings associated with conflictual aspects of self and/or the other. Expressing emotions assisted the partners in shifting from one position to another as disowned feelings and experiences were owned and experienced. The clients became more genuine, self-assured and slightly more open to themselves during 217 this process. Expressing emotions was also amply evident during the client category "couple working through blocks to intimacy" when the partners disclosed and shared untold stories of trauma associated with sexual abuse, abandonment, neglect and betrayal. Other researchers have also concluded that shifting in the emotional domain of experience facilitates marital change. From the perspective of Emotionally Focused Therapy, for instance, Greenberg et al., (1988) concluded that marital change is facilitated by the expression of feelings and needs. As well, these authors suggested that interpersonal perceptions in marital therapy change when partners express deeply felt underlying feelings. Also, the resulting model of family therapy change proposed by Friedlander et al. (1994) noted that one of the steps in resolving an impasse is the emotional disclosure about the impasse by all family members. Finally, Coulehan et al.'s (1998) model of family therapy change, from a constructivist perspective, identified a shift in family members' affective responses, as a particular transformational stage in the movement away from the old stories and the creation of new ones. Cognitive Domain Change within the cognitive domain of experience of the clients was evident during the shifting that occurred from distance and alienation toward intimate engagement of the partners. In "owning one's part in the relational conflict," for instance, cognitive change was noted by the subcategories "reflecting" and "acknowledging." The partners reflected, wondered and pondered verbally and nonverbally about their experiences and actions concerning themselves. The partners questioned their own role in the marital conflict as they shifted from 218 blaming their partner to self blame for the marital conflict. Cognitive shifting was evident as the partners acknowledged their own part in the marital conflict and a new realization or insight about the conflict occurred. Cognitive change in the marital change process has also been identified by Greenberg et al. (1988) by the category "acquiring understanding of relationship, self and partner's dynamics" in E.F.T. Friedlander et al.'s (1994) conceptual model of family change identified four of the five steps of change as cognitive in nature. In fact, the first step, recognition of one's personal contribution to the impasse, and the third step, acknowledgment of others' thoughts and feelings, closely resembles the category "owning one's part in the relational conflict" of the present investigation. Finally, Coulehan et al.'s (1998) model of change in family therapy identified acknowledgment of hope as the last stage in their model. Acknowledgment referred to a cognitive aspect of the change process. Behavioral Domain The behavioral domain in the process of marital change referred to actions and practices engaged by the partners in effecting change. Behavioral shifts in verbal and physical distancing, restricted contact, direct interaction and physical expressions of intimacy were observed in the findings of this study. These behavioral changes were predominant in the phases "couple contacting: restricted and limited" and "couple engaging compassionately." Other researchers have also identified behavioral shifts as part of the process of marital and family therapy change. For instance, Christensen et al. (1998) reported that a shift in clients' style of relating and talking was a salient aspect of marital change. Also, Wark (1994) 219 identified the routine provided by the therapy process as a positive incident in effecting couple change. Finally, Greenberg et al.'s (1988) investigation concluded that the category "taking responsibility for therapy process" emerged as one of the five categories accounting for the change process in Emotionally Focused Therapy. Experiential Change Experiential change occurred when all domains (emotional, behavioral, cognitive) converged into one holistic and unified experience. Shifting of the experience occurred when the partners worked through blocks hindering their intimate engagement. For instance, during the subcategory "sharing tales of abuse and neglect" the partners expressed deep vulnerability and self-expression as all components of the experience were felt and experienced. Deep experiencing assisted in the release of rigidity and facilitated intimate interaction. Johnson and Greenberg (1988) suggested that experiential change increased couples affiliation, self-disclosure and acceptance. In this study, deep experiencing also helped the couples, especially the husbands, to release ghosts, demons and blocks by opening up tightly locked experiences and thoughts hidden within the self. The partners displayed flexibility and openness as these tightly locked blocks were uncovered. This idea is congruent with Johnson and Greenberg's (1988) findings that experiencing facilitates "softening," particularly on the husband's part, and decreases blaming, accusative and punitive interactions. Other Related Clinical Findings Clinical commonalties between this study's findings and other models of marital change recently published were also identified. Two noteworthy issues were 220 the shift in focus from an intrapersonal to an interpersonal realm of experience in working through conflicts and a clinical practice issue identified as therapist perseverance. In the following section, a brief description of these two issues is addressed. Intrapersonal to Interpersonal Shift during Marital Change As depicted in the resulting model, the actions and interactions of the clients progressed from an intrapersonal/ individual to an interpersonal/relational focus. That is, the first phase in the model consisted of an individual/intrapersonal process of "owning one's part in the relational conflict" in which each of the partners identified and took responsibility for intrapersonal issues which negatively impinged on the relationship. Once the partners were able to own their part in the conflict, a shift toward a relational/ interpersonal focus occurred. This was manifested in the phases identified as: "couple" contacting, "couple" working through and "couple" engaging. Coulehan et al. (1998) reported a similar pattern of change in the change events from successful sessions of family therapy. These authors concluded that family members' view of problems in events in successful sessions shifted emotionally and cognitively from an intrapersonal to an interpersonal perspective. Perseverance A salient theme in the episodes of change was the perseverance displayed by the therapist despite the couples' attempts to deflect the focus of change. Therapist's perseverance was not necessarily an intervention; rather, it referred to a particular stance taken by the therapist under conditions of extreme distancing and 221 detachment by one or both partners. The therapist pursued the client's responses and focused attention on the thoughts, experiences or feelings of the client in the moment without diversion into other experiences. A similar pattern was noted by Coulehan et al. (1998) in comparing events from successful and unsuccessful sessions. These authors reported that during the first stage of successful therapeutic events, the therapist displayed significant persistence in pursuing responses from family members. Likewise, in the present study, during "owning one's part in the relational conflict," the first phase of change as depicted in synergetic shifting, the therapist selectively attended, maintained focus and pursued the clients' responses. Limitations of the Study This section addresses the limits of this investigation. Quality control requires evaluation of research practices based on their generalizability, objectivity, validity and reliability. Given the qualitative, discovery-oriented nature of this investigation, the evaluation of this study should be governed by the cannons of science proposed for qualitative investigations. What follows is a discussion of the main issues related to the external validity of multiple-case and qualitative analysis of therapy process research. Generalizability In quantitative investigations, evaluations are made of the extent to which one can generalize from the sample to the population via statistical generalization. In statistical generalization, inferences regarding a population are made based on the data collected from a representative sample. However, in qualitative case 222 studies, it is erroneous to apply statistical generalization to the findings because cases have not been selected to be representative of a population (Yin, 1989). That is, cases are not sampling units from a population. Rather, study cases are chosen based on how well they reflect a given theory or phenomenon under investigation. Yin (1989) coined the term analytic generalization to evaluate whether the findings generated by the investigation can be generalized beyond the case investigated to broader theory. The analytic generalizability of a particular set of results to some broader theory is achieved as previous theory is compared with the findings of the case study. Later, as similar cases are studied and are shown to support the theory, replication is attained. Replication is also achieved via multiple-case studies. However, contrary to the logic of sampling where a sample is presumed to represent a universe, the logic of replication assumes that cases are carefully selected so that they either predict similar results or produce diverse results but for predictable reasons (Yin, 1989). Accordingly, multiple case studies may replicate findings in a manner similar to multiple experiments, either with similar results (literal replication) or contrary results (theoretical replication). The provision of an answer to the research questions posed by this research called for a multiple-case embedded design. In a multiple-case embedded design more than one case, consisting of more than one unit of analysis is involved (Yin, 1989). To answer the first research question of this study regarding the presence of observable, identifiable, and recurrent in-session episodes of change, theoretical rather than literal replication of cases was intended. The three chosen cases 223 represented three distinct patterns of change. Two cases were retained for further analysis because they contained observable evidence of change episodes. As such, the findings from this investigation were the result of the analysis of these two cases with ten units (episodes of change) embedded within the cases. The resulting conceptual model of change emerging from the analysis of these ten change episodes provided clear evidence of the process of change as conceptualized by ExST. Furthermore, the resulting model of change expanded the notions of change as postulated by the developers of ExST by actually describing how change occurred in marital ExST. In addition, although the present model was generated over a period of time when other models of marital change were being published, many similarities were identified regarding the process, nature, and interactions of the clients during marital change. However, the degree of similarity that may exist between the context of this research and some other research context to which one may wish to apply the findings may vary considerably. Indeed, the method of research in this study does not permit generalization of findings to other therapeutic settings or client populations. However, the richness, detail, and depth of data and analysis allows for an expansion of the range of interpretations of the process of change in marital therapy. Furthermore, the depth, richness, and detailed descriptions of the data and the resulting model may facilitate comparison with future models of therapeutic change in marital therapy. 224 Objectivity Objectivity refers to the distance that must be established between the researcher and the researched, the need to follow rigorous standards, and the importance of staying detached in order to minimize biases. In qualitative investigations, the researcher enhances and increases the value of the findings by maintaining a close and prolonged contact with the data and by keeping memos and records (of basis for generating insights and theoretical interpretations) of research process (Guba, 1981). In addition, the objectivity of the findings is also enhanced through triangulation (Denzin, 1989). Triangulation refers to collecting data from a variety of sources or utilizing different methods of data collection and analysis in order to cross-check the data and the interpretations. In this study, an extensive and prolonged period of time was spent analyzing, reflecting on, and evaluating the insights and interpretations arising from the data. In addition, a large quantity of memos and notes were maintained for recording the research process, ideas and insights as they emerged from the data. These notes and memos were constantly reviewed, analyzed and consulted. However, absent from the analysis were the couples' input as well as reflections from other research-analysts regarding the theoretical insights and interpretations. Limited triangulation was also implemented during the identification and selection of the episodes of change. The identified and subsequently selected episodes of change were cross-checked with the supervisor of the present study, who was also one of the originators of ExST and the principal investigator of TARP. In addition, alternative sources of data, such as the Weekly Situation Diaries 225 (Appendix C) for all couples were cross-checked for similarities between therapeutic experiences and related events in the daily lives of the couples. Feedback from the couples regarding the selection of the episodes and the results of the analysis was precluded due to a time-limited access contract established between the clients and TARP team of researchers. Finally, one of the advantages of a naturalistic, qualitative, participant-observer method of research was, paradoxically, a disadvantage in regard to the objectivity of the study. A significant and large body of findings was uncovered and a valuable, deep and rich level of understanding of a complex and intricate process was acquired. However, the objectivity of the findings was compromised due to the subjective nature of this investigation. Internal Validity Internal validity refers to whether the findings are an accurate representation of the phenomena they purport to represent. In qualitative investigations, internal validity is achieved when the investigator presents an accurate description and/or interpretation of the topic under study (Guba, 1981). Internal validity is established when the researcher represents, as accurately as possible, the reality of the participants so others in similar situations can recognize themselves as they encounter the findings. According to Stiles (1993), validity is supported by the consistency of the model with the existing literature, the model's internal coherence, and its clinical relevance. An important limitation of the present study concerned the absence of input from the couples regarding their perceptions and thoughts on the selection of the 226 episodes of change, the change process, and the findings uncovered in the study. Also, the scarcity of research literature on the change process in marital therapy, particularly conceptual models of therapeutic marital change, hampered considerably an evaluation of the internal validity and consistency of the findings. However, two fairly recent investigations on the change process of marital therapy (Christensen et al., 1998) and family therapy (Coulehan et al., 1998) closely parallel the findings of the present study. In fact, the model of change events of successful family therapy generated by Coulehan et al. (1998) closely approximates and reflects the process of change as depicted on the first client-category of this study. Also, the idea of therapist perseverance was suggested by both models as a valuable and important therapist action. In addition, this study confirmed Johnson and Greenberg's (1988) and Newman's (1995) conclusions that experiential learning facilitates change in marital therapy. Finally, although Christensen et al., (1998) did not generate a model of the process of change in marital therapy, findings from this study are consistent regarding the identification of change in the domains of affect, cognition, and communication of couples. Reliability In qualitative research, reliability is supported by the consistency in the patterns identified in the study (Stiles, 1993). Consistency evaluates whether the findings are replicable with similar participants and similar contexts. In the present study, consistency was attained by the vigilant and diligent attention paid to the many sources of variation occurring in the data throughout the analysis. 227 Evaluation of a Grounded Theory Investigation As indicated in chapter three, the developers of the grounded theory method (Glaser & Strauss, 1967; Glaser, 1978) suggested specific criteria by which to evaluate a grounded theory investigation. These criteria were identified as fit, relevance, work, and modifiability. The criterion of fit refers to the the idea that the conceptual model generated from the analysis along with its categories and sub-categories must fit the data. This was accomplished by allowing the concepts and categories to emerge freely from the data rather than forcing pre-conceived ideas or concepts into the data. The emerging concepts and categories gradually gained a place within the emergent model based on indications from the data. As well, the emerging concepts and categories captured as closely as possible the language utilized by the couples and the therapist. The criterion conceptualised as work refers to the extent to which the conceptual model describes and explains what took place; that is, the events under study. Throughout the analysis, a significant effort was made to stay as close as possible to the data and produce a model that represented as throroughly as possible the actions and interactions of the participants. In an attempt to consider as many variations as possible in accounting for the actions of the participants, the analysis entailed the utilization of three media. That is, the data were analysed through the reading and analysis of transcripts, the observing of videotapes, and the listening of audio-tapes separately. This was followed by a second analysis in 228 which the data were analyzed concurrently through observation and reading of materials. Work is closely connected to the criterion identified as relevance. Relevance means that the resulting conceptual model must be relevant to the actual actions taking place. Relevance was achieved by allowing the core themes and processes to freely emerge from what the data were suggesting. The final evaluative criterion of a conceptual model concerns its amenability to modifications as new data comes in. The resulting model appears to be sufficiently malleable and flexible and therefore, the possibility for potential expansions and modifications seems conceivable and workable given new data from marital ExST. Finally, a theory generated through the grounded theory approach must provide clear categories and sub-categories as well as be understandable to others in the particular area of investigation. Rennie, Phillips and Quartaro (1988) further explained these criteria by stating that: It should be believable in that it should seem to the reader to be a plausible explanation. It should be adequate in that it should present a comprehensive account that does not omit large or important portions of the data. It should be grounded in terms of the appropriate procedures and thereby inductively tied to the data. Finally, it should be applicable and should lead to hypotheses and additional investigations, (p. 145). Other Methodological Considerations The present study demonstrated the potential and fruitfulness of a discovery-oriented methodology by meanigfully understanding and describing how ExST 229 marital psychotherapy produces change. As well, the discovery oriented nature of the method generated valuable ideas, insights and a range of interpretations which may potentially stimulate future research. Also, this study demonstrated the feasibility of discovery-oriented methods, such as the grounded theory method of analysis, as profitable in the generation of knowledge in change process research. However, a cautionary statement regarding the considerable amount of time and ability to manage an overwhelming amount of complex, convoluted, rich, and intricate data is necessary. In fact, qualitative-discovery oriented investigations are usually conducted by teams of analysts because of the required amount of time, resources, and effort as well as the need for consensus during the analytic process. Given that the present study was conducted by a single analyst, verification of ideas and insights with others was not feasible. Suggestions for Future Research The discovery-oriented nature of this investigation prevents conclusions regarding its outcome. Further investigations are required to confirm or disconfirm the qualitatively derived resulting model of change of marital ExST. However, valuable, adequate, and substantial ideas were generated to suggest future research. In fact, the ideas, issues and problems advanced by this study rest on many unresolved theoretical and methodological issues. From a theoretical viewpoint, for instance, further investigations on how change occurs in marital therapy and how couples shift from distance and alienation to engagement and intimacy are needed. Also, questions concerning the 230 notion of synergetic shifting along with the categories and subcategories explaining the process of change, and the therapist operations facilitating change, may expand understanding and knowledge of marital therapy for researchers and practitioners. For instance, further research could examine (1) the point at which supporting, shifting, and transitional operations are most useful and helpful in facilitating synergetic shifting for the couple; (2) the extent and frequency of therapist operations during the various client categories; (3) the extent of couples' intrapersonal and interpersonal readiness in facilitating shifts through transitional operations; (4) the replicability of therapist's operations during the four different phases of the model; (5) the identified need to maintain a collaborative atmosphere throughout the episodes of change; and (6) the identified importance of a focus on a here and now in the interactions maintained and encouraged by the therapist during moments of intense emotional and experiential expression by the clients. As well, this study examined the process of change in the context of couples that showed some level of improvement. Comparative studies on the process of change of improved and non-improved couples are needed in order to continue to expand and illuminate therapist and client aspects that may be helpful and hindering to the change process. From a methodological standpoint, questions regarding the utilization of the researcher as a research instrument in the process of change, the employment of posteriori sources of data and the lack of input from participants are important in planning future studies. Also, future research could explore the possible differences generated from direct observational analysis of events through video-tapes and 2 3 1 transcripts versus the exploration of participants' perceptions of the process of change through interview formats. Conclusion A discovery-oriented approach was employed to study the process of change of three couples treated with Experiential Systemic Marital Therapy (ExST). The discovery-oriented observational approach yielded episodes of change embedded within the therapy sessions. The actions and interactions of the members of the therapeutic system, in these episodes of change, were closely studied and scrutinized in order to describe, understand and explain how change occurred in marital ExST. This approach proved useful and effective in fulfilling the stated objective. This investigation significantly contributed to and expanded the knowledge base of marital therapy. It provided a conceptual framework of what occurs in marital therapy by identifying the clients' change processes and the therapist interventions that assisted change for couples. This conceptual framework linked the clients' process of change with the therapist interventions as they occurred in their natural environment, conceptualized change as a shifting process, identified an intrapersonal and an interpersonal component to change in marital therapy and uncovered therapist's actions such as transitional operations and perseverance as valuable in facilitating the process of change for couples. The present study provides valuable clinical and conceptual insights to clinicians and researchers. For clinicians, this study offers a map from which to generate hunches and evaluate their practices. For researchers, this study 232 contributes many rich ideas and conceptual links which could be recreated into questions and hypotheses about the process of change in marital therapy. 233 REFERENCES Alexander, J. F., Holtzworth-Munroe, A., & Jameson, P. B.(1994). The process and outcome of marital and family therapy: Research review and evaluation. In A. E. Bergin & S. L. 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APPENDIX A PARTICIPANT FAMILY'S CONSENT FORM APPENDIX B THERAPIST COMPETENCY FORM 248 SITE: • CLIENT f : THERAPY DATE: WESTERN FAMILY LEARNING INSTITUTE THE ALCOHOL RECOVERY PROJECT EXPERIENTIAL SYSTEMIC THERAPY THERAPIST COMPETENCY RATING FORK • o a FORM CARD I i I I EVALUATION CODE: CD THERAPY SESSION #: 1,1 J c n c a c a THERAPIST*: MO RATER CODE ID/ DAY YR CONSULTATION DATE: czo a=i c a MO DAY YR Please answer the following questions, based on the information you have about this therapist's conduct in this experiential systemic therapy session in The Alcohol Recovery Project. 1. In this session, how close does the therapist come to emulating your concept of the-principles of experiential systemic therapy? | 1 1 1 \ 1 2 3 4 5 Completely Somewhat Completely unlike like matches emulation emulation emulation This item is meant to measure your iapression of the therapist over the course of the entire session. 2. In this session, how close does the therapist come to emulating your concept of the appropriate selection of techniques in this therapeutic circumstance? I 1 1 1 1 1 2 3 4 5 Completely Somewhat Completely unlike like matches emulation emulation emulation This item is meant to measure your opinion regarding the appropriateness of vhat the therapist did in the session considering issues, such as timing, client receptiveness, f i t in the therapeutic mandate. - 2 - 2 4 9 In this session, hov c l o u does the therapist C O S M to emulating your concept of the s k i l l f u l implementation and u t i l i z a t i o n of techniques? 1 1 1 : 1 1 1 2 3 * 5 Completely Somewhat Completely unlike l i k e matches emulation emulation emulation This item i s designed to measure your assessment of how well the therapist used techniques towards the ends of the therapeutic mandate. Principle issues of concern In t h i s item are the smoothness of introduction, rationale provided to contextualixe tasks, appropriate l e v e l of therapeutic i n t e n s i f i c a t i o n of experience and the systemic connection of the a c t i v i t y to the c l i e n t ' s r e l a t i o n a l context. In t h i s session, how close does the therapist come to emulating your concept of being i n an ex p e r i e n t i a l systemic therapeutic relationship with the c l i e n t ( • ) ? j , 1 1 1 1 1 2 3 4 5 Completely Somewhat Completely unlike l i k e matches emulation emulation emulation This item i s meant to measure your view on the degree to which the therapist assumed an interpersonal stance congruent with the collaborative, warm, empathic. open, spontaneous, respectful and sincere and developmental attributes seen'as central to experiential systemic therapy. If you were conducting an Outcome study i n experiential systemic therapy, how comfortable would you be i n selecting t h i s therapist to participate at t h i s time (assuming t h i s session i s typical)? | 1 1 1 1 1 2 3 4 5 extremely ambivalent extremely uncomfortable comfortable This item i s meant to measure the degree to which you endorse t h i s therapists conduct as being an acceptable representation of experiential systemic therapy. Bow r i g i d l y entrenched did you f e e l t h i s c l i e n t was to work with i n t h i s session? | 1 1 1 1 1 2 3 4 5 not moderately extremely entrenched entrenched entrenched This item i s meant to measure your assessment of the degree d i f f i c u l t y and challenged the therapist was faced with i n working with t h i s c l i e n t . Row productive.was t h i s session i n moving towards the goals of the therapy? | 1 1 1 1 1 2 3 4 5 not somewhat optimally productive productive productive This item i s meant to measure your impression of the quality of the session i n terms of accomplishing tne therapeutic mandate. APPENDIX C WEEKLY SITUATION DIARY 251 ® T H E A L C O H O L R E C O V E R Y P R O J E C T WEEKLY SITUATION DIARY FOR MOTHER P l e a s e complete t h i s d i a r y on Sunday, put i t i n the enve l o p e p r o v i d e d , and b r i n g i t to the C l i n i c a t your e a r l i e s t convenience. The c o n t e n t s of t h i s d i a r y w i l l be t r e a t e d as C o n f i d e n t i a l . Veek # I.D. # THE ALCOHOL RECOVERY PROJECT 252 WEEKLY S I T U A T I O N D I A R Y : PART ONE We ask you to f i l l out t h i s d i a r y so t h a t we can get a sense of how you are d o i n g on a weekly b a s i s . 1. C o n s i d e r the past week and t h i n k about how your l i f e has changed, i f at a l l . C o n s i d e r whether i t has changed f o r b e t t e r or f o r worse. Rate your e x p e r i e n c e of change w i t h r e s p e c t to each of the f o l l o w i n g on t h e s c a l e p r o v i d e d by c i r c l i n g t h e a p p r o p r i a t e number. (Note: " f a m i l y " means you. your spouse and your c h i l d r e n ) : Hue h V o r a a K i r n S o f l i w M t W o r n Ha C h a n g * Somev h a t 9* 1 1 a r a#tt«r Much a * t t a r (a) Your s e l f -3 -2 -1 0 + 1 + 2 +3 (b) Your ma r r i a g e -3 -2 -1 0 + 1 . *2 + 3 (c) Your f a m i l y -3 -2 -1 0 + 1 + 2 +3 (d) Your f r i e n d s h i p s -3 -2 -1 0 + 1 +2 +3 (e) Your work -3 -2 -1 0 + 1 +2 +3 2. G i v e n your e x p e r i e n c e s of the past week, r a t e how s a t i s f i e d you a r e w i t h each of the f o l l o w i n g . ( C i r c l e the a p p r o p r i a t e number): Extremely Somewhat Somewhat Extremely Dissat is f ied Dissat is f ied Sat is f ied Sat i s f i ed (a) Your s e l f 1 2 3 4 5 6 7 (b) Your ma r r i a g e 1 2 3 4 5 6 7 <c> Your f a m i l y 1 2 3 4 5 6 7 (d) Your f r i e n d s h i p s 1 2 3 4 5 6 7 (e) Your work 1 2 3 4 5 6 7 C o n s i d e r i n g the past week, r a t e how c l o s e each of the f o l l o w i n g came to your i d e a l . For example: how c l o s e d i d your marriage come to your view of an i d e a l m a r r i a g e in the past week? ( C i r c l e the a p p r o p r i a t e number): I d e a l (a) Your s e l f 0 L 2 3 4 5 6 7 8 9 10 (b) Your m a r r i a g e 0 I 2 3 4 5 6 7 8' 9 10 (c) Your f a m i l y 0 I 2 3 4 5 6 7 8 9 10 (d) Your f r iendsh i p s 0 1 I 2 3 4 5 6 7 8 9 10 (e) Your work 0 1 I 2 3 4 5 6 7 8 9 10 WEEKLY SITUATION DIARY: PART TWO 2 5 3 Please answer the following questions which have to do with more specific a c t i v i t i e s in your l i f e . 1 . In the last week have you: (Circle your answer) a) consumed any alcohol? Yes No b) used any prescription drugs? Yes No c) used any over-the-counter drugs? Yes No d) used any type of drugs other than the above? Yes No 2. i) Have you attended any kind of support group meeting in the last week? Yes No [If Yes, complete i i ) and i i i ) ; i f No go to #3.] i i) Write in how many of the following support group meetings you attended in the last week: Alcoholics Anonymous Narcotics Anonymous Adult Children of Alcoholics Alanon i i i ) If you have attended any other kind of support group meetings in the last week, l i s t the name of the group and the number of times you attended in the last week. Groups: No. of meetings attended No. of meetings attended No; of meetings attended 3. Were you absent from work in the last week? Yes No Not Applicable If Yes, how much time did you miss (in hours)? . hours 4. Did you attend any medical (not dental) appointments in the last week? Yes No If Yes, write in the number of times you attended: times WEEKLY SITUATION DIARY: PART THREE 254 C o m p l e t i o n of P a r t Three i s O p t i o n a l Use t h i s b l a n k page to r e c o r d any a d d i t i o n a l comments, t h o u g h t s , f e e l i n g s , e v e n t s , dreams or a n y t h i n g e l s e you c o n s i d e r i m p o r t a n t about the p a s t week. 255 ® T H E A L C O H O L R E C O V E R Y P R O J E C T WEEKLY SITUATION DIARY FOR FATHER P l e a s e complete t h i s d i a r y on Sunday, put i t i n t h e en v e l o p e p r o v i d e d , and b r i n g i t t o the C l i n i c a t your e a r l i e s t c onvenience. The c o n t e n t s of t h i s d i a r y w i l l be t r e a t e d as C o n f i d e n t i a l . Week # I.D. # THE ALCOHOL RECOVERY PROJECT 256 WEEKLY SITUATION DIARY: PART ONE We ask you to f i l l o u t " t h i s d i a r y so t h a t we can get a sense of how you are d o i n g on a weekly b a s i s . 1. C o n s i d e r the past week and t h i n k about how your l i f e has changed, i f at a l l . C o n s i d e r whether i t has changed f o r b e t t e r or f o r worse. Rate your e x p e r i e n c e of change w i t h r e s p e c t to each of the f o l l o w i n g on the s c a l e p r o v i d e d by c i r c l i n g t he a p p r o p r i a t e number. (Note: " f a m i l y " means you, your spouse and your c h i l d r e n ) : Much V i r n V o n i Son*wha t U o n t No Chang* Soatwhat S t t t t r Much B « t t«r (a) Your s e l f -3 -2 -1 0 + 1 +2 + 3 (b) Your m a r r i a g e -3 -2 0 + 1 +2 + 3 (c) Your f a m i l y -3 -2 0 + 1 + 2 +3 (d) Your f r i e n d s h i p s -3 -2 0 + 1 +2 +3 (e) Your work -3 -2 0 + 1 +2 +3 2. G i v e n your e x p e r i e n c e s of the past week, r a t e how s a t i s f i e d you a r e w i t h each of the f o l l o w i n g . ( C i r c l e t he a p p r o p r i a t e number): Extremely Somewhat Somewhat Extremely Dissatisfied Dissatisfied Satisfied Satisfied 2 3 4 5 6 7 2 3 4 5 6 7 2 3 4 5 6 7 2 3 4 5 6 7 2 3 4 5 6 7 (a) Your s e l f (b) Your m a r r i a g e (c) Your f a m i l y (d) Your f r i e n d s h i p s (e) Your work 3. C o n s i d e r i n g the past week, r a t e how c l o s e each of the f o l l o w i n g came to your i d e a l . F or example: how c l o s e d i d your m a r r i a g e come to your view of an i d e a l m a rriage i n the past week? ( C i r c l e t he a p p r o p r i a t e number): I d e a l (a) Your s e l f 0 1 1 2 3 4 5 6 7 8 9 10 (b) Your m a r r i a g e 0 1 i 2 3 4 5 6 7 8 9 10 (c) Your f a m i l y 0 1 I 2 3 4 5 6 7 8 9 10 (d) Your f r i e n d s h i p s 0 1 1 2 3 4 5 6 7 8 9 10 (e) Your work 0 1 L 2 3 4 5 6 7 8 9 10 WEEKLY SITUATION DIARY: PART TWO 257 We ask you to f i l l out this diary so that we can get a sense of how you are doing in your recovery. You may also find i t interesting to f i l l out this diary each week to get a sense of the quantity, frequency and pattern of your own drinking. 1 . In the last week have you: (Circle your answer) a) consumed any alcohol? Yes No b) used any prescription drugs? Yes No c) used any over-the-counter drugs? Yes No d) used any type of drugs other than the above? Yes No 2. How much d i f f i c u l t y have you experienced in achieving or maintaining abstinence this week? No Moderate Extreme D i f f i c u l t y D i f f i c u l t y D i f f i c u l t y 3 . i) Have you attended any kind of support group meeting in the last week? Yes No [If Yes, complete i i ) and i i i ) ; i f No go to #4.] i i ) If you attended any of the following support group meetings, write in how many you attended in the last week: Alcoholics Anonymous Narcotics Anonymous Adult Children of Alcoholics ' i i i ) Write in how many of the following support group meetings you attended in the last week: Groups: No. of meetings attended: No. of meetings attended: No. of meetings attended: 258 Were you absent from work in the last week? Yes No Not Applicable If Yes, how much time did you miss (in hours)? hours Were you in contact with any law enforcement agency in the last week? If Yes, write in the type of agency, the reason for contact and the number of contacts. Type of Agency Reason for Contact No. of Contacts Did you attend any medical (not dental) appointments in the last week? Yes No If Yes, write in the number of times you attended: times IF YOU DID NOT USE ALCOHOL AT ALL IN THE LAST WEEK PLEASE SKIP PART THREE AND GO DIRECTLY TO PART FOUR WEEKLY SITUATION DIARY: PART THREE 259 Please f i l l out the following alcohol use record as follows: 1. If you did not drink at a l l on a particular day, put a check mark for that day beside "didn't drink" in Part A. 2. If you did drink on a particular day, find the kind of drink you had and write in the number of drinks consumed on that day. 3. If you topped up or refreshed your drink, count this as a separate drink. Mon Tues Wed Thurs Fri Sat Sun A. Didn't drink at al1 B. Beer, Ale. Malt-Liquor 12 oz. bottle or can (5%) (341 ml) Draft beer; home brew 8 oz. glass 16 oz. pint Light beer (2.5%- H.0%) Heavy beer (5.7% - 6.0%) C. Cider. Coolers 12 oz. bottle (M% - 6.0%) D. Wine (including Sangria) Standard glass (1 oz.) Half-bottle (13.2 oz.) Bottle (26.H oz.) (750 ml) Litre (35.2 oz.) E. Distilled Spirits (HO%) (Gin. Vodka. Whiskey. Scotch Rum, Brandy. Tequila, etc.) 1 shot (1 oz. ) Jigger (1.5 oz .) Double (2 oz.) Mixed drink (e.g. Rum & Cola 1 oz.) Mickey (12.5 oz. ) 26 oz. bottle MO oz. bottle F. Miscellaneous Alcoholic Drinks Mon Tues Wed Thurs Fri Sat Sun (Sherry. Vermouth, Muscatel, Port, Sake, Fortified Wine) Standard-size glass (1.5 oz.) (20%) Liqueurs, fruit flavoured brandies Standard glass (1.5 oz.) (30%) Special coffees (e.g. Irish, Spanish (1 oz.) (40%) ; Shooters (1 oz.) (H0%) . Other WEEKLY SITUATION DIARY: PART FOUR The following chart is for you to record your use of drugs, i f any. This includes prescript ion, ovei—the-counter and other kinds of drugs. If you used no drugs on a particular day, put a check under the column labelled "None". If you did use drugs on a part icular day, specify the drug, how you took i t and how much you took. Type of Drug How Taken How Much None Monday Tuesday Wednesday Thursday F r i d a y S a t u r d a y [ Sunday __, 260 Mon Tues Wed Thurs Fri Sat Sun WEEKLY SITUATION DIARY: PART F I V E 261 C o m p l e t i o n of P a r t F i v e i s O p t i o n a l Use t h i s b lank page to r e c o r d any a d d i t i o n a l comments, t h o u g h t s , f e e l i n g s , e v e n t s , dreams or a n y t h i n g e l s e you c o n s i d e r i m p o r t a n t about the pas t week. 262 APPENDIX D ILLUSTRATIONS OF CATEGORIES AND SUBCATEGORIES 263 SAMPLE OF ILLUSTRATIONS OF CATEGORIES AND SUBCATEGORIES Phase One: Owning One's Part in the Relational Conflict Distancing H: What wounds though! T: What wounds. Silence (52 seconds) T: I am aware that it's a bit scary Peter, to open the door. H: I really can't think of you know the wounds, eh what wounds? T: I am aware that you told me they are there, the wounds are there you said today. And when you focus on the wounds What wounds? Who has wounded you? Reflecting T: And I want you, and I, and Carol to imagine what and how would it be like when the demons are not there. How many demons do you think are there? H: I don't know I don't know silence. T: Do you have any names for the demons, are they big, little? Silence (20) H: It feels like a few! At a later point the client reflected in the following manner. H: It is kind of confusing....because lately I have been getting the feeling that there is more than one demon. But I don't know what the truth is. What is real? And it is confusing for me.. A lot of it is because I have been digging within myself and that forces issues, so I don't know what I am projecting or what is real anymore. Expressing H: No I am frightened of you, not necessarily angry I am frightened! T: Frightened. H: Because then you are pushing my buttons, bringing these things back and that's T: It is a frightening experience, it's scary. H: You are rocking the boat! T: Rocking the boat. 264 H: It's like Joan rocks the boat., you know about my drinking? It is the same sort of feeling. Acknowledging T: How would you like me to relate with you? H: Not focus on me!!! Wife and husband laughs H: Take the pressure off me yeah! (laughing) T: Take the pressure off you. H: I hope I would have thought of that one before!(both laughing) T: Take the pressure off you. H: But then you can't do that because it's....It takes 2 to have a problem you know. Therapist's Actions and Interactions Related to Phase One Supporting Operations 1. Accepting W: And if you don't normally talk to people outside of your marriage and then you start talking to people then you just loose it. T: So you feel you are loosing it, I feel like right now you are honouring your husband. You are trusting your inner self and what is going on inside. And perhaps that has been going on inside of you for a long time and what you are sharing with your husband right now is all this pain that you have accumulated inside of you. And this hurt and the tears are welcome in this room. I welcome them. Actually I thank you for letting me and letting your husband as much as he feels uncomfortable with your tears right now... And he touched your hand! (he laughed nervously). H: Now you are embarrassing me! 2. Empathizing and Validating Client's Experiences T: I am aware that it's a bit scary Peter to open the door. H: I really can't think of you know the wounds, eh what wounds? Shifting Operations 1. Reifying client's experiences and feelings T: These, the demons did really bad things to you.They were miserable, and they still do bad things to you, and they get you your heart and they squeeze your 2 6 5 heart and they don't let your heart breathe. Maybe that is how you feel that at times you are going crazy because the demons are squeezing your heart they.... H: Yeah!! T: And they don't let your heart be alive.Then you feel so confused and that is part of what the demons are doing to your heart. So what we are doing right now is trying to bring the demons out. It doesn't matter who they are right now, what matters is that they let the heart breathe and begin to palpitate. And let those eyes feel sad when they want to feel sad and to shed some tears H: Hohhhh Nope!!.... (Laughs) They won't let me! 2. Linking the Couple T: What are you saying to him? (in an inquiring tone but gentle, she sounded soft) W: Humm not understood. T: What are you saying to him? (therapist sounds gentle) W: Humm what am I saying to him? (questioning tone) T: Yeah, he is gone now, (as therapist is talking she comes back to her chair and sits right beside the wife). He is gone now with his own anger and rage in his own space. 3. Encouraging Self-Focus and Self-Connection T: And you , and your experience. When he is gone from your space, when he is far away from you what happens for you? Right now he is gone. He is far away. W: I feel very sad. (she responds in a matter of fact stance, she feels short) T: And for you? (therapist comes back to the wife's experience, her tone continues to be gently, she stresses you, as if saying that she is important as well) 4. Utilizing Client's Metaphors and Language H: You are rocking the boat! T: Rocking the boat. H: It's like Joan rocks the boat., you know about my drinking, it is the same sort of feeling. T: So Joan rocks the boat with the drinking and I am rocking the boat with the... 5. Challenging Act ions and Interactions T: You are feeling hurt because Walter doesn't care for you. W: I know he.... I know he loves me. T: And you feel in your heart his love his care and his consideration for you. 266 W: I don't know he...He just seems to be very compassionate and caring to other people but he just can't do it with me for some reason I don't know why! 6. Therapist Perseverance H: Humm humm What do you want to know? T: Well, what is important for you....you have come here for therapy to share your story and to work through that story that only you know. H: Am not sure that I came to therapy for that! T: Oh! H: I came to therapy to actually hoping that Joan would get something out of it so that there wouldn't be there wouldn't be uncertainty. T: So you came for her. H: Basically yeah! I didn't really come to... you know go through therapy myself sort of thing but something interesting might happen I might learn something. Phase Two: Couple Contacting: Restricted. Limited Distancing: flipping/fear/anger W: I am terrified to let him get close to me again because I don't want him to hurt me again. T: And I want you to be close me. W: Yeah? Conflictual messaging: accusing/distancing T: You don't know why Carol is feeling in pain why she is feeling hurt. Maybe you would like to share with him H: I don't know why she is crying why? T: Maybe you would like to share your feelings of hurt. W: I have already talked to him. T: Maybe you can try right now you are feeling hurt because (long pause; she is deeply crying) Brief, restricted contact T: So can you say that to him? Or maybe you can ask him if he is here with you right now. W: I think he is here right now because he is not angry with me but if he were angry at me.... T: Can you ask him? W: Are you here right now? H: Yes. 267 T: Are you here with me? W: Are you here with me? H: Humm,..humm... Therapist's Actions and Interactions Related to Phase Two Transitional Operations 1. Bridging the couple T: (addressing the wife) What do you think from just what you know of Peter Do you feel he has other wounds others than from his relationship with Gina that you...you maybe you want to help him? W: That's really putting me on the spot. T: Ohhh W: Because if I say something then I am afraid that he will be really angry with me. T: Maybe you can ask him... maybe you can ask him right now. He is here with you. Shifting operations 1. Encouraging Direct Interaction T: What would you like to say to Joan? H: I don't' know why she doesn't trust me! T: I want to know (therapist encouraged him nonverbally to address his wife directly by motioning with her hands). 2 . Linking the Couple T: You don't know why Carol is feeling in pain why she is feeling hurt. Maybe you would like to share with him. H: I don't know why she is crying why? T: Maybe you would like to share your feelings of hurt. W: I have already talked to him. T: Maybe you can try right now you are feeling hurt because (long pause; she is deeply crying). 3. Challenging Actions and Interactions T: OK, and are you going to start telling her who you are? ..Is that a way that perhaps that she can know who you are so that she can accept you? 268 H: She is always saying talk to me but then what does she want? You know. She wants to know when I am mad? Phase Three: Couple Working through Blocks to Intimacy Disclosing, sharing tales of abuse, betrayal. •' ' '>?!«' J • W: And I can remember the first time he touched me... and I felt so ashamed... that I didn't tell him to stop because as he was doing it he was telling me how nice I was., and how pretty I was Unlocking blocks/ghosts/demons W: Yeah! I am afraid that you will hurt me, I am afraid that I can't trust you! T: Because if I trust you W: That you are going to hurt me (laughs) that I leave myself open to being hurt again I am afraid that I can't trust you that you'll be.... true to our marriage humm I am afraid that you wont let me grow...in to being somebody that I like instead and be somebody that you don't have an idea of I am afraid that you I don't want to be your mother I don't want to be a referee, I ma afraid that if I let you close enough that those are the things that I am going to become and I don't want to be those things Transforming stories and metaphors H: She is having the impossible dream! W: Well it's like 10 years of all my wants and dreams coming out of her mouth. And I'm thinking back to all those times that no matter what I said or done. I am not laughing at you honest. I don't mean it to come across that way I don't I don't. It's just all the years of frustrations and everything. I am sorry I find it humorous and I don't mean it that I am laughing at you as much as I am probably laughing at myself. Letting go of blocks H : Well what am...What I want to let go off is the way she affects me still! T : Ok. H : You know in my relationships where I can't get close and I can't trust and I want to get rid off that so that I can trust and get close and love. T : So for you by burring or burning or what ever or letting go., of her name written on this piece of paper what are you letting go off? H : Her effect upon me, her control over me! 269 Therapist's Actions and Interactions: Phase Three i • Shifting operations " 1. Linking the couple W: Why didn't she tell somebody? T: Why do you think? Why do you think this little girl didn't tell anybody Peter? Why did this little girl didn't tell anybody? H: Humm ...because she didn't know any better that ...ah..a., no one told her that she could do that. That she could tell somebody yeah.... 2. Reifying client's experiences T: You still see yourself with a knife toward him. W: Yeah! Yeah I haven't got the words yet! T: You haven't got the words yet, I will get a knife for you then. 3. Challenging clients W: Yeah he never dances with me! And you'll say whatever, and I don't know. Maybe like you have a way of putting it into words so that he has to have an answer. I don't have the way of putting into so that he has to give me an answer a specific answer. All I get is nothing, I don't know. T: I feel that Peter is dancing with you right now and with me, he is dancing he has a very important role. 4. Utilizing Client's Language and Metaphors W: Afraid of stepping over the edge. T: What is the worst thing that can happen if you were to step over the edge? W: It like hegg huffg.... I don't know how to explain it.... ghufff not being able to come back! See what I have now is crazy and if I... if I let too much of that out at one time, I am afraid of not being able to get it back in control., back together! Phase Four: Couple Engaging Compassionately Interacting freely T: It is symbolic of something. I am wondering as you are with one another right now. What does it feel like to be with one another without the ghosts? 270 W: Strange. H: Calm. ) •; ' T: Is that how you want to sit, looking at one another? W: It's nice to look at one another instead of the ghosts. Accepting, supporting H: Yeah! Why are you putting all these conditions on yourself? You say I won't let you grow. I have no reason for stopping you from growing that would be good for me if you grew, if you became fulfilled and became happier. T: I want to grow with you. H: Yeah...!l want to teach you lots of things. I have learned lots living with you, experiencing life with you. Physical expressions of intimacy H: Do you want a hug? W: I do! But it will only make me cry again! T: That's ok if you cry. H: It's ok. W: I guess. (Husband gets up and gently hugs her) Therapist's Actions and Interactions Related to Phase Four Transitional operations 1 . Bridging the couple T: Because these are the ghosts, in this relationship, that keep you apart. Now I want to Peter I know you haven't heard before Joan's experience with the bastard. And as you hear, as you heard her experiences and her story what has been going on for you? H: Well, I had heard bits of it but I hadn't heard the whole thing like that. T: So. H: Hummm what was going on for me? T: What are you feeling for your wife as you heard the story? 

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